PROTEIN ENERGY MALNUTRITION

INTRODUCTION:

Nutrition is essential for human survival and Nutrients are substances that are essential for growth, human life, well being and the totality of a person. Nutrients are necessary for our physical state, sharpen the mind and brain, makes us think wisely and intelligent. Basically it makes us full of life and vigour.

When the body is deficient of certain nutrients or has more than is required by the body, malnutrition comes in, making the individual weak, sick ling, mentally retarded, discolouration in certain parts of the body. Victims of malnutrition are mainly children. Nutrient can be divided into macronutrients and micronutrients. Macronutrients are Carbohydrate, Protein, Lipids and Water. These macronutrients provide the body with energy, help in cell replication and growth. Micronutrients are trace elements and vitamins that are essential for metabolic process.

Nutrients play vital roles in the body, hence a healthy child is more intelligent and attractive that a child that is malnourished. Two main ends of malnutrition are under-nutrition and obesity. A diet can be termed ‘Healthy’ if it provides balanced nutrients that satisfy the metabolic needs of the body without excess or shortage. Dietary requirements of a child vary according to age, sex, and development. Protein consist of carbons, hydrogen, oxygen, and nitrogen. Amino acids are the basic building blocks of protein. Amino acids can be divided into either essential amino acids or non-essential amino acids. Protein and carbohydrate contain 4 Calories per gram as opposed to lipids which contain 9 Calories per gram. The liver, and to a much lesser extent the kidneys, can convert amino acids used by cells in protein biosynthesis into glucose by a process known as gluconeogenesis.

The essential amino acids, which must be obtained from food sources, leucine, isoleucine, valine, lysine, threonine,tryptophan, methionine, phenylalaline and histidine. On the other hand, non-essential amino acids can be made by the body from other amino acids. The non-essential amino acids are argine, asparagines, aspartic acid, cysteine, glutamine, glutamic acid, glycine, proline, serine, tyrosine.

In nutrition, proteins are broken down in the stomach during digestion by enzymes known as proteases into smaller polypeptides to provide amino acids

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for the body, including the essential amino acids that the organism cannot be biosynthesized by the body itself. Thus, protein from one's diet should provide both essential and non-essential amino acids for protein synthesis.

Most animal sources and certain vegetable sources have the complete complement of all the essential amino acids in adequate proportions. However, it is not necessary to consume a single food source that contains all the essential amino acids, as long as all the essential amino acids are eventually present in the diet.

Fig 1 : Diagrammatic representation of the basic structure of Amino acids which are the building blocks of protein.

Protein Functions in Body

Protein is a nutrient needed by the human body for growth and maintenance. Aside from water, protein is the most abundant molecule in the body. Protein is found in all cells of the body and is the major structural component of all cells in the body, especially muscle. This also includes body organs, hair and skin. Proteins also are utilized in membranes, such as glycoprotein. When broken down into amino acids, they are used as precursors to nucleic acid and vitamins. Hormones and enzymes are also formed from amino acids in which they help regulate metabolism, support the immune system and other body functions.

Finally, protein is needed to form blood cells.

Protein Function in Exercise

Proteins is one of the key nutrients for success in terms of sports. They play a major role in the response to exercise. Amino acids, the building blocks of proteins, are used for building new tissue including muscle, as well as repairing damaged tissues. Proteins, however, only provide a small source of fuel for the exercising muscles when carbohydrates and lipid resources are low.

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Sources

Fig 2 Picture Representation of Protein milkshakes, made from protein powder (center) and milk (left), are a common bodybuilding supplement.

There are many different sources of protein ranging from whole protein foods (such as milk, meat, fish, egg, and vegetables) to a variety of protein powders (such as casein, whey, soy). Protein powders are processed and manufactured sources of protein. Protein powders may provide an additional source of protein for exercising muscles. The type of protein is important in terms of its influence on protein metabolic response and possibly on the muscle's exercise performance. The different physical and/or chemical properties within the various types of protein may affect the rate of protein digestion. As a result, the amino acid availability and the accumulation of tissue protein is altered because of the various of protein metabolic responses.

DigestionDigestion typically begins in the stomach when pepsinogen is converted to pepsin by the action of hydrochloric acid, and continued by trypsin and chymotrypsin in the intestine. The amino acids and their derivatives into which dietary protein is degraded are then absorbed by the gastrointestinal tract. The absorption rates of individual amino acids are highly dependent on the protein source; for example, the digestibilities of many amino acids in humans differ between soy and milk proteins and between individual milk proteins, beta-lactoglobulin and casein. For milk proteins, about 50% of the ingested protein is absorbed between the stomach and the jejunum and 90% is absorbed by the time the digested food reaches the ileum. Biological value (BV) is a measure of the proportion of absorbed protein from a food which becomes incorporated into the proteins of the organism's body.

