Protein Energy Malnutrition

Question 1

What is protein energy malnutrition?

Answer 1

• Not enough calories – energy requirements trump all
• multi-nutritional deficiency complex; energy deficiency most outstanding
• If negative energy balance, obligatory negative N balance

Question 2

Broad categories of PEM

Answer 2

Marasmus - severe wasting due to energy deficiency; slower onset and better adaptation

Kwashiorkor - edematous PEM, generally w/o wasting; protein deficiency, rapid onset, “mal-adaptation”

Starvation - pure caloric deficiency (conserve lean body mass & increase fat metabolism)

Cachexia - associated with inflammatory or neoplastic conditions (not reversed by feeding; anorexia)

Sarcopenia - subnormal amount of skeletal muscle w/o weight loss

Question 3

Global magnitude…

Answer 3

20% underweight
26% stunted
8% wasted
45% deaths related to malnutrition

Question 4

Causes of PEM

Answer 4

• Social and economic factors: poverty, ignorance, restricted diets
• Biologic factors: maternal under-nutrition, low birth weight infants
• Environmental factors: overcrowding, infectious burden, agricultural patterns

Question 5

What is the most common PEM for infants?

Answer 5

Marasmus

Question 6

What is the most common PEM for older infants?

Answer 6

Kwashiorkor (12-24 mos)

Question 7

What is the most common PEM for elderly?

Answer 7

Cachexia and sarcopenia

Question 8

Underweight, Stunting, Wasting

Answer 8

Underweight: low weight-for-age (

Question 9

Mild underweight/wasting is commonly referred to as _____

Answer 9

failure to thrive

Question 10

Response to starvation

Answer 10

Switch from glucose to ketone bodies and fatty acids

Question 11

Since marasmus is normal response to starvation, where do the tissues get their energy?

Answer 11

Muscle = TG/FA; decreased protein degradation
Brain = Ketones
Liver = decreased gluconeogenesis; urea production decreases and excretion of urea decreases

Result: utilization of fat stores, minimize muscle wasting –> Reduced BMR

Question 12

Normal physiologic responses to starvation

Answer 12

• decreased physical activity
• dec BMR (Hypothermia, hypotension, bradycardia)
• Endocrine: dec insulin, dec thyroid, inc. epi and corticosteroid
• GI atrophy
• Myocardial atrophy, dec CO

Loss of functional reserve and physiologic responsiveness to stress

Question 13

Etiology of kwashiorkor

Answer 13

• protein deficiency with adequate energy
• • infectious stress, cytokine release, + micro-nutrient deficiency, oxidative damage

** hypoalubinemia and edema **

• increased insulin, decreased lipolysis
• increased FA synthesis –> fatty, enelarged liver

Question 14

What does kwashiorkor look like?

Answer 14

• hepatomegaly
• edema
• misery
• flaky paint rash (pellagroid)
• flag sign - dry brittle depigmented hair

Question 15

Principles of Tx for severe PEM

Answer 15

GO SLOWLY!!!

• resolve life-threatening conditions
• restore nutritional status w/o abruptly disrupting homeostasis
• ensure nutritional rehabilitation (macro and micro nutrients)

Kwashiorkor has higher mortality

Question 16

Reefeeding Syndrome

Answer 16

• Broad range of metabolic consequences with rapid re institution of nutrients and substrate
• can result in sudden death
• catabolic –> anabolic leads to fluid shifts and heart failure
• Common deragements: K+, P+, Mg++: Thiamine