Environmental enteric dysfunction in well-nourished and undernourished women in Bangladesh

Environmental Enteric Dysfunction (EED) is a subacute inflammation of the small intestinal (SI) mucosa associated with undernutrition and perturbation of the SI microbiota. Its diagnosis relies on histopathological assessment of small intestinal biopsies, with a lack of validated biomarkers contributing to underdiagnosis. This study assessed the prevalence and histological features of EED in undernourished Bangladeshi women living in an urban slum in Dhaka, compared to well-nourished women from slum and non-slum areas, and examined the factors associated with histologically confirmed EED.

This analysis included non-pregnant, non-lactating Bangladeshi women aged 18-45 years classified by location of residence and nutritional status: well-nourished non-slum residents (WNNS), well-nourished slum residents (WNS), and undernourished slum residents (UNS). Data were obtained from two ongoing studies and one completed study. Well-nourished women (BMI 20-24.9 kg/m²) who consented to upper gastrointestinal endoscopy for functional dyspepsia were also enrolled. During endoscopy, mucosal biopsies were collected from the distal duodenum, and the presence of EED was determined by histologic assessment of lymphocyte infiltration, villous atrophy, and/or crypt hyperplasia.

Between October 2, 2022, and June 30, 2024, 1059 WNNS and 445 WNS women were screened for eligibility. Of these, 33 WNNS and 55 WNS women underwent endoscopic evaluation. Histological data were available from a prior study of 38 UNS women. Histological examination showed EED in 21% of WNNS, 18% of WNS, and 100% of UNS women. Multiple logistic regression analysis indicated that BMI (aOR: 0.70, 95% CI: 0.58-0.85; p < 0.001) was significantly associated with the presence of EED in women in this study.

Although EED was expectedly common in undernourished women, its detection in well-nourished women indicates that environmental conditions may influence intestinal health beyond nutritional status alone. These findings indicate that attention to environmental risks is important for wider groups of women and support further work to understand the pathways that lead to EED in different community settings.