GROUP

C2
Physiology Laboratory
Small Group Discussion
Output

March 22, 2016

[PROTEIN-CALORIES, MALNUTRITION &

NUTRITIONAL DEFICIENCIES]
By: ASUBARIO, Olufunmilola Omonike; BALADAD, Alvin Bryan; DE JESUS, Chrislou; GURUNG, Man
Bahadur; KALANGEG, Kristie; MAHALEE, Naphitcharak; MONTHATHONG, Thanapol; PANLASIGUI,
Rikkimae Maria; SAMSON, Chino Paolo; SOLONIO, Natalie Keith; VALDEZ, Gregorio
 PROTEIN-CALORIES, MALNUTRITION & NUTRITIONAL DEFICIENCIES

Protein–energy malnutrition (PEM) or protein–calorie malnutrition- refers to

a form of malnutrition where there is inadequate calorie or protein intake.

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 (see the images below), 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." 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.

Fig. 1: Kwashiorkor & Marasmus

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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 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."

Marasmus and kwashiorkor can both be associated with impaired glucose

clearance that relates to dysfunction of pancreatic beta-cells. In utero, plastic
mechanisms appear to operate, adjusting metabolic physiology and adapting postnatal
under nutrition and malnutrition to define whether marasmus and kwashiorkor will
develop.

In 2012, a report from Texas noted an 18-month-old infant with type 1 glutaric
acidemia who had extensive desquamative plaques, generalized non-pitting edema,
and red-tinged sparse hair, with low levels of zinc, alkaline phosphatase, albumin, and
iron. This patient has a variation on kwashiorkor, and the authors suggest that it be
termed acrodermatitis dysmetabolica. On the same note, a boy aged 18 months with
type 1 glutaric academia suffered from zinc deficiency and acquired protein energy
malnutrition.For complex reasons, sickle cell anemia can predispose suffers to protein
malnutrition.Protein energy malnutrition ramps up arginase activity in macrophages and
monocytes

Causes and symptoms

Kwashiorkor is a condition of insufficient protein in the presence of adequate
calories. Found most commonly in children as they wean from nursing mothers,

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kwashiorkor also is called wet protein-energy malnutrition. Identifying characteristics
include severely thin arms and legs with a distended abdomen.
The following also accompany this condition:

 Anemia
 Diarrhea
 Electrolyte imbalances

Kwashiorkor causes:

 Dry, peeling skin

 Fluid retention (edema)
 Hair discoloration

For the hospitalized patient, kwashiorkor may occur in patients who suffer from:

 Life-threatening illness
 Sepsis
 Severe burns
 Trauma

Marasmus is a condition of insufficient protein in conjunction with insufficient

calories and also is commonly found in children weaning from nursing mothers. It is
characterized by extreme weakness, loss of body fat and muscle strength, and a
skeletal appearance in the hands and in the temporal muscle in front of and above each
ear. Children with marasmus are small for their age.
Also associated with marasmus:

 Behavioral retardation
 Diarrhea
 Loss of appetite
 Low body temperature (hypothermia)
 Mental retardation
 Skin that is dry and baggy
 Slow pulse and breathing rates
 Sparse hair that is dull brown or reddish yellow

Marasmus causes:

 Stunted growth
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  Wasted muscle tissue

Mild, moderate, and severe PCM in adults

Mild, moderate, and severe PCM classifications are not precisely defined. A
statement was released by the Academy of Nutrition and Dietetics and the American
Society of Parenteral and Enteral Nutrition in 2012 recommending a proposed set of
diagnostic criteria to identify and document adult malnutrition.
These guidelines are a dynamic work in progress that suggest the categorization of
adult malnutrition as:

 Starvation-related malnutrition, such as pure chronic starvation or anorexia

nervosa
 Chronic-disease related malnutrition, such as organ failure, pancreatic cancer,
rheumatoid arthritis, sarcopenic obesity
 Acute disease or injury-related malnutrition, such as major infection, burns,
trauma, or closed head injury

Six characteristics are recommended to diagnose malnutrition:

 Insufficient energy intake

 Weight loss
 Loss of muscle mass
 Loss of subcutaneous fat
 Localized or generalized fluid accumulation that could mask weight loss
 Diminished functional status as measured by hand grip strength

Diagnosis
A thorough physical examination and a health history that probes eating habits
and weight hanges, focuses on bodyfat composition and muscle strength, and assesses
gastrointestinalsymptoms, underlying illness, and nutritional status is often as accurate
as blood tests andurinalyses used to detect and document abnormalities.