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ASSESSMENT OF NUTRITIONAL STATUS

Nutritional status is the balance between the intake of nutrients by an organism and the expenditure of these in the processes of growth, reproduction, and health maintenance. Because this process is highly complex and quite individualized, nutritional status assessment can be directed at a wide variety of aspects of nutriture. These range from nutrient levels in the body, to the products of their metabolism, and to the functional processes they regulate. Nutritional status can be measured for individuals as well as for populations. Accurate measurement of individual nutritional status is required in clinical practice. Population measures are more important in research. They can be used to describe nutritional status of the group, to identify populations or population segments at risk for nutrition-related health consequences, and to evaluate interventions.

The choice of nutritional status assessment method must be made mindful of the level at which one wants information, as well as of the validity and reliability of the method. All methods have error. All methods produce imperfect measures that are indirect approximations of the process. Whatever method is chosen for assessment of nutritional status, the data obtained must be compared with reference data to produce an indicator of nutritional status. The quality of the available reference data is, therefore, another factor that affects the assessment data.

Ideal methods are sensitive and specific. Unfortunately, it is difficult to achieve both in the assessment of nutritional status. Sensitivity refers to the ability of a technique to correctly identify those affected by a condition (for example, under nutrition) as having that condition. Specificity refers to the ability of a technique to correctly classify normal individuals as having normal nutritional status. Body mass indexis a global measure of nutritional status that illustrates the difference between these two constructs.

The assessment of nutritional status is commonly summarized by the mnemonic "ABCD," which stands for anthropometric measurement, biochemical or laboratory tests, clinical indicators, and dietary assessment. This review will focus on anthropometric and dietary techniques. These four can be categorised under DIRECT assessment of nutritional status. INDIRECT includes health statistics and ecological values.

ANTHROPOMETRIC:

It is objective with high specificity and sensitivity. Anthropometric approaches are, for the most part, relatively non-invasive methods that assess

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the size or body composition of an individual. Measuring Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI. For adults, body weight and height are used to evaluate overall nutritional status and to classify individuals as at healthy or non-healthy weights. In the United States of America and other industrialized countries, the emphasis for unhealthy weight is over-weight and obesity. The standards for these have changed over time. The most recent classification is to use body mass index (BMI, in kg/m2) (Kuczmarski and Flegal, 2000). BMI, regardless of age or population, is normal at 18.5 to 25.0 kg/m2, overweight at 25.0 to 29.9 kg/m2, and obese at over 30.0 kg/m2 (USDA & USDHHS, 2000). In general BMI greater than 30 is assumed to be due to excessive adiposity.

Reading are numerical and gradable on standard growth chart, this is the approach common to children. For children, low height-for-age is considered stunting, while low weight-for-height indicates wasting. In addition to weight and height, measures of mid-arm circumference and skin-fold measured over the triceps muscle at the mid-arm are used to estimate fat and muscle mass. Anthropometric measures of nutritional status can be compromised by other health conditions. For example, edema characteristic of some forms of malnutrition and other disease states can conceal wasting by increasing body weight. Head circumference can be used in children 36 months and younger to monitor brain growth in the presence of malnutrition. Brain growth is better spared than either height or weight during malnutrition. To interpret anthropometric data, they must be compared with reference data. The choice of the appropriate reference has been discussed by Johnston and Ouyang. Because well-nourished children in all populations follow similar patterns of growth, reference data need not come from the same population as the children of interest. It is of greater importance that reference data be based on well-defined, large samples, collected in populations that are healthy and adequately nourished. Reference growth charts (Kuczmarski et al., 2002) have been compiled from cross-sectional data collected from population surveys of U.S. children. These have been adopted as international standards by the World Health Organization.

Anthropometric is non expensive and requires minim al training. It’s limitations are: Inter observers error in measurement

Limited Nutritional diagnosis

Problems with reference standards

Arbitrary statistical cut off levels for abnormality

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BIOCHEMICAL OR LABORATORY ASSESSMENT:

Laboratory assessment can be categorised as biochemical, haematological and microbiology.

Biochemical: serum protein, creatinine/hydroxyproline

Haematological: CBC, iron, vitamin levels

Microbiology: Parasites/infection

CLINICAL ASSESSMENT:

It is useful in severe forms of protein energy malnutrition, based on thorough physical examination for features of Protein Energy Malnutrition and vitamin deficiency. It focuses on skin, eye, hair, mouth and bones. Chronic illness and goiter are excluded.

