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Flashcards in Protein Energy Malnutrition Deck (16):

What is protein energy malnutrition?

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


Broad categories of PEM

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


Global magnitude...

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


Causes of PEM

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


What is the most common PEM for infants?



What is the most common PEM for older infants?

Kwashiorkor (12-24 mos)


What is the most common PEM for elderly?

Cachexia and sarcopenia


Underweight, Stunting, Wasting

Underweight: low weight-for-age (


Mild underweight/wasting is commonly referred to as _____

failure to thrive


Response to starvation

Switch from glucose to ketone bodies and fatty acids


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

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


Normal physiologic responses to starvation

- 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


Etiology of kwashiorkor

- 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


What does kwashiorkor look like?

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


Principles of Tx for severe PEM

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

Kwashiorkor has higher mortality


Reefeeding Syndrome

- 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