Some doctors further quantify a patient's nutritional status by:

 comparing height and weight to standardized norms

 calculating body mass index (BMI)
 measuring skinfold thickness or the circumference of the upper arm

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Treatment
Treatment is designed to provide adequate nutrition, restore normal body comp
osition, and curethe condition that caused the deficiency. Tube feeding or intravenous fe
eding is used to supplynutrients to patients who can't or won't eat protein-rich foods.

In patients with severe PEM, the first stage of treatment consists of correcting flui
d andelectrolyte imbalances, treating infection with antibiotics that don't affect protein s
ynthesis, andaddressing related medical problems. The second phase involves replenis
hing essential nutrientsslowly to prevent taxing the patient's weakened system with mor
e food than it can handle.Physical therapy may be beneficial to patients whose muscles
have deteriorated significantly.

NUTRITIONAL DEFICIENCIES

1. Nutritional deficiencies, known as malnutrition, are the result of your body not
getting enough of the nutrients it needs.
2. Children are more at risk for serious complications due to nutritional deficiencies
than adults.
3. You can prevent nutritional deficiencies by making sure you get enough nutrients
from your diet. You should talk to your doctor and dietitian to help make any
decisions on dietary changes and before taking any nutritional supplements.

The body requires many different vitamins and minerals that are crucial for both
development and preventing disease. These vitamins and minerals are often referred to
as micronutrients. They aren’t produced naturally in the body, so you have to get them
from your diet. A nutritional deficiency occurs when the body doesn’t absorb the
necessary amount of a nutrient. Deficiencies can lead to a variety of health problems.
These can include problems of digestion, skin problems, stunted or defective bone
growth, and even dementia.

The amount of each nutrient you should consume depends on your age. In the United
States, many foods that you buy in the grocery store (such as cereals, bread, and milk)
are fortified with nutrients that are necessary to prevent nutritional deficiency. But
sometimes your body is unable to absorb certain nutrients even if you are consuming
them.

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Types of Nutritional Deficiency
It’s possible to be deficient in any of the nutrients that your body needs. Some
common types of nutritional deficiencies include:

IRON DEFICIENCY
The most widespread nutritional deficiency worldwide is iron deficiency. Iron
deficiency can lead to anemia, a blood disorder that causes fatigue, weakness, and a
variety of other symptoms.

Iron is found in foods such as dark leafy greens, red meat, and egg yolks. It helps
your body make red blood cells. When you’re iron deficient, your body produces fewer
red blood cells. The red blood cells it produces are smaller and paler than healthy blood
cells. They’re also less efficient at delivering oxygen to your tissues and organs.

According to the World Health Organization (WHO), over 30 percent of the

world’s population suffers from this condition. In fact, it’s the only nutritional deficiency
that is prevalent in both developing and industrialized countries. Iron-deficiency anemia
affects so many people that it’s now widely recognized as a public health epidemic.
spnoea on exertion.

VITAMIN A DEFICIENCY
Vitamin A is a group of nutrients that is crucial for eye health and functioning and
reproductive health in men and women. It also plays a part in strengthening the immune
system against infections. According to the WHO, a lack of vitamin A is the leading
cause of preventable blindness in children. Pregnant women who are deficient in
vitamin A have higher maternal mortality rates as well.

For newborn babies, the best source of vitamin A is breast milk. For everyone
else, it’s important to eat plenty of foods that are high in vitamin A. These include:

 milk
 eggs
 green vegetables, such as kale, broccoli, and spinach
 orange vegetables like carrots, sweet potatoes, and pumpkin
 reddish yellow fruits, like apricots, papaya, and peaches

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The RDAs of vitamin A for various age groups are as follows:

 Infants aged 1 year or younger - 375 mcg

 Children aged 1-3 years - 400 mcg
 Children aged 4-6 years - 500 mcg
 Children aged 7-10 years - 700 mcg
 All males older than 10 years - 1000 mcg
 All females older than 10 years - 800 mcg

VITAMIN B-1 (THIAMINE) DEFICIENCY

Another common nutritional deficiency occurs with vitamin B-1, also known as
thiamine. Thiamine is an important part of your nervous system. It also helps your body
turn carbohydrates into energy as part of your metabolism. A lack of thiamine can result
in weight loss and fatigue, as well as some cognitive symptoms such as confusion and
short-term memory loss. Thiamine deficiency can also lead to nerve and muscle
damage and can affect the heart. In the United States, thiamine deficiency is most often
seen in those who chronically abuse alcohol. Alcohol reduces the absorption of
thiamine, the body’s ability to store thiamine in the liver and the body’s ability to convert
thiamine to a usable form. Thiamine deficiency is a common cause of Wernicke-
Korsakoff syndrome. Many breakfast cereals and grain products in the United States
are fortified with thiamine. Pork is also a good source of the vitamin.