Advantages: Fast and easy to perform

Inexpensive

Non-invasive

Limitations: Did not detect early cases

Trained staff needed

DIETARY ASSESSMENT:

Several techniques exist for collecting dietary data with which to estimate nutritional status. Because these techniques vary in cost for data collection, burden on the respondent, and which aspects of diet they are designed to measure, it is important to clearly articulate the goals of dietary assessment of nutritional status before choosing an assessment strategy.

The primary consideration in choosing a dietary assessment method is the specific type of data needed. Is the research intended to document intake of "foods" or of "nutrients"? If the answer is foods, the method must take account

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of the population's foodways. These include variability in food intake patterns (for example, day-today, seasonal, ritual cycles); differences in food consumption by sex, age, and ethnicity; and what items the population considers to be legitimate "food." If the objective is to measure nutrient intake, the method must take into account several additional factors: food preparation techniques, including the addition of condiments and the effects of the technique on nutrient composition of the food; sources of error in the determination of amounts of foods consumed; differentiation distribution of nutrients among foods; and the contribution of "non-food" consumption to total nutrient consumption.

Another important consideration is the time period the data are intended to represent. If the period is a relatively discrete one, it may be possible to document diet quite precisely. However, if the interest is in measuring "usual" diet, the methods must allow this abstract concept to be estimated statistically.

Population measures of dietary status can be derived either from data describing the entire population or population sub-group, or from data describing samples of individuals. Population-wide data include food availability figures, which allow the assessment of food balance—the amount of food produced or imported by a population less that exported or used as nonhuman food.

Dietary assessment include: breast and complementary feeding details, 24hr dietary recall, home visits, calculation of protein and dietary calorie content of children foods, feeding technique and food habits.

OVERVIEW

Protein energy malnutrition is prominent in developing countries, and many children are affected. A large percentage of the world’s population is found in developing countries. Children commonly affected are victims of dirty water, bad food, poor sanitation, dirty and unkempt environment. Malnutrition is implicated in >50% of deaths of <5 children (5 million/yr)

Protein-energy malnutrition (or protein-calorie malnutrition) refers to a form of malnutrition where there is inadequate protein intake.

Types include:

Kwashiorkor (protein malnutrition predominant) Marasmus (deficiency in both calorie and protein nutrition) Marasmic Kwashiorkor (marked protein deficiency and marked calorie

insufficiency signs present, sometimes referred to as the most severe form of malnutrition)

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this may also be secondary to other conditions such as chronic renal disease or cancer cachexia in which protein energy wasting may occur.

Fig 3 : Pie chart Showing the Various Diseases that could occur due low Protein intake

Protein-energy malnutrition affects children the most because they have less protein intake. The few rare cases found in the developed world are almost entirely found in small children as a result of fad diets, or ignorance of the nutritional needs of children, particularly in cases of milk allergy.

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EPIDEMOLOGY:

Description

English: Age-standardised disability-adjusted life year (DALY) rates from Protein-energy malnutrition by country (per 100,000 inhabitants).

no data

less than 10

10-100

100-200

200-300

300-400

400-500

500-600

600-700

700-800

800-1000

1000-1350

more than 1350

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The World Health Organization (WHO) defines malnutrition as "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions." The term protein-energy malnutrition (PEM) applies to a group of related disorders that include marasmus, kwashiorkor, and intermediate states of marasmus-kwashiorkor. The term marasmus is derived from the Greek word marasmos, which means withering or wasting. Marasmus involves inadequate intake of protein and calories and is characterized by emaciation. The term kwashiorkor is taken from the Ga language of Ghana and means "the sickness of the weaning." Breast milk contains proteins and amino acids vital to a child's growth. In at-risk populations, kwashiorkor may develop after a mother weans her child from breast milk, replacing it with a diet high in carbohydrates, especially starches, but deficient in protein. Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake. Edema is characteristic of kwashiorkor but is absent in marasmus. Studies suggest that marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation. Children may present with a mixed picture of marasmus and kwashiorkor, and children may present with milder forms of malnutrition. For this reason, Jelliffe suggested the term protein-calorie (energy) malnutrition to include both entities.

Although protein-energy malnutrition affects virtually every organ system, this article primarily focuses on its cutaneous manifestations. Patients with protein-energy malnutrition may also have deficiencies of vitamins, essential fatty acids, and trace elements, all of which may contribute to their dermatosis.ll children with PEM have micronurtrient deficiency

Pathophysiology

In general, marasmus is an insufficient energy intake to match the body's requirements. As a result, the body draws on its own stores, resulting in emaciation. In kwashiorkor, adequate carbohydrate consumption and decreased protein intake lead to decreased synthesis of visceral proteins. The resulting hypoalbuminemia contributes to extravascular fluid accumulation. Impaired synthesis of B-lipoprotein produces a fatty liver.

