PBL 1 - Marasmus + Kwashiorkor

Question 1

What are the three main fuels for the body in prolonged starvation. What
are their sources? [3

Answer 1

1) Amino acids - body protein/muscle
2) Triglycericdes - Adipose tissue
3) Ketone bodies - Liver

Question 2

List the four main physiological causes that can lead to oedema
formation?

Answer 2

Increased capillary hydrostatic pressure
Decreased oncotic pressure
Lymphatic blockage
Inflammation leading to increased capillary permeability.

Question 3

Where is the main potassium store in the body? What effect does
refeeding have on serum potassium and why? [2]

Answer 3

Intracellular storage. [1]
Serum potassium will drop during refeeding. As metabolism kicks in it creates an
intracellular shift of electrolytes. [1/2] in particular, rising blood sugar leads to
increased insulin, which stimulates the absorption of potassium into the cells [1/2]

Question 4

Which of the diets is most like the metabolic starvation states seen in the
first part of the scenario. Explain your choice and the main difference [3]

Answer 4

ATKINS [1]: The very low carbohydrate diet makes the body metabolise as if it is
starving with high (but not too high!) levels of ketones in the blood. [1]Thus in
Atkins the main fuels are fat and ketones as in the starved children.
Unlike the children suffering from malnutrition, muscle wasting is prevented by a
small amount of carbohydrate and high levels of dietary protein

Question 5

Normal range of blood glucose

Answer 5

3-5mmol/l

Question 6

What does insulin stimulate

Answer 6

glycolysis, glycogenesis, uptake via GLUT 4 into cells/adipocytes

Question 7

Function of glucagon

Answer 7

after absorption of meal stimulates glycogenolysis, gluconeogenesis from other sources
 Catabolism of protein  a.a  alanine/glutamine
 3 Carbon compounds, glycerol/lactate/pyruvate recycled in liver. E.g. cori cycle
 Lipolysis via hormone sensitive enzyme  glycerol and f.a.

Question 8

What happens to body in starvation state

Answer 8

24hour glycogen store
Then fat metabolism
Then ketone body utilisation

Question 9

Which parts of the body cannot survive without glucose

Answer 9

Brain
Renal medulla
RBC
Nervous system

Question 10

Why does body switch over to lipid metabolism

Answer 10

to conserve glucose and protein for parts of the body that cant live without

Question 11

Why should you eat carbs in a diet

Answer 11

To prevent excess muscle wastage

to produce glucose for cells which only use glucose

Question 12

What age do you have kwashiorkor usually

Answer 12

6mths - 2 years

Follows weaning

Question 13

What is kwashiorkor

Answer 13

Protein deficiency but adequate calories –> Oedema due to lack of intake of protein
water flow out of bloodstream into the tissues causing oedema

Question 14

When do you get marasmus

Answer 14

Babies mainly

Question 15

Why marasmus

Answer 15

Muscle wastage due to inadequate proteins and calories

Body uses muscle as fuel by breaking it down

Question 16

Why no ascites in marasmus

Answer 16

As muscle is broken down it provides the AA for albumin

Question 17

Why does the pt have hypoalbuminaemia

Answer 17

pitting oedema + ascites, not enough protein in diet to synthesis more –> reduced oncotic pressure + unopposed HS pressure leading to leaking out of the capillaries.

Question 18

Why does the pt have skin problems

Answer 18

collagen type I (a protein) + zinc problems, lack of protein in diet means lack of collagen needed for healthy skin

Question 19

What causes the foul smelling breath

Answer 19

acetoacetate/B-hydroxybutarate –> acetone –> foul smelling breath
Ketoacidosis

Question 20

Why anaemia in pt

Answer 20

lack of food, iron deficiency, B12/folate deficiency from lack of veg and meat

Question 21

Symptoms of re-feeding syndrome

Answer 21

fluid retention, dysrhythmia, heart failure
Convulsions, wernike’s encephalopathy
delerium, renal failure,arrhythmia

Question 22

Deficiency in re-feeding syndrome

Answer 22

Hypokalaemia
Hypomagnesaemia
Hypophosphataemia 
Thiamine deficiency 
Sodium and water retention

Question 23

What occurs in refeeding syndrome

Answer 23

• During starvation, body changes –> glycogenolysis, gluconeogenesis + catabolism of protein, insulin also suppressed
• When food is reintroduced –> insulin secreted –>uptake of potassium/magnesium, thiamine and phosphates –> stimulate protein synthesis and glycogen/fat synthesis (requires all those minerals/vitamins) –>low levels in blood.
  o When muscles break down, minerals lost in urine is not replaced
• These were already low in serum due to starvation and reduced intake in diet.

Question 24

How to manage undernutrition

Answer 24

Administer anti-microbials to remove infection
Correction of fluid and electrolyte abnormalities
Vitamin A and supplements of k+
Feed slowly and frequently

Question 25

How does the weight watchers diet work

Answer 25

o Smart points allocated to foods based on calories, saturated fats, sugar and protein, each weak a maximum number of points tailored towards you. Help groups online or IRL. Low calorie diet.
o Switch from glucose –> fat, no ketones generated as fats can be directly metabolised by muscle tissues –> gradual weight loss

Question 26

What is a low glycaemic index diet and how does it work

Answer 26

o Having foods which gradually and over time increase BSL after consumption e.g. fructose, beans, lentils, veg and fruits compared to white bread, cakes and biscuits (high Gi)
o Used in T2D patients to prevent sugar highs
o Slow releasing glucose –> less hungry, less snacking, less insulin secretion –> less fat storage

Question 27

What is the Atkins Diet and how does it work

Answer 27

o Ketone diet- no/v low carbs –> only proteins and fats, low insulin levels –> prevent fat storage
o Muscle wasteage prevented by presence of proteins

Question 28

What is glycogenolysis

Answer 28

Mobilisation of glucose from glycogen stores in the liver

Question 29

What is gluconeogenesis

Answer 29

Glucose from body protein, lactate, glycerol + pyruvate

Question 30

Glucogenic amino acids

Answer 30

Alanine

Glutamine

Question 31

What are ketone bodies

Answer 31

Produced from acetyl coAc

can be used to provide energy