Protein Energy Malnutrition (Look @ handout)

Question 1

If negative energy balance…

Answer 1

obligatory negative Nitrogen balance

Question 2

Masamus

Answer 2

Severe wasting, due to energy deficiency

Slower onset, better adaptation

Question 3

Kwashiorkor

Answer 3

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

Question 4

Starvation

Answer 4

pure caloric deficiency

Organism adapts to conserve lean body mass & increase fat metabolism

Question 5

cachexia

Answer 5

associated w/ inflammatory or neoplastic conditions

Not reversed by feeding; anorexia

Question 6

Sarcopenia

Answer 6

subnormal amount of skeletal muscle, w/o weight loss

Question 7

Causes of PEM

Answer 7

Social & economic factors
Poverty
Inadequate breastfeeding
Ignorance
Inappropriate weaning/CF
Monotonous/restricted diets, plant-based	

Biologic factors: maternal under-nutrition, low birth weight infants – persistence of effects (epigenetic?)

Environmental factors: overcrowding, infectious burden, agricultural patterns, etc

Question 8

Who is at risk for PEM?

Answer 8

Infants (0-12 mo): marasmus/severe wasting most common
Older infants (12 - 24 mo): esp kwashiorkor; voluntary restrictive/alternative feeding
Acute weight loss: e.g. anorexia nervosa, s/p bariatric surgery, intentional restriction, social deprivation
Chronic illnesses: alcoholism, pancreatitis, HIV/AIDS, malabsorption
Elderly: wasting/loss of LBM (sarcopenia)

Question 9

underweight definition

Answer 9

-low weight for age
->2 SD below median (50th percentile)
-

Question 10

Stunting

Answer 10

“chronic malnutrition”
-Length for age (% of median)

Normal 95 - 105 %
Mild 90 - 94 %
Moderate 85 - 89 %
Severe:

Question 11

Wasting

Answer 11

decreased weight relative to length (approx equal to BMI)

“ideal body weight”
50th % wt/ht

%IBM
90-110 Normal weight
80-89 Mild wasting
75-79 Moderate

Question 12

Fuel utilization during starvation

Answer 12

blood sugar drops some and levels
mobilization of fat stores
ketone bodies rise

Blood sugar remains in normal range: gluconeogenic aa + glycerol

Question 13

Marasmus

Answer 13

“normal” response to starvation

Muscle: increase utiliz of triglycerides/fa
brain: inc utiliz of ketones
liver: decreased gluconeogenesis
muscle: decreased protein deg (increased recycing aa, but contiues esp skel muscle)
liver/kidney: decreased urea production and excretion

result:Utilization of fat stores, minimize muscle wastingleading to decreased Basal Metabolic Rate

Question 14

Other “normal” responses to starvation

Answer 14

Dec Physical activity/ ↑ resting
Decreased Basal Metabolic Rate:
Hypothermia, hypotension, bradycardia

Endocrine changes:
dec insulin, dec thyroid, ↑ epinephrine & corticosteroid
GI tract: mucosal atrophy, decreased secretions, decreased motility
Myocardial atrophy, decreased cardiac output;

Loss of functional reserve & physiologic responsiveness to stress

Question 15

Kwashiorkor: “abnormal” adaptive response

Answer 15

Classic etiologic description:
protein deficiency (qualitative &/or quantitative) w/ adequate energy
Current description: + Infectious stress, cytokine release, + micro-nutrient deficiency, oxidative damage, (“dysbiosis”?)
** Hypoalbuminemia & edema **
increased insulin, decreased lipolysis (esp. w/ continued CHO )
increased hepatic fatty acid syn (inc CHO & dec lipolysis, dec protein) –> fatty, enlarged liver

Question 16

Signs of kwashiorkor

Answer 16

misery, edema, hepatomegaly

• erythematous, hyperpigmentation, “flaky paint”
• dry, brittle, depigmented “flag sign”

Rash looks like pelagra (“pelagroid”)

“moon facies” (swollen cheeks)

Question 17

sx more in marasmus

Answer 17

Weight loss, loss of muscle, loss of fat, diarrhea

Question 18

sx more in kwashiorkor

Answer 18

edema, psychologic changes, anorexia, hepatomegaly, infections, diarrhea, skin lesions, hair changes, moon facies

Question 19

Principles of tx for Severe PEM

Answer 19

GO SLOWLY!!
Resolve life-threatening conditions (e.g. infections)
Restore nutritional status w/o abruptly disrupting homeostasis / “adapted state”
Ensure nutritional rehabilitation (Macronutrients & micronutrients)

Question 20

Refeeding syndrome

Answer 20

Broad range of metabolic consequences occurring due to rapid reinstitution of nutrients (& energy/substrate) in pt w/ PEM; can result in sudden death
Catabolic state –> anabolic state:
Fluid shifts –> heart failure
Requires E, nutrients, enzymes
Common derangements: K+, P+, Mg,++ Thiamine (look at slide for specifics)

Question 21

Management of refeeding syndrome

Answer 21

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)