MALNUTRITION

Nutrition Department Medical Faculty University of Sumatera Utara 2011

Nutrition Status
Anthropometric status Biochemical status Clinical status Dietary status Laboratory and radiology status

Nutrition Imbalance
Underweight Overweight

Malnutrition
Can arise from primary or secondary causes With the former resulting from inadequate or poor quality food intake and the latter from disease that alter food intake or nutrition requirement, metabolism, or absorption

Risk Factor
Diet imbalance intake Social religion, tradition, divorce in family, working mother, no breast feeding Poverty low income Infections chronic disease Increasing population decreased quantity and quality of food

Protein-Energy Malnutrition
PEM still one of Indonesias nutrition problem High prevalence could be found in children under five years Some cases: pregnant women, lactating mother, patological conditions due to low energy and protein

The two major types of PEM are marasmus and kwashiorkor Can occur singly or in combination, as marasmic kwashiorkor Kwashiorkor occur rapidly Marasmus the end result of a gradual wasting process that passes through stages of underweight mild moderate severe cachexia

Marasmus
The most severe or end stage of the process of cachexia Low energy/calorie intake Body fat stores exhausted due to starvation Marasmus in adults: caused by chronic and indolent, such as cancer, chronic pulmonary disease, and anorexia nervosa

Marasmus in children: caused by baby with no breastfeeding, diarrhea, gastrointestinal or heart disease, malabsorption, metabolic disorders, kidney disease Some cases happened in children with over-protective or over-care so the children become spoiled children and refused any food

Marasmus is easy to detect because of the patientss starved appearance The diagnosis is based on severe fat and muscle wastage resulting from prolonged calorie deficiency Diminished skinfold thickness reflects the loss of fat reserves

Reduced arm muscle circumference with temporal and interosseous muscle wasting reflects the catabolism of protein throughout the body, including vital organ such as the heart, liver, and kidneys

Clinical findings
Appearances : old man face, wasting Mental changes: crying all the time because still hungry decreased consciousness apathy Skin changes: dry, cold, and lossing fat under the skin and the muscles (turgor ) Hair changes: dry hair Gastrointestinal system: diarrhea or constipation

Laboratory findings
The creatinine height index: low Serum albumin level is reduced, but it may not drop below 2.8 g/dL Despite a morbid appearance, immunocompetence, wound healing , and the ability to handle short-term stress

Marasmus is a chronic, fairly well-adapted form of starvation rather than an acute illness Should be treated cautiously Overly aggressive repletion can result in severe , even lifethreatening metabolic imbalance such as hypophosphatemia and cardiorespiratory failure

Suggest: enteral nutritional support is preferred Treatment started slowly allows readaptation metabolic and intestinal functions

Kwashiorkor
Occuring in developed countries Low protein intake Mainly in connection with acute, lifethreatening illnesses such as trauma and sepsis, and chronic illnesses that involve an acute-phase inflammatory response

Hypoalbuminemic stress state Eq: acutely stressed patient who receives only 5% dextrose solutions for periods as short as 2 weeks In its early stages, the physical findings are few and subtle Fat reserves and muscle mass may be normal or even above normal, giving deceptive appearance of adequate nutrition

Clinical findings
Appearances: fat baby like (suger baby), buttock: atrophy Growth development: delayed Mental changes: crying Edema: (+), some cases ascites (+) Muscle atrophy: (+), weak, lying down Gastrointestinal system: refusing all the food through oral NGT, diarrhea lactic acids (+) nematoda (+)

Hair changes: easy hair pluckability, dry, color changes (black red, brown, grey, white) flag sign/ transverse depigmentation of hair, long eye lashes Skin changes: crazy pavement dermatosis, start with red spots black spots, wet and pressure area (back, buttock, around vulva) flaky paint

Poor wound healing Hepatomegaly Anemia In later stage: stomatitis gangrainosa (NOMA) lost nose, could not close the eyes due to fibrosis

Laboratory findings
Severe reduction of levels of serum proteins such as albumin (less than 2.8 g/dL) Reduced transferrin (less than 150 mg/dL) Reduced iron binding capacity (less than 200 g/dL) Lymphopenia (less than 1500 lymphocytes/mm3)

The prognosis of adult patients not good Surgical wounds often dehisce (fail to heal) Unlike treatment in marasmus, aggressive nutritional support is indicated to restore better metabolic balance rapidly

Marasmic Kwashiorkor
Combine form of PEM Develops when cachectic or marasmic patient is subjected to an acute stress such as surgery, trauma, or sepsis It is important to determine the major component of PEM so that the appropriate nutritional plan can be developed

If kwashiorkor predominates need for vigorous nutritional therapy urgent If marasmus predominates feeding should be more cautious

Micronutrient Malnutrition
PEM is not the only type of malnutrition found in sick patients The same illnesses and reductions in nutrient intake produce deficiencies of vitamins and minerals

Deficiencies
Vitamin that only stored in small amounts (water-soluble vitamins) Minerals that losst through external secretions (zinc in diarrhea fluid or burn exudate)

Some deficiencies: vitamin C, folic acids, zinc Hypophosfatemia