GD03: Pellagra in low-income settings: can we prevent it?

I. Navarro-Fernandez,^1,2 E. Mateche,^2,3 I. Vilanova-Urdaniz,^2,4 and C. Galvan-Casas^2,5

¹Hospital Universitario de Cabuenes, Gijon, Spain; ²DerMalawi Project, Nkhotakota, Malawi; ³Alinafe Community Hospital, Nkhotakota, Malawi; ⁴Hospital General Universitario de Elche, Alicante, Spain; and ⁵Hospital Universitario de Móstoles. Universidad Rey Juan Carlos, Madrid, Spain

Pellagra is characterized by the triad of dermatitis, diarrhoea and dementia. Caused by niacin (vitamin B3) deficiency, it can lead to death if left untreated. It is particularly common in impoverished areas where the population relies on a maize-based diet (Hegyi J, Schwartz RA, Hegyi V. Pellagra: dermatitis, dementia, and diarrhea. Int J Dermatol 2004; 43: 1–5). Maize contains niacin in a bound, unavailable form. However, to make niacin available, it can be treated by alkaline hydrolysis, cooking the grain with lime or ashes (nixtamalization). Nixtamalization also significantly reduces the number of mycotoxins naturally present in organic maize. This technique was performed by pre-Columbian cultures (https://www.researchgate.net/publication/228453826). Although maize became a staple crop in the continent, this ancient process has not been commonly adopted in Africa. Alerted by the large number of patients with pellagra attending our dermatological clinic in rural Malawi, we conducted an intervention to introduce local population to maize nixtamalization. Niacin supplements are expensive and unavailable for most of the population in poor African countries, where many are not able to maintain a sufficiently nutrient-rich diet. Ash is freely available in all households in Malawi. The campaign was structured in parallel with dermatological medical consultations that were carried out in the area. Local health managers were previously trained. Announcements were made to encourage participation, especially by women, traditionally responsible in the country’s social structure for the after-harvest processing and cooking of maize. Meetings were held at health centres while patients were waiting to be seen at the clinics. The audience was informed about the manifestations and cause of pellagra and the benefits of the nixtamalization technique. They were instructed on how to boil maize grain with ash after harvest, using diagrams and performing actual demonstrations. Pellagra is currently uncommon in developed countries but it is still an important health issue in developing African countries. The main drawback of the intervention is the transculturation and difficulty in modifying the ancestral method of grain processing, which is passed on from generation to generation. However, we consider the implementation of nixtamalization very useful, for its simplicity, inexpensiveness and accessibility, and the improvement in the safety and nutritional quality of the inhabitants’ staple diet. We believe this cheap intervention can have an enormous impact on health and could be transferred to other areas in rural Africa. Studies are needed to confirm its effectiveness.