DRY BERIBERI

Thiamine deficiency with nervous system involvement is termed dry beriberi.This

presentation usually occurs when poor caloric intake and relative physical inactivity are
present. The neurologic findings can be peripheral neuropathy characterized by
symmetrical impairment of sensory, motor, and reflex functions of the extremities,
especially in the distal lower limbs. Histologic analysis has shown that the lesions arise
from a degeneration of the myelin in the muscular sheaths without inflammation.

Another presentation of neurologic involvement is Wernicke encephalopathy, in

which an orderly sequence of symptoms occurs, including vomiting, horizontal
nystagmus, palsies of the eye movements, fever, ataxia, and progressive mental
impairment leading to Korsakoff syndrome. Improvement can be achieved at any stage
by the addition of thiamine, unless the patient is in frank Korsakoff syndrome. Only half
of the patients treated at this stage recover significantly.

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WET BERIBERI

Wet beriberi is the term used for thiamine deficiency with cardiovascular
involvement. The chronic form of wet beriberi consists of 3 stages. In the first stage,
peripheral vasodilation occurs, leading to a high cardiac output state. This leads to salt
and water retention mediated through the renin-angiotensin-aldosterone system in the
kidneys. As the vasodilation progresses, the kidneys detect a relative loss of volume
and respond by conserving salt. With the salt retention, fluid is also absorbed into the
circulatory system. The resulting fluid overload leads to edema of the dependent
extremities.

By the time significant edema occurs, the heart has been exposed to a severely
high workload in order to pump the required cardiac output needed to satisfy end organ
requirements. Parts of the heart muscle undergo overuse injury, which results in the
physical symptoms of tachycardia, edema, and high arterial and venous pressures.
These changes can lead to myocardial injury, expressed as chest pain.

A more rapid form of wet beriberi is termed acute fulminant cardiovascular

beriberi, or Shoshin beriberi. The predominant injury is to the heart, and rapid
deterioration follows the inability of the heart muscle to satisfy the body's demands
because of its own injury. In this case, edema may not be present. Instead, cyanosis of
the hands and feet, tachycardia, distended neck veins, restlessness, and anxiety occur.
Treatment with thiamine causes low-output cardiac failure, because systemic
vasoconstriction is reinstated before the heart muscle recovers. Support of heart
function is an added requirement at this stage, and recovery is usually fairly quick and
complete if treatment is initiated promptly. However, if no treatment is available, death
occurs just as rapidly (within hours or days)

VITAMIN B-3 (NIACIN) DEFICIENCY

Vitamin B-3 (niacin) is another mineral that helps the body convert food into
energy. A severe deficiency of niacin is often referred to as pellagra. Niacin is found in
most proteins. As a result, this condition is rare in meat eating communities. Symptoms
of pellagra include diarrhea, dementia, and skin problems. You can usually treat it with a
balanced diet and vitamin B-3 supplements.

VITAMIN B-9 (FOLATE) DEFICIENCY

Vitamin B-9, often referred to as folate (folic acid is the synthetic form found in
supplements or fortified foods), helps the body create red blood cells and produce DNA.
It also helps brain development and nervous system functioning.

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 Folate is especially important for fetal development. It plays a crucial role in the
formation of a developing child’s brain and spinal cord. Folate deficiency can lead to
severe birth defects, growth problems, or anemia.

You can find folate in foods, including:

 beans and lentils

 citrus fruits
 leafy green vegetables
 asparagus
 meats such as poultry and pork
 shellfish
 fortified grain products

VITAMIN D DEFICIENCY
According to the Vitamin D Council, about 40 percent of the population worldwide
is affected by vitamin D deficiency. Dark skinned individuals are at a higher risk of
vitamin D deficiency.

Vitamin D is essential for healthy bones. It helps the body maintain the right
levels of calcium in order to regulate the development of teeth and bones. A lack of this
nutrient can lead to stunted or defective bone growth. Osteoporosis, caused by a lack of
calcium and vitamin D, can lead to porous and fragile bones that break very easily.
Vitamin D is found naturally in only a few foods. Foods with vitamin D include:

 fish liver oils

 fatty fish
 mushrooms
 egg yolks
 liver

CALCIUM DEFICIENCY
Calcium helps your body develop strong bones and teeth. It also helps your
heart, nerves, and muscles work they way they should. A calcium deficiency often
doesn’t show symptoms right away, but it can lead to serious health problems over time.
If you aren’t consuming enough calcium, your body will use the calcium from your bones
instead, leading to bone loss. Calcium deficiencies are related to low bone mass,
weakening of bones due to osteoporosis, convulsions, and abnormal heart rhythms.

