UNDERNUTRITIONPEM

ANOREXIA NERVOSABULIMIA

Healthy diet provides

Sufficient energy

PRIMARY MALNUTRITION :

• One or all of these components are missing from the diet

SECONDARY MALNUTRITION :

• Dietary intake of nutrients is adequate, and malnutrition develops from malabsorption, impaired utilization or storage, excess loss or increased requirements

PROTEIN - ENERGY MALNUTRITIONCommon in poor countries.Malnutrition is the major

cