30 - Clinical Manifestation of Malnutrition Flashcards Preview

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1

Malnutrition

Condition resulting from a diet in which certain nutrients are lacking, in excess or in the wrong proportions

2

Hunger, and its associated malnutrition

Greatest single threat to the world's public health

3

Protein-Energy Malnutrition (PEM)

Body's needs for:

Protein
Energy fuels
or
Both

cannot be satisfied by diet

4

Protein-Energy Malnutrition (PEM) Syndromes

Kwashiorkor (edematous) - Predominant Protein Deficiency

Marasmus - Predominant Energy Deficiency

Marasmic Kwashiorkor (edematous) - Chronic Energy Deficiency PLUS acute or chronic Protein Defiiciency

5

Edematous PEM

Kwashiorkor
Marasmic Kwashiorkor

6

Secondary PEM - Causes

Diseases causing poor intake - Anorexia of disease

Inadequate nutrient absorption or utilization with increased losses - IBD, Celiac, CF

Increased nutritional requirements - CF, Lung, Heart, Kidney

Increasd nutrient losses - CF, Celiac

7

Where do most malnourished patitents live?

Developing countries
30% in Africa and Far East
15% in Latin America and Near East
33% o chidlren

8

PEM - Social & Economic Factors

Poverty - Low food availability, overcrowding, unsanitary conditions
Ignorance
Decline in practice and duration of breast feeding
Inadequate weaning practices
Abuse
Deprivation
Abandonment
Dependence
Taboo
Fads
Migration

9

PEM - Biologic Factors

Maternal Malnutrition

Infectious Diseases:
Measles
Diarrhea
Respiratory

Diets

10

PEM - Environmental Factors

Overcrowding
Unsanitary living conditions

Agricultural patterns:
Droughts
Floods
Wars
Forced migration

11

PEM - Age

Increased frequency in infants and young children

Older kids experience milder forms

Pregnant and lactating women have increased nutritional requirements that can lead to PEM

Elderly and unable to care for themselves also experience PEM

Adolescents, adult men, non-pregnant, non-lactating women have a low prevalence of PEM

12

Marasmus - Age

Most common form of PEM in children

13

Kwashiorkor - Age

More frequent in children >18 mo

14

PEM - Pathophysiology

Develops gradually over weeks to months

Series of metabolic and behavioral adjustments:
Decreased nutrient demands and nutritional equilibrium compatible with lower level of nutrient availability

The slower PEM develops, the better adaptation to current nutritional status - Maintain a less fragile metabolic equilibrium.

15

PEM - Adaptive mechanisms

Energy mobilization and expenditure
Protein breakdown and synthesis
Endocrine changes
Hematologic changes
Cardiovascular and renal function changes
Immune changes
Monokines
Electrolytes
GI function
CNS & PNS

16

PEM - Energy mobilization and expenditure

Decreased energy intake
Decreased energy expenditure (body fat mobilized)
Decreased adiposity with weight loss as subQ fat is reduced
Protein catabolism with muscle wasting

17

PEM - Energy mobilization and expenditure - Marasmic Patients

Visceral protein usually preserved
Increased basal O2 consuption
Increased basal metabolic rate

More severe:
Decreased basal metabolic rate
Blood glucose usually normalized by glycerol from fats & gluconeogenesis of AA

18

PEM - Energy mobilization and expenditure - Kwashiorkor Patients

Early visceral depletion of amino acids
Decreased basal O2 consumption
Decreased basal energy expenditure/unit body mass

19

PEM - Protein Breakdown & Synthesis

Poor availability of dietary proteins
Decreased protein synthesis

Initial adaptations:
Sparing body protein and essential protein dependent functions

20

PEM - Protein Breakdown & Synthesis - Long term deficits

Loss of skeletal muscle
Increased loss of visceral protein
Death

21

PEM - Amino Acid Recycling

90 - 95% of dietary AAs are recycled (normal metabolism is 75%)
Proportional decrease in AA catabolism (normally 25%)
Decrease in urea synthesis
Decrease in urinary nitrogen excretion.

22

PEM - Albumin

Decreased rate of synthesis and breakdown

Shift of albumin from extravascular to intravascular to maintain oncotic pressure

Severe depletion:
Adaptive mechanisms fail
Decreased serum protein
Decreased intravascular oncotic pressure
Outflow of water into extravascular space
Edema of Kwashiorkor

23

PEM - Cardiovascular & Renal Function

Decreased Cardiac Output
Decreased Heart Rate
Decreased Blood Pressure

Central circulation takes precedence over peripheral circulation

Altered cardiovascular reflexes
Postural hypotension
Decreased venous return

Severe:
Peripheral circulatory failure
Hemodynamic compensation
Tachycardia
Decreased renal plasma flow & GFR (secondary to decreased cardiac output)

Normal water clearance with normal concentration and acidification of urine

24

PEM - Immune System

Depletion of T-Lymphocytes from Thymus
Atrophy of Thymus gland

Decrease in complement production
Increased susceptibility to Gram (-) sepsis

Decreased functional activity of the complement system
Increased susceptibility to Gram (-) sepsis

Decreased opsonic activity of serum
Increased susceptibility to Gram (-) sepsis

Decreased phagocytosis
Decreased chemotaxis
Decreased intracellular killing

Possible defects in secretory IgA
Increased predisposition to infections and severe complications from otherwise less-important infectious diseases.

25

PEM - Monokines

Peptide/glycoprotein mediators of the body's response to injury.

Decreased IL-1 - Poor febrile response and decreased leukocyte counts in infection

Increased TNF - Anorexia, muscle wasting, lipid abnormalities

26

PEM - Electrolytes

Decrease of total body potassium

Altered cellular exchange Na+ and K+ loss
Potassium loss
Increased intracellular Na+
Intracellular overhydration

27

PEM - GI Function

Impaired absorption of:
Lipids
Disaccharides
Glucose

Decreased gastric, pancreatic & bile production

Normal - low enzyme and conjugated bile
Further impairment of absorption
Diarrhea

Irregular intestinal motility
Diarrhea

Bacterial overgrowth
Diarrhea

28

PEM - CNS & PNS

Severe PEM at early age:

Decreased brain growth
Decreased nerve myelination
Decreased neurotransmitter production
Decreased velocity of nerve conduction

29

PEM - Hormones

Gonadotropins - Decreased

Hypothalamic - Pituitary Axis & Medulla Oblongata are preserved, so patients can still respond to stress. Epi and corticosteroids can still go up in response to stress.

30

PEM - Classifications (Severity)

Normal (90 - 110% weight for height)
Mild (80 - 89% weight for height)
Moderate (70 - 79% weight for height)
Severe (