RESEARCH LETTERS

This study was supported in part by Lipha-Santé, a subsidiary of the Merck

group, F-69379, Lyon CEDEX 08, France.

1 Delange F, Dunn JT, Glinoer D. Iodine deficiency in Europe: a

continuing concern. New York: Plenum Press, 1993.
2 Hercberg S, Preziosi P, Briançon S, et al. A primary prevention trial
using nutritional doses of antioxidant vitamins and minerals in
cardiovascular diseases and cancers in a general population: the
SU.VI.MAX study-design, methods, and participants, characteristics.
Controlled Clin Trials 1998; 19: 336–51.
3 WHO/UNICEF/ICCIDD/. Indicators for assessing iodine disorders
and their control through salt iodisation. Document WHO/NUT/94.6.
Geneva: WHO, 1994.
4 Hollowell JG, Staehling NW, Hannon WH, et al. Iodine nutrition in the
United States—trends and public health implications: iodine excretion
data from National Health and Nutrition Examination Surveys I and III
(1971–1974 and 1988–1994). J Clin Endocrinol Metab 1998; 83:
3401–08.
5 Delange F, Benker G, Caron P, et al. Thyroid volume and urinary
iodine in European schoolchildren: standardization of values for
assessment of iodine deficiency. Eur J Endocrinol 1997; 136: 180–87.
Institut Scientifique et Technique de la Nutrition et de l’Alimentation,
ISTNA/CNAM, 2 rue Conté, F-75003 Paris, France (P Valeix e-mail:
s_valeix@vcnam.cnam.fr); and Lipha-Santé, Lyon, France

Regional patterns of median UI ( ␮g/100 mL) in adults aged Ready-to-use therapeutic food for
45–60 years (male/female)
treatment of marasmus
The age-related decrease in iodine intake, although André Briend, Radandi Lacsala, Claudine Prudhon,
moderate in degree, might be the result of food-pattern Béatrice Mounier, Yvonne Grellety, Michael H N Golden
changes paralleling the observed physiological reduction in
energy intake, but could also be due to the public awareness Children with severe wasting are treated with special diets.
of the need for a voluntary reduction in added salt to control After a child’s appetite returns, a diet is given that enables
hypertension. Regional variations in median concentrations of rapid weight gain. This diet is usually F100, a liquid diet with
UI are in part a reflection of fluctuations in the total iodine 100 kcal/100 mL. It is prepared by mixing dried skimmed
content of foodstuffs and pasture grasses, which depends on milk, oil, sugar, and a vitamin and mineral mix (without iron)
the quantities supplied to soil by the weathering of primary with water.1 Specifications for its industrial preparation have
bedrocks, by the atmosphere in the form of rain or aerosols, been published.2
through incidental additions of iodine to the environment, Because F100 is an excellent medium for bacteria, it has to
by agricultural practices (compound fertilisers, herbicides, be prepared before each meal and used by experienced staff.
iodine-supplemented feedstuffs), and food processing (iodine- This is a problem because recovery usually takes 4 weeks,
sanitising agents on farms). Conclusions from recently residential facilities are limited and expensive, and outpatient
published data on iodine nutrition in the USA should remind management with F100 not advisable. Therefore we
health officials in industrialised countries of the inconsistency formulated and tested a ready-to-use therapeutic food
of iodine intake, since the presence of iodine in the food chain (RTUF) with a nutritional composition similar to F100, but
may be driven largely by commercial rather than health that could be eaten directly. The RTUF complied with the
interests.4 F100 formula,2 except that part of the dried skimmed milk was
Although iodised household salt was introduced on a replaced with lactoserum and groundnut paste (Nutriset,
voluntary basis from 1952 onwards (10–15 mg sodium iodide France). The formula contained 543 kcal/100 g. Bacteria,
per kg salt) results of the SU.VI.MAX study definitively when added to the product, failed to grow. The product
underlined the risk for the French adult population of being looked and tasted like peanut butter.
exposed to mild iodine deficiency. By contrast, a study The study took place in a therapeutic feeding centre, in
pointed to a significant improvement of the hitherto prevailing Mao, Chad, run by Action Contre la Faim (Paris) and
borderline iodine deficiency among French school pupils the Tchadian Ministry of Health. 20 severely malnourished
(10–14 years of age). 5 Surveillance of iodine nutrition in children without oedema (weight-for-height <70% of
pregnant women to prevent the occasional risk of intellectual
impairment should be emphasised, and a nationwide effort to
promote iodised salt and to provide women of child-bearing
age with advice on dietary sources of iodine should be
implemented. In addition, efforts to improve iodine nutrition
through generalised iodine prophylaxis would reduce
radiation-induced damage to the thyroid in case of nuclear
accident.
In our study, the overall goitre prevalence ranged from
11·3% for the entire male population to 13·9% for the female
sample, suggesting that the thyroid is most probably exposed
to a mild goitrogenic effect due to moderate iodine deficiency.
Forthcoming results concerning thyroid function tests, and
results from goitre surveys and ultrasonographic scans will
illustrate the interrelations between iodine nutrition and Comparison of energy intake with F100 and RTUF (20 children,
underlying thyroid dysfunctions. average for three meals)

