Protein energy malnutrition

The two classic types of protein-energy malnutrition (PEM) often seen in developing countries are marasmus and kwashiorkor. Marasmus and kwashiorkor can occur separately or in combination as marasmic kwashiorkor. Marasmus is characterized by a state of chronic deprivation of energy intake to maintain body weight. This is a gradual process that passes through stages of underweight then mild, moderate and severe cachexia. Severe marasmus occurs with extreme weight loss and cachexia, when virtually all available body fat stores have been exhausted due to starvation. In developed countries, chronic illnesses such as cancer, chronic pulmonary disease, and anorexia nervosa are conditions most likely to cause marasmus. The diagnosis is based on severe fat and muscle wastage resulting from prolonged calorie deficiency. These conditions are compared in Table 2.1, and criteria used by the authors for diagnosing them are listed in Table 2.2.

In contrast to marasmus, kwashiorkor is a condition that has been assumed to occur when carbohydrates are the main source of energy and protein is relatively absent from the diet for a long period of time. However, in developed countries the manifestations of acute and chronic illnesses and of kwashiorkor (e.g., hypoalbuminemia) have led to debate over whether true kwashiorkor exists [1]. Kwashiorkor is thought to occur mainly in connection with acute, life-threatening illnesses such as trauma and sepsis, and chronic illnesses

Table 2.1

Comparison of Marasmus and Kwashiorkor



Clinical setting ^ Energy intake

Time course to Months or years develop

Clinical features Starved appearance

Weight < 80% standard for height

Triceps skinfold < 3 mm Midarm muscle circumference < 15 cm Laboratory Creatinine-height index findings < 60% standard

Clinical course Reasonably preserved responsiveness to short-term stress

Mortality Low unless related to underlying disease

I Protein intake during stress state


Well-nourished appearance Easy hair pluckability Edema

Serum albumin < 2.8g/dl Total iron binding capacity < 200 |xg/dl

Lymphocytes < 1, 500/mm3



Poor wound healing, decubitus ulcers, skin breakdown High

From Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4th edn. St Louis: Mosby Elsevier, 2006, with permission.

that involve an acute-phase inflammatory response. The physiologic stress produced by these illnesses is thought to increase the protein and energy requirements at a time when intake is often limited. Although the etiologic mechanisms are not clear, the fact that the adaptive response of protein sparing normally seen in starvation is blocked by the stress state and by carbohydrate infusion may be important factors. It has been argued that this stress state of malnutrition differs enough from kwashiorkor seen in developing countries and that it should be given a different label such as "stressed-induced hypoalbu-minemia" [2]. However, these two conditions are substantially similar in physiology, clinical findings, and prognosis. When clinical findings such as poor skin integrity, poor wound healing, edema unexplained by other conditions, and easy hair pluckability are noted in addition to hypoalbuminemia, it is difficult not to label the conditions as kwashiorkor. Furthermore, the long-term stress-induced condition does

Table 2.2

Minimum Criteria for the Diagnosis of Marasmus and Kwashiorkor

Marasmus Kwashiorkor*

Triceps skinfold < 3 mm Serum albumin < 2.8g/dl

Mid-arm muscle circumference < 15 cm

At least one of the following:

• Poor wound healing, decubitus ulcers, or skin breakdown

• Easy hair pluckabilityf

* The findings used to diagnose kwashiorkor must be unexplained by other causes ^ Tested by firmly pulling a lock of hair from the top (not the sides or back), grasping with the thumb and forefinger. An average of three or more hairs removed easily and painlessly is considered abnormal hair pluckability From Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4th edn. St Louis: Mosby Elsevier, 2006, with permission.

not reflect a state of malnutrition, but rather the body's physiologic response to injury and infection.

The prognosis of adult patients with full-blown kwashiorkor is not good, even with aggressive nutritional support. Surgical wounds often dehisce, pressure sores develop, gastroparesis and diarrhea can occur with enteral feeding, the risk of gastrointestinal bleeding from stress ulcers is increased, host defenses are compromised, and death from overwhelming infection may occur despite antibiotic therapy. Unlike treatment in marasmus, aggressive nutritional support is indicated to restore better metabolic balance rapidly. Marasmic kwashiorkor, the combined form of PEM, develops when the cachectic or marasmic patient is subjected to an acute stress such as surgery, trauma, or sepsis, superimposing kwashiorkor onto chronic starvation. An extremely serious, life-threatening situation can occur because of the high risk of infection and other complications.

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