PROTEIN ENERGY MALNUTRITION

Question 1

Kwashiorkor:

Answer 1

Edematous PEM, generally w/o wasting
Protein deficiency (+ metabolic stress + micronutrient deficiency/imbalance)
Rapid onset, “mal-adaptation”

Protein Energy Malnutrition

Question 2

Marasmus

Answer 2

Severe wasting, due to energy deficiency
Slower onset, better adaptation

Protein Energy Malnutrition

BMI

Question 3

Protein Energy Malnutrition

Answer 3

Of the world’s children…

20% underweight (> 2 S.D.

Question 4

PEM: “Underweight”

Answer 4

Low Weight-for-Age

> 2 SD below median (50th%)

Question 5

PEM: Stunting aka “______”

Answer 5

chronic malnutrition

Gets a “z-score”
Length-for-Age
% of Median
measurement

Question 6

Wasting measured in

Answer 6

“Ideal Body Weight”

50th % Wt/ht

Question 7

Marasmus:“Normal” Response to Starvation

Answer 7

↑ FA and trigly in m
↑ Ketones for brain
↓ Gluconeogen in liver 
↓ Urea 
↓ m. aa degrading (aa start to recycle)

Question 8

“Normal” Responses to Starvation

Answer 8

Result: Utilization of fat stores, minimize muscle wasting–> ↓ Basal Metabolic Rate

Question 9

Kwashiorkor:“Abnormal” Adaptive Response

Answer 9

Hypoalbuminemia + edema
protein deficiency
↑ insulin, ↑ FA synth, ↓ lipolysis

Question 10

Signs of Kwashiorkor

Answer 10

• Misery, edema, hepatomegaly**
• Erythematous, hyperpigmentation, “Flaky Paint”
• Dry, brittle, depigmented “Flag Sign”

Question 11

Principles of Management Severe PEM: (esp Kwashiorkor – higher mortality)

Answer 11

GO SLOWLY!!

Resolve life-threatening conditions first

Restore nutritional status w/o abruptly disrupting homeostasis / “adapted state”

Ensure nutritional rehabilitation (Macronutrients + micronutrients)

Question 12

Broad range of metabolic consequences occurring due to rapid reinstitution of nutrients ( energy/substrate) in pt w/ PEM; can result in sudden death

Answer 12

Refeeding Syndrome

Catabolic state –> anabolic state:
-Fluid shifts –> heart failure

Common derangements: K+, P+, Mg,++ Thiamine

Question 13

Refeeding Syndrome: Management

Answer 13

Refeed slowly (start w/ 50-75% of basal needs)

Avoid fluid overload (enteral vs IV)

Monitor levels – supplement as necessary (K, P, Mg); provide micronutrients

Monitor vital signs

Monitor physical exam (e.g. edema, rash)

Resolution of edema before full feeding (wt loss first w/ edematous PEM)

Question 14

Refeeding Syndrome- Potassium

Answer 14

↑ insulin secretion (in response to feeding) –> intracellular glucose and K+–>

↓ serum K+ ==> altered nerve/muscle function

Question 15

Refeeding Syndrome

Phosphorus

Answer 15

↑ insulin secretion

↑ intracellular phosphorylated intermediates (including glucose); P “trapped” intracelluar

↓ serum P ==> altered nerve/muscle function

Question 16

Refeeding Syndrome

Magnesium

Answer 16

↑ requirement w/ ↑ metabolic rate; (= co-factor for ATPase)

Question 17

Refeeding Syndrome

Thiamine

Answer 17

rapid depletion (co-factor glycolysis) w/ CHO ==> cardiomyopathy +/- encephalopathy