Protein-energy malnutrition also involves an inadequate intake of many essential nutrients. Low serum levels of zinc have been implicated as the cause of skin ulceration in many patients. In a 1979 study of 42 children with marasmus, investigators found that only those children with low serum levels of zinc developed skin ulceration. Serum levels of zinc correlated closely with the presence of edema, stunting of growth, and severe wasting. The classic "mosaic

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skin" and "flaky paint" dermatosis of kwashiorkor bears considerable resemblance to the skin changes of acrodermatitis enteropathica, the dermatosis of zinc deficiency.

In 2007, Lin et al stated that "a prospective assessment of food and nutrient intake in a population of Malawian children at risk for kwashiorkor" found "no association between the development of kwashiorkor and the consumption of any food or nutrient."

Frequency

United States

Protein-energy malnutrition is the most common form of nutritional deficiency among patients who are hospitalized in the United States. As many as half of all patients admitted to the hospital have malnutrition to some degree. In a recent survey in a large children's hospital, the prevalence of acute and chronic protein-energy malnutrition was more than one half.

In a survey focusing on low-income areas of the United States, 22-35% of children aged 2-6 years were below the 15th percentile for weight. Another survey showed that 11% of children in low-income areas had height-for-age measurements below the 5th percentile. Poor growth is seen in 10% of children in rural populations.

In hospitalized elderly persons, up to 55% are undernourished. Up to 85% of institutionalized elderly persons are undernourished. Studies have shown that up to 50% have vitamin and mineral intake that is less than the recommended dietary allowance and up to 30% of elderly persons have below-normal levels of vitamins and minerals.

International

In 2000, the WHO estimated that malnourished children numbered 181.9 million (32%) in developing countries. In addition, an estimated 149.6 million children younger than 5 years are malnourished when measured in terms of weight for age. In south central Asia and eastern Africa, about half the children have growth retardation due to protein-energy malnutrition. This figure is 5 times the prevalence in the western world.

A cross-sectional study of Palestinian adolescents found that 55.66% of boys

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and 64.81% of girls had inadequate energy intake, with inadequate protein intake in 15.07% of boys and 43.08% of girls. The recommended daily allowance for micronutrients was met by less than 80% of the study subjects.

Mortality/Morbidity

Approximately 50% of the 10 million deaths each year in developing countries occur because of malnutrition in children younger than 5 years. In kwashiorkor, mortality tends to decrease as the age of onset increases.

Race

Dermatologic findings appear more significant and occur more frequently among darker-skinned peoples. This finding is likely explained by the greater prevalence and the increased severity of protein-energy malnutrition in developing countries and not to a difference in racial susceptibility.

Age

Marasmus most commonly occurs in children younger than 5 years. This period is characterized by increased energy requirements and increased susceptibility to viral and bacterial infections. Weaning (the deprivation of breast milk and the commencement of nourishment with other food) occurs during this high-risk period. Weaning is often complicated by geography, economy, hygiene, public health, culture, and dietetics. It can be ineffective when the foods introduced provide inadequate nutrients, when the food and water are contaminated, when the access to health care is inadequate, and/or when the patient cannot access or purchase proper nourishment.

In some studies, the protein-energy malnutrition prevalence among elderly persons is estimated to be as high as 4% for those living in the community, 50% for those hospitalized in acute care units or geriatric rehabilitation units, and 30-40% for those in long-term care facilities. Protein-energy malnutrition has also been found to be a primary factor of poor prognosis in elderly persons.

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Physical

In marasmus, the child appears emaciated with marked loss of subcutaneous fat and muscle wasting. The skin is xerotic, wrinkled, and loose. Monkey facies secondary to a loss of buccal fat pads is characteristic of this disorder. Marasmus may have no clinical dermatosis. However, inconsistent cutaneous findings include fine, brittle hair; alopecia; impaired growth; and fissuring of the nails. In protein-energy malnutrition, more hairs are in the telogen (resting) phase than in the anagen (active) phase, a reverse of normal. Occasionally, as in anorexia nervosa, marked growth of lanugo hair is noted.

Kwashiorkor is an acute form of childhood protein-energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. The presence of edema caused by poor nutrition defines kwashiorkor. Kwashiorkor was thought to be caused by insufficient protein consumption but with sufficient calorie intake, distinguishing it from marasmus. More recently, micronutrient and antioxidant deficiencies have come to be recognized as contributory. Cases in the developed world are rare.

