Protein Energy Malnutrition

Question 1

spectrum of manifestations depends on what 5 factors?

Answer 1

severity
duration
age
cause
association w/ other problems

Question 2

maramus

Answer 2

simple wasting of fat and muscle mass due to energy deficiency

Question 3

kwashiorkor

Answer 3

• edematous without wasting and is attributed to protein deficiency
• related to metabolic stress and inflammation

Question 4

marasmic kwashiorkor

Answer 4

combination of chronic energy deficiency with chronic or acute protein deficit manifested as wasting and edema

Question 5

global burden malnutrition

Answer 5

• poor nutrition causes half of deaths of children under the age of 5
• 1/5 global disease burden attributed to effects of protein energy malnutrition and micronutrient deficiency

Question 6

FTT

Answer 6

mild protein energy malnutrition

Question 7

malnutrition occurs in what percentage of hospitalized patients

Answer 7

50%

-is associated with higher rates of morbidity and mortality and longer hospital stays

Question 8

anorexia nervosa

Answer 8

• represent a successful adaptation to starvation
• less than critical total lean tissue depletion, weight stability, normal plasma albumin, normal peripheral blood total lymphocyte count, intact immune response
• susceptible to abrupt decompensation with minor insult

Question 9

5 at risk groups for protein energy malnutrition

Answer 9

1. 0-12mths: marasmus/severe wasting
2. 12-24mths: kwashiorkor/ edematous PEM
3. Older children: stunting common; milder wasting
4. pregnant/lactating women: PEM
5. Elderly: PEM

Question 10

wasting deficit is represented by what ratio

Answer 10

weight for height

Question 11

stunting deficit is represented by what ratio

Answer 11

height for age

Question 12

alternative use of z scores

Answer 12

Stunting:

Question 13

clinical features

marasmus > kwashiorkor

Answer 13

weight loss
loss of muscle
loss of fat

Question 14

clinical features that are absent in marasmus

Answer 14

edema
hepatomegaly
skin lesions

Question 15

+/- in marasmus but present in kwashiorkor

Answer 15

anorexia

hair changes

Question 16

clinical features

kwashiorkor > marasmus

Answer 16

psychological impairment
infections

+/- in kwashiorkor:
anorexia
hair changes

absent in marasmus:
edema
hepatomegaly
skin lesions

Question 17

clinical feature

marasmus = kwashiorkor

Answer 17

diarrhea

Question 18

6 physiologic responses to severe acute malnutrition: marasmus

Answer 18

1. decreased energy expenditure (decreased activity, bradycardia, hypothermia)
2. decreased Na pump activity
3. fuel utilization to mobilization body fat (increased ketones, decreased gluconeogenesis)
4. muscle protein catabolism (decreased overall protein turnover)
5. decreased inflammatory response/ immune fxn
6. impaired GI fxn (dismotility, malnutrition)

Question 19

hallmarks of adaptation to severe PEM

Answer 19

1. loss of functional reserve

2. loss of physiological responsiveness

Question 20

pathophysiology of kwashiorkor

Answer 20

failure of normal adaptive response of protein sparing normally seen in fasting state

Question 21

contributing factors to kwashiorkor

Answer 21

infectious stress, cytokine release, relative micronutrient deficiencies, free radical exposure, oxidative damage

-possible role of microbiome

Question 22

why would some assume that nutritional status is adequate in kwashiorkor?

Answer 22

fat reserves and muscle mass unaltered

Question 23

Signs of kwashiorkor

Answer 23

• Flaky paint: skin lesions
• Flag sign: hair texture/ color change
• moon facies: generalized edema

Question 24

5 metabolic derangements associated with kwashiorkor

Answer 24

1. hypoalbuminemia & enlarged fatty liver –> edema
2. Increased permeability of biological cell membranes –> edema
3. impaired Na/K homeostasis (Na excess, K deficiency)
4. hypotransferrinemia (anemia)
5. Impaired immune system (infection)

Question 25

things to avoid when resolving life threatening conditions in PEM

Answer 25

over-hydration
excessive Na
hypoglycemia

Question 26

resolving life threatening conditions in PEM

Answer 26

1. restore circulation with enteral
2. K+ supplements (+/-) Mg
3. treat infections
4. small, frequent oral feeds

Question 27

restore nutritional status

Answer 27

Goal= Maintain

-small, frequent

Question 28

Nutritional rehabilitation

Answer 28

• advance energy intake to 1.5X normal and 3-4X protein needs
• prolonged restoration of appetite
• familiar foods
• physical activity: recover cardiorespiratory and skeletal function

Question 29

when to start nutritional rehabilitation

Answer 29

1-2 weeks after initial stabilization

after resolution of edema

Question 30

3 derangements seen in re-feeding syndrome that can lead to sudden death

Answer 30

Potassium: intracellular
Phosphorus: intracellular
Magnesium

Question 31

Potassium in re-feeding syndrome

Answer 31

increased insulin secretion 
-->
intracellular glucose and K+
--> 
decreased serum K+
-->
altered nerve/ muscle fxn

Question 32

phosphorus in re-feeding syndrome

Answer 32

increased insulin secretion
-->
intracellular P
-->
Increased intracellular phosphorylated intermediates
-->
P trapped in intracellular space

Question 33

magnesium in re-feeding syndrome

Answer 33

increased metabolic rate
–> increased requirement

= cofactor for ATPase