Minerals in malnutrition: miscellaneous
phosphorus in malnutrition Michael H.N. Golden 16.04.97
Iron absorption Nevin S. Scrimshaw 16.04.97
magnesium replacement Maurice Levy 05.05.97
Mg in KWK André Briend 05.05.97
Mg and Zn interactions Tor Strand 02.06.97

Subject: phosphorus in malnutrition

Date: Wed, 16 Apr 1997 10:16:24 +0100 (BST)

From: "Michael H.N. Golden" <m.goldenatabdn.ac.uk>


To answer George Fuchs' query about phosphorus.

We did a study of acid-base status in children in Jamaica because we found that, with the regimen we were using, they were becoming progressively more acidotic in the ward. In retrospect we should have guessed the reason - it was the use of magnesium chloride as the Mg supplement (significant numbers of the children have achlorhydria so that insoluble magnesium salts are not appropriate such as magnesium oxides) without any compensatory weak anion.

During this study we found that the children had a very very low urinary phosphate output and a low titratable acid output despite the mounting acidosis. Low/marginal plasma phosphate (and we did not measure intracellular phosphate). When they were put onto a high milk diet the urinary phosphorus increased, titratable acid output increased and their acidosis reversed.

We concluded that they were unable to excrete an acid load because of phosphorus depletion and wanted to supplement them with phosphorus to see if this would increase their ability to deal with acidosis and to aid in their rate of recovery (phosphorus being a type II nutrient).

Therefore we designed the experiment to supplement with KH2PO4 and K2HPO4, Ph 7.3 (exactly like a standard phosphate buffer), replacing some of the KCl in the diet. We started the experiment as soon as the children had been admitted. The first child we used this protocol on deteriorated on the diet in a non-specific way (decreasing alertness, decreasing spontaneous movement, decreasing appetite) and she was withdrawn from the trial by the independent clinician (Alan Jackson) after 2 days on clinical grounds and made an uneventful recovery there after. The second and third child that we started on the regimen followed exactly the same course. Plasma phosphate was normal, urinary phosphate output rose substantially to the levels seen in children on a milk-based diet, plasma potassium was within normal limits and the children were not alkalotic (base excess within +/- 3). The trial was abandoned. I have no explaination for these results - I can only suppose that there was some form of dysequilibrium syndrome.

The paper that John Waterlow and I wrote a few years ago in Br J Nutr recording verity Wills' early measurements records this problem at the end of the discussion.

I do think that phosphorus deficiency is a major problem for these children and the diffuculty we have with acetate could well be related to this as phosphated intermediates are required in every metabolic pathway known. They are also very prone to acidosis when phosphate depleated.

Incidentally, one of the problems with calculation of phsophate intakes is that food

composition tables give total phosphate. But in most diets the phosphate is in the form of phytic acid (inositol-hexaphosphate) the storage form of phosphorus for the plant. The problem with phytic acid is not just its ability to chelate some divalent cations, the child is deprived of phosphorus.

I am unsure how best to supply phosphate - giving a milk based diet is I think the best way, and I have often thought that it might be the high phosphorus content of cow's milk that makes it such a good food for rehabilitation from malnutrition, rather than the other components that are present. The other way might be to peruse the phytase/ fermentation of the cereal based porridges to that the vegetable phosphorus becomes available.

Phosphorus, with sulphur, is one of the "forgotten nutrients" that is critical to recovery.

Best wishes,


Prof. Michael H.N.Golden

From: Nevin S. Scrimshaw

DATE: 16 April 1997

Subject: Iron absorption


I have forwarded the recent exchange of food composition data relating to iron absorption to the Coordinator of the International Network of Food Data Systems (INFOODS) network fo possible comment. She has computer access to food composition data bases for Latin America, China, Southeast Asia, Western Pacific including Australia and New Zealand, North America and some European data. She also coordinates a lively e-mail exchange on food composition issues.

If you wish to sample this network the computer address to subscribe is:


If you want to ask a food composition question of her the email address is:



Dr. Nevin S. Scrimshaw, Director

United Nations University, Food and Nutrition Programme for Human and Social Development

Charles St. Sta., P. O., Box 500

Boston, MA 02114-0500

Tel: (617) 227-8747 Fax: (617) 227-9405

Email: Scrimshawatinfoods.unu.edu

From: levy <levyatdhfrere.el.healthlink.org.za>

Date: Mon, 05 May 97 11:19:08 -0200

Subject: magnesium replacement


Please advise me on replacement of Mg. in kwashiorkor. What oral formulations are suitable, in what dosage? I do not want to precipitate diarrhoea!



Maurice Levy

Date: Mon, 5 May 1997 12:50:46 +0200 (METDST)

From: briendatext.jussieu.fr (Andre' BRIEND)

Subject: Mg in KWK


For the last few years, relief agencies have used the following mineral mix for treatment of severe PEM including kwashiorkor:

KCl 24 mmoles
K3 citrate 2 mmoles
MgCl2.6H2O 3 mmoles
Zn acetate.2H2O 300 micromoles
Copper Sulfate.7H2O 45 micromoles
Sodium selenate 0.6 micromoles
KI 0.6 micromole

This mix is added to the feeds (to 1 litre). It brings all Mg needed for KWK.


Details are given in:

Treatment of severe child malnutrition in refugee camps. Eur J Clin Nutr 1993; 47 : 750-4.

Magnesium salt may induce diarrhoea, to my knowledge, only through an osmotic effect.

Physiological dosis such as present in this supplement carry absolutely no risk of diarrhoea.

Mg Cl2 may induce acidosis in severely malnourished patients. In this mix, MgCl 2 is balanced by K3 citrate.

I understand that this mix is to be taken up by WHO (see Appendix 4 of who manual on treatment of severe malnutrition, to be published).


Dr. Andre' Briend

Date: Mon, 2 Jun 1997 15:16:55 +0200

From: Tor Strand <torstratsn.no>

Subject: Mg and Zn interactions


I have a question regarding supplementation of Zinc and Magnesium to children. Is there any known interactions between these two elements such that one of them might inhibit the absorption of the other?


Dr. Tor A Strand

Centre of International Health, University of Bergen

5021 Bergen, Norway

tel: -47 55 97 49 84 fax: 47 55 97 79