SIGNS AND SYMPTOMS

The defining sign of kwashiorkor in a malnourished child is pedal edema (swelling of the feet). Other signs include a distended abdomen, muscle wasting an enlarged liver with fatty infiltrates, thinning hair, loss of teeth, skin depigmentation and dermatitis. Children with kwashiorkor often develop irritability and anorexia.

Victims of kwashiorkor fail to produce antibodies following vaccination against diseases, including diphtheria and typhoid. Generally, the disease can be treated by adding food energy and protein to the diet; however, it can have a long-term impact on a child's physical and mental development, and in severe cases may lead to death. Usually presented signs are: moon face, hair changes, skin depigmentation, anaemia

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Another malnutrition syndrome includes cachexia, although it is often caused by underlying illnesses. These are important considerations in the treatment of the patients. Kwashiorkor can lead to death. People can recover from the illness by having a gradual build up of nutrients, but they will not grow properly and will probably be quite small.

Marasmus:

It is a form of severe protein-energy malnutrition characterized by energy deficiency.

A child with marasmus looks emaciated. Body weight may be reduced to less than 80% of the average weight that corresponds to the height. Marasmus occurrence increases prior to age 1, whereas kwashiorkor occurrence increases after 18 months. It can be distinguished from kwashiorkor in that kwashiorkor is protein wasting with the presence of edema. In dry climates, marasmus is the more frequent disease associated with malnutrition.

The prognosis is better than it is for kwashiorkor

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.

Signs and symptoms

The malnutrition associated with marasmus leads to extensive tissue and muscle wasting, as well as variable edema. Other common characteristics include dry skin, loose skin folds hanging over the glutei, axillae, etc. There is also drastic loss of adipose tissue from normal areas of fat deposits like buttocks and thighs. The afflicted are often fretful, irritable, and voraciously hungry.

Causes

Marasmus is caused by a severe deficiency of nearly all nutrients, especially protein and calories.Vitamin B5 - possibly used for treatment of related vitamin B5 deficiency

Treatment

It is necessary to treat not only the symptoms but also the complications of the disorder, including infections, dehydration, and circulation disorders, which are frequently lethal and lead to high mortality if ignored.

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Ultimately, marasmus can progress to the point of no return when the body's machinery for protein synthesis, itself made of protein, has been degraded to the point that it cannot handle any protein. At this point, attempts to correct the disorder by giving food or protein are futile.

CLINICAL ASSESSMENT:Interrogation & physical exam including detailed dietary history.Anthropometric measurementsTeam approach with involvement of dieticians, social workers & community support groups.

Investigations for PEM

Full blood counts

Blood glucose profile

Septic screening

Stool & urine for parasites & germs

Electrolytes, Ca, Ph & ALP, serum proteins

CXR & Mantoux test

Exclude HIV & malabsorption

NON-ROUTINE TESTSHair analysis, Skin biopsy, Urinary creatinine over proline ratio, Measurement of trace elements levels, iron, zinc & iodine

Complications of P.E.MHypoglycemia, Hypothermia, Hypokalemia, Hyponatremia,Heart failure, Dehydration & shock, Infections (bacterial, viral & thrush)

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Consultations

Any patient at risk for nutritional deficiency should be referred to a registered dietician or other nutritional professional for a complete nutritional assessment and dietary counselling.

Other subspecialty referrals should be considered if findings from the initial evaluation indicate that the underlying cause is not poor nutritional intake. If signs indicate malabsorption, a gastroenterologist should be consulted. Further, in paediatric cases, a paediatrician, preferably one with experience in the management of protein-energy malnutrition (PEM), should oversee care of the patient. Any patient with significant laboratory abnormalities, as discussed above, may benefit from consultation with the appropriate subspecialty (eg, endocrinology, haematology).

Children with poor nutrition secondary to inadequate intake and/or neglect should be referred to the appropriate social agencies to assist the family in obtaining resources and providing ongoing care for the child.

Further Outpatient Care

Patients should receive follow-up care with nutrition professionals and social services.

PROGNOSISKwashiorkor & Marasmus-Kwashiorkor have greater risk of morbidity & mortality compared to Marasmus and under weight.

Early detection & adequate treatment are associated with good outcome.

Late ill-effects on IQ, behavior & cognitive functions are doubtful and not proven.

The extent of growth failure and the severity of hypoproteinemia, hypoalbuminemia, and electrolyte imbalances are predictors of a poorer prognosis. Additionally, underlying HIV infection is associated with a poor prognosis.

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