Thirty years ago, hospital malnutrition was described as being very prevalent, yet poorly identified by medical teams [1]. Unfortunately, this situation has not changed. Protein calorie malnutrition (PCM) is still very common in hospitalized patients and remains poorly recognized by many clinicians [2]. In a recent study of Brazilian hospitalized patients, 48% of the patients were deemed to be malnourished. Despite this alarming number, the majority of physicians in this study did not assess their patient's nutritional status nor make nutritional therapy a major component of their patient's hospital medical plan [3].

PCM is important clinically when it is severe enough to impact patients' physiologic functions, inhibit their response to medical therapies and/or prolong the time to recovery. The physiologic devastation seen with PCM is secondary to loss of total body protein and muscle function [4].When more than 20% of a patient's usual body weight is lost, most physiologic body functions become significantly impaired [5]. Studies evaluating the relationship of loss of body weight to loss of body protein have shown a strong correlation [6].

End organ function is adversely affected by malnutrition Protein malnutrition can be divided into two generalized categories: marasamus and kwashiorkor. Patients with marasmus have a significant deficit of total body fat and body protein with a slight increase in extracellular water. Clinically, this presents as obvious body wasting (Fig. 1.1). The eyes may be sunken and the skull and cheekbones may be prominent [7]. The plasma albumin is often in the low normal range. Resting energy expenditure in these individuals is not increased

despite severe physiologic dysfunction. In contrast, while patients with kwashiorkor have similar deficits of body protein and fat, they also have markedly increased extracellular fluid and low plasma albumin levels (Fig. 1.2) [7]. To the casual observer, this increase in extracellular fluid may mask underlying weight loss. Patients with kwashiokor typically have an accelerated metabolic rate, and if measured, their physiologic function would also be significantly impaired.

With malnutrition muscle strength decreases over time. Respiratory function, including forced expiratory volume, vital capacity and peak expiratory flow, all decline. An association between impaired respiratory gas exchange and malnutrition in chronic obstructive respiratory disease patients has been described [8]. Malnutrition can also reduce

Fig. 1.2. Kwashiokor.

cardiac output, impair wound healing and depress immune function [9]. Nutritional repletion, however, can often reverse these degenerative processes and significantly improve patient outcomes. The difficulty lies not only in the treatment of such conditions, but also in identifying individuals at risk so that appropriate interventions can be made.

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