THE LANCET • Vol 353 • May 22, 1999 1767

RESEARCH LETTERS

standard), aged over 12 months, were sequentially included in Wernicke’s encephalopathy induced
the study when they had been gaining weight rapidly for at
least 3 days. The objectives of the study, with the description by magnesium depletion
of the new food, was explained to the mothers in detail in the Jordan McLean, Simon Manchip
different local languages. Mothers were free to choose not to
be included in the study. A teetotal women aged 85 years had congestive heart failure
Before the study, children received six locally prepared managed by daily 40 mg co-amilofruse. She became
F100 feeds daily. During the study, alternative F100 feeds confused, anorexic, and had ophthalmoplegia. She was
were replaced by RTUF. The order of the feeds was changed admitted to hospital with hypotension. A demand pacemaker
every day to avoid bias. Each day, one child was randomly was fitted. She developed ptosis and lost consciousness.
selected to have its intake measured by weighing the cup- Intravenous thiamine, 250 mg, was administered for
sachet (to 1 g) before, during, and after the six meals. The suspected Wernicke’s encephalopathy. She regained
mothers fed the children. They were told to repeatedly offer consciousness within 2 h. 8 days later, she became stuporose
food over 1 h, not to force-feed the child, and to give plain with low blood pressure and responded again to thiamine.
water to thirst. Each feed was compared with the subsequent She had severe anterograde memory loss and
feed in the same child (3⫻20 pairs of observations) with the confabulation. Over the next few weeks she developed
Wilcoxon-rank test. gegenhalten, cogwheel rigidity, grasping reflexes, and signs of
The energy intake was 40·2 (SD 20·9) kcal/kg per feed for tetany.
RTUF versus 20·2 (11·5) kcal/kg per feed for F100 (p<0·001) Her family searched for an explanation. She had taken
(figure). There were two children who took substantially more 40 mg co-amilofruse for 3 years. Frusemide impedes
F100 than RTUF—one with a chronic cough and another magnesium (Mg) reabsorption in the kidney by up to 400%.
with a peak of fever on the day measurement. Mg is an essential cofactor in the conversion of thiamine into
The higher intake of RUTF compared with F100 does not active diphosphate and triphosphate esters.1,2 There have
mean that overall energy intake increased, because we been reports of thiamine deficiency aggravated by Mg
calculate that the average energy intake of F100, before the depletion with refractory response to thiamine until Mg was
study, was about 30 kcal/feed—the same as these children given.1,2 Mg depletion has been reported among patients on
took from the combined diets. This comparison suggests that long-term diuretics.3,4 It seemed plausible that Mg depletion
ultimate replacement of all F100 by RTUF should not lead to could provoke Wernicke’s encephalopathy, possible by
a major increase in overall energy intake. Heart failure has suboptimum thiamine phosphorylation. Her diet was
supplemented with 500 mg daily chelated magnesium and
been reported in case of excessive energy intake3 and a major
thiamine diphosphate. Gegenhalten and cogwheel rigidity,
increase from those obtained with F100 is clearly undesirable.
grasping reflexes, and tetany subsided within 4 weeks. There
RTUF might be useful in contaminated environments or
has been a sustained improvement in her Korsokoff amnesia.
where residential management is not possible, such as during
Computed tomography scan showed Binswanger type
a war or disaster. It might also be useful for treatment at
periventricular hyperintensities. Her pacemaker precludes
home4 or in centres without a kitchen. In this case, the amount
magnetic resonance imaging which would elucidate further
