More than one-fifth of the world's population live in extreme poverty, where a lack of safe water and adequate sanitation enables high rates of enteric infections and diarrhoea to continue unabated. Although oral rehydration therapy has greatly reduced diarrhoea-associated mortality, enteric infections still persist, disrupting intestinal absorptive and barrier functions and resulting in up to 43% of stunted growth, affecting one-fifth of children worldwide and one-third of children in developing countries. Diarrhoea in children from impoverished areas during their first 2 years might cause, on average, an 8 cm growth shortfall and 10 IQ point decrement by the time they are 7–9 years old. A child's height at their second birthday is therefore the best predictor of cognitive development or 'human capital'. To this 'double burden' of diarrhoea and malnutrition, data now suggest that children with stunted growth and repeated gut infections are also at increased risk of developing obesity and its associated comorbidities, resulting in a 'triple burden' of the impoverished gut. Here, we Review the growing evidence for this triple burden and potential mechanisms and interventions that must be understood and applied to prevent the loss of human potential and unaffordable societal costs caused by these vicious cycles of poverty.
High diarrhoea rates continue unabated in developing countries, despite benefits from oral rehydration therapy in reducing mortality
One-fifth (178 million) children worldwide have stunted growth; early childhood enteric infections, with or without overt diarrhoea, are predicted to account for 25–43% of this burden
Malnutrition severe enough to cause stunting contributes to more than half of global mortality in children >5 years old, as well as to impaired cognitive development
Enteric infections and undernutrition each increase the risk of the other in a vicious cycle
Increasing data show that early childhood infections and stunting are associated with obesity and its comorbidities in later life, forming a triple burden of poverty
Enteric infections, malnutrition and noncommunicable diseases form vicious cycles with poverty that are best reduced using multiple approaches including improved water purity and availability, sanitation, vaccines and supplementary nutrients
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The authors' collaborative work in this area is supported in part by NIH (ICIDR-UO1AI026512, FIC GIDRT D43TW006578) and the MAL-ED study, funded by an award from the Bill and Melinda Gates Foundation to the Foundation for the National Institutes of Health (FNIH). S. Moore is supported by an Independent Scientist in Global Health Award K02-TW008767 from the Fogarty International Center at NIH.
The authors declare no competing financial interests.
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Guerrant, R., DeBoer, M., Moore, S. et al. The impoverished gut—a triple burden of diarrhoea, stunting and chronic disease. Nat Rev Gastroenterol Hepatol 10, 220–229 (2013). https://doi.org/10.1038/nrgastro.2012.239
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