Hospital Based Practice – Nutrition.

Biological effects of malnutrition

• An extended period can result in starvation or deficiency disease.
• Malnutrition increases risk of infection and infectious disease.
○ Major risk factor for TB
• Malnutrition increases activity and movement in many animals.
○ Experiment in spiders showed increased activity and predation, resulting in larged weight
gains.

Kwashiorkor
• Cause is controversial
○ Thought to be due to insufficienct protein intake.
• Virulent form of childhood malnutrition characterised by.
○ Oedema
○ Irritability
○ Anorexia
○ Ulcerating dermatoses
○ Enlarged, fatty liver.
• Kwashiorkor is defined by presence of oedema due to poor nutrition.
• Often presents in a child soon after it is weaned.
○ Compared to mother’s milk, the weaned diet is often high in starches and other carbohydrates,
and low in protein.
○ Name is derived from the Ghanian word “Kwa” which means “first – second”, reflecting the
development of the condition in the first child when a younger sibling arrives and requires
breast milk.
• Symptoms.
○ Swollen, pot – bellied abdomen.
 Ascites due to reduced oncotic pressure.
 Hepatomegaly.
• Due to inability to transport lipids away from the liver with deficiency of
apolipoprotiens.
○ Alternating bands of pale and dark hair.
○ Weight loss.
○ Skin signs.
 Dermatitis
 Depigmented skin
○ Failure to produce antibodies following vaccination.
 Diptheria
 Typhoid.
○ Failure to thrive.
○ Mental retardation
○ Loss of teeth.
 • Cause.
○ Controversial.
○ Known that protein deficiency is important, but this may not be the key factor.
○ Likely to be due to deficiency of several nutrients, particularly those involves in anti – oxidant
production.
 Iron
 Folic aicd
 Iodine
 Selenium
 Vitamin C
○ This suggestion is supported by the fact that children with kwashiorkor tend to deficienct in.
 Glutathione
 Albumin
 Vitamin E
 Polyunsaturated fatty acids.
○ Children can be sub – clinically deficient in nutrients, but then pushed into kwashiorkor by
stresses (eg. Infection or toxin).
• One of the reasons that kwashiorkor is common in the developing world is because of the high
carbohydrate, low protein, content of staple foods like cassava.
• Another factor which seems to play a large part is the prevalence of moulds producing aflatoxins.
○ Kwashiorkor only tends to develop in warm, humid areas where mould growth is encourages.
 People in drier areas tend to develop maramus instead.
○ Aflatoxin are toxified by the cytochrome P450 system.
○ They cause liver damage, and so predispose to hypoprotienaemia.
• Management.
○ Replace protein for anabolic purposes only.
 Catabolic needs should be satisfied with fat and carbohydrates.
 Protein catabolism involves the urea cycle, and so will strain a damaged liver.
 Resulting liver failure may be fatal.

Marasmus.
• Form of severe protein – energy malnutrition.
• Characterised by energy deficiency.
• Children with marasmus look emaciated.
○ Body weight may be reduced to less than 80% of normal weight for height.
○ Although the child looks far worse, prognosis in marasmus is better than that in kwashiorkor
• Signs & symptoms.
○ Extensive tissue and muscle wasting.
○ Variable amounts of oedema
○ Dry skin
○ Skin folds on.
Glutei
Axillae
○ Dramatic loss of adipose tissue from
 Buttocks
 Thigh
○ Frefulness
○ Irritability
○ Voraciously hungry
 • Complications.
○ Often lethal.
○ Lead to a high mortality.
 Infection
 Dehydration
 Circulation disorders.
 Permanent loss of the ability to synthesise proteins.
• The pathway itself involves proteins, which are lost.
• Treatment.
○ Treat both disorder and complications.
○ Once the patient has lost the ability to synthesise proteins, attempts to reverse the disorder are
futile.

Catabolism.
• Biological process by which the body breaks down fat and muscle tissue in order to survive.
• Only occurs when there is no longer any other source of protein, carbohydrate or vitamins to feed all
the body systems.
• Is the most severe type of malnutrition.
• Disease setting.
○ Seen in starved and malnourished people.
○ Over 20,000 people a day die from starvation.
○ A child dies every 5 seconds from starvation.
○ There are about 800,000,000 people who are chronically undernourished.
• Mechanism.
○ Due to normal metabolic rate of humans (which requires going 12 hours a day without food),
catabolysis only becomes life threatening after 1 – 2 months of starvation.
○ After this time, muscles and organs can become permanently damaged.
 Eventually causes death if left untreated.
○ Catabolism is the last resort of the body to keep itself, particularly the nervous system, alive.
○ Prognosis is poor when the patient starts to lose muscle mass.
 This is a sign that body fat has been broken down and the body is now breaking
down muscle tissue.
 This results in loss of muscle strength.
• Investigations.
○ Fever.
 Due to body working hard to break down muscles and fat.
○ High blood levels of products of muscle and fat breakdown.
 Lipids
 Proteins
 Amino acids.
• Treatment.
○ While catabolysis can be deadly over time, early medical treatment can reverse the process.
○ Patient may require.
 Intravenous nutrition
 Blood transfunion.
 Oxygen replenishment.
○ May require weeks to months for muscle mass to return.
 If disease was severe, muscle mass may never fully recover.