of RTUF needed for the treatment should be given regularly
the diagnosis.
in small quantities to avoid overfeeding and misuse. Frequent Many cases of Wernicke’s encephalopathy may also have
contact with the health service, ideally daily, would also magnesium depletion. Alcohol ingestation causes increased
be needed to closely monitor the progress of the child. This excretion of Mg; hyperemesis gravidarum can lead to Mg
scheme could, however, lead to an increase in the cost- depletion;5 and diarrhoea due to Chron’s disease or gluten
effectiveness and coverage of nutrition rehabilitation enteropathy hinders Mg absorption from the gut.5 In elderly
programmes. people, Mg intake may be suboptimum. Stress,
Currently recommended treatment protocols are derived hypochlorhydria, secondary aldosteronism provoked by
from studies and experience over 30 years.1 Such information congestive heart failure, and loop diuretics all prejudice
is lacking for RTUF, which has not been tested in infants (in Mg reserves.5 Confusion, ataxia, and opthalmoplegia makes
whom an assured water intake is more critical) or in cases of Wernicke’s encephalopathy as plausible in someone taking
oedematous malnutrition, and may not be appropriate for diuretics as in an alcohol abuser. Symptoms may be
children with infection. Thus, wide promotion of this new diet misattributed to senile dementia. If a depletion of Mg
is premature in settings where the use of standard protocols reserves impedes the phosphorylation of thiamine, Mg
is possible. Nonetheless. RTUF avoids problems of quality depletion could have an effect on other enzymes whose
control and bacterial contamination. activities depend on Mg. The patient’s gegenhalten and
André Briend received a personal consultancy from the Nutriset company cogwheel rigidity with grasping reflexes, which are atypical of
which produces this food commercially. The study was partly funded by Wernicke’s encephalopathy and are generally ascribed to
Nutriset, and partly by Action Contre la Faim. pyridoxine deficiency. Pyridoxine is only phosphoryaled into
1 Golden MHN. Severe malnutrition. In: Weatherall DJ, its coenzyme in the presence of Mg. Because 70% of enzymes
Ledingham JGG, Warell DA, eds. The Oxford textbook of medicine, are dependent on Mg, it would be interesting to know how
vol 1, 3rd edn. Oxford: Oxford University Press, 1995: 1278–97. many other enzyme systems are affected by Mg depletion.
2 UNDP-IAPSO. Emergency relief items—compendium of generic
specifications, vol 1. Copenhagen: UNDP, 1995: 107. 1 Zieve L. Influence of magnesium deficiency on the utilization of
3 Patrick J. Death during recovery from severe malnutrition and its thiamine. Ann NY Acad Sci 1969; 162: 732–43.
possible relationship to sodium pump activity in the leucocyte. BMJ 2 Dyckner T, Ek B, Nyhlin H, Wester PO. Aggravation of thiamine
1997; 1: 1051–54. defiiciency by magnesium depletion. Acta Med Scand 1985; 218:
129–31.
4 Khanum S, Ashworth A, Huttly SR. Controlled trial of three
approaches to the treatment of severe malnutrition. Lancet 1994; 344: 3 Lim P, Jacob E. Magnesium deficiency in patients on long-term
1728–32. diuretic therapy for heart failure. BMJ 1972; 3: 620.
4 Ryan MP. Magnesium and potassium-sparing effects of amiloride.
IRD-ISTANA , 5 Rue du Vert Bois, 75003 Paris, France (A Briend e-mail: Review and recent findings. Magnesium 1984; 3: 274–88.
brienda@cnam.fr); Centre de Nutrition et de Technologie Alimentaire,
5 Durlach J. Magnesium in clinical practice. London: John Libbey and
N’Djamena, République du Tchad; Action Contre la Faim, Paris, France;
Co Ltd, 1998.
and Department of Medicine and Therapeutics, University of Aberdeen,
Aberdeen, UK Littlecourt, Down Ampney, Cirencester GL7 5QS, UK (J McLean)

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