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They can even be life-threatening. Postmenopausal women experience greater bone
loss due to changing hormones and have more trouble absorbing calcium.

The best sources of calcium are dairy products such as milk, yogurt, cheese,
calcium-set tofu, and small fish with bones. Vegetables like kale and broccoli also have
calcium, and many cereals and grains are calcium-fortified.

Causes of Nutritional Deficiencies

The usual cause of nutritional deficiencies is a poor diet that lacks essential
nutrients. The body stores nutrients, so a deficiency is usually caught after it’s been
without the nutrient for some time.

A number of diseases and conditions — including colon cancer and

gastrointestinal conditions — can lead to an iron deficiency. Pregnancy can also
cause a deficiency if the body diverts iron to the fetus.

Researchers have found associations between bariatric surgery (surgery

that reduces the size of the stomach to achieve weight loss) and nutritional
deficiency. People who are candidates for bariatric surgery may already be
nutrient deficient due to poor diet. Before and after the surgery, you should talk to
your doctor and dietitian to set up a thorough nutrition plan.

Symptoms of Nutritional Deficiencies

The symptoms of a nutritional deficiency depend on which nutrient the body lacks.
However, there are some general symptoms you might experience, including:

 pallor (pale skin)

 fatigue
 weakness
 trouble breathing
 unusual food cravings
 hair loss
 periods of lightheadedness
 constipation
 sleepiness
 heart palpitations
 feeling faint or fainting
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  depression
 tingling and numbness of the joints
 menstrual issues (such as missed periods or very heavy cycles)
 poor concentration

Diagnosis

Your doctor will discuss your diet and eating habits with you if they suspect
you have a nutritional deficiency. They will ask what symptoms you’re
experiencing. Make sure to mention if you have suffered from any periods of
constipation or diarrhea, or if blood has been present in your stool.

Your nutritional deficiency may also be diagnosed during routine blood tests,
including a complete blood count (CBC). This is often how doctors identify anemia.

Treatments
The treatment for a nutritional deficiency depends on the type and the severity of
the deficiency. Your doctor will find out how severe the deficiency is, as well as the
likelihood of long-term problems caused by the lack of nutrients. They may order further
testing to see if there is any other damage before deciding on a treatment plan.
Symptoms usually fade when the correct diet is followed or supplemented.

Dietary Changes
A doctor may advise you on how to change your eating habits in the case of a
minor deficiency. For example, anemia sufferers should include more meat, eggs,
poultry, vegetables, and cereals.

Your doctor may refer you to a dietitian if your deficiency is more severe. They
may recommend keeping a food diary for a few weeks. When you meet with the
dietitian, you’ll go over the diary and identify changes you should make.

Typically, you will meet with the dietitian regularly. Eventually, you may have a
blood test to confirm that you’re no longer deficient.

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Supplements
The federal government’s Dietary Guidelines for Americans recommends that
you get most of your nutrients from food. In some cases, you may need to take
supplements or a multivitamin. It may also be necessary to take an additional
supplement to help your body absorb the supplements, such as taking calcium and
vitamin D together. The frequency and dosage of a supplement will depend on how
severe the deficiency is. This will be decided by your doctor or a dietitian.

Parenteral Administration
In very severe cases, such as when a nutritional deficiency doesn’t respond to
oral medications, it may be necessary for the nutrient to be given parenterally (through
the veins or muscles). This can carry the risk of additional side effects. It’s usually done
in a hospital.

Parenteral iron, for example, can cause side effects, including:

 chills
 backache
 dizziness
 fever
 muscle pain
 fainting
In rare cases, it can even cause a severe allergic reaction. Once you have been
given the treatment, your doctor will have you do a repeat blood test to confirm
that it was successful. You may need to attend the hospital for repeat
appointments until you’re no longer deficient.

Nutritional Deficiency Cause Long-Term Problems

Most problems caused by nutritional deficiencies will stop once you’re no longer
deficient. However, in some cases, there may be lasting damage. This usually only
occurs when the deficiency has been severe and has lasted a long time.

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References:

1. Guyton, AC; Hall, JE: Textbook of Medical Physiology, 11 th edition. Elsevier Inc.
2006.

2. Koeppen, BM; Stanton, BA: Berne and Levy Physiology, 6 th edition. Elsevier Inc.
2010.

3. en.wikipedia.org

4. http://www.healthline.com/health/malnutrition#LongTerm7

5.http://bestpractice.bmj.com/best-practice/monograph/641/basics/pathophysiology.html

6. http://emedicine.medscape.com/

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