Editors' ChoiceENVIRONMENTAL ENTEROPATHY

A Simple Solution for a Big Problem

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Science Translational Medicine  29 Jan 2014:
Vol. 6, Issue 221, pp. 221ec19
DOI: 10.1126/scitranslmed.3008079

Environmental enteropathy is a disorder of the small intestine thought to be associated with repeated exposure to pathogens common in developing countries with poor sanitation. This condition is characterized by abnormal intestinal villous architecture, infiltration of inflammatory cells, and increased epithelial permeability resulting in reduced absorptive capacity of the small intestine and systemic inflammation, leading to malabsorption of nutrients and impaired growth of children. There is no treatment to reverse the changes induced by environmental enteropathy, but multiple micronutrient supplementation has been proposed as a potential therapy.

Now, Louis-Auguste and colleagues investigate the effects of high-dose multiple micronutrient supplementation on environmental enteropathy by measuring the small intestinal villous architecture in patients with or without HIV infection. In this double-blinded, placebo-controlled randomized trial, endoscopic proximal small bowel biopsies were obtained after high-dose multiple-micronutrient supplementation of adult volunteers living in Lusaka, Zambia, a community with widespread environmental enteropathy. In this study, 38 participants were randomized to receive either 6 or 24 weeks of micronutrient supplementation in the form of a daily capsule or placebo. Using automated image analysis, biopsy sections were measured for villous height, villous width, crypt depth, and villous perimeter in order to assess epithelial surface area; cross-sectional area was measured in order to assess villous compartmental volume.

Complete analysis was done on 18 participants receiving the supplement and 20 participants receiving placebo. Six participants in the supplement group and 9 participants in the placebo group were HIV-infected. Jejunal biopsies showed that mean villous height in HIV-negative participants was 24% greater in the supplement group as compared with the placebo group. Similarly, mean villous area and median villous perimeter were 27.6 and 29.7% greater, respectively, in HIV-negative participants in the supplement group compared with placebo. However, no difference was observed in villous morphology between HIV-positive patients given the supplement or placebo.

Around 2 billion people worldwide are living under conditions in which environmental enteropathy is prevalent. This study suggests that high-dose multiple-micronutrient supplementation might be a useful and cost-effective treatment for HIV-negative individuals with environmental enteropathy resulting in improved intestinal absorption and permeability. Small sample size is the major limitation of this unique study. Therefore, a larger trial is required to establish physiological and clinical outcomes of multiple micronutrient supplementation for environmental enteropathy.

J. Louis-Auguste et al., High dose multiple micronutrient supplementation improves villous morphology in environmental enteropathy without HIV enteropathy: Results from a double-blind randomized placebo controlled trial in Zambian adults. BMC Gastroenterol. 14, 15 (2014). [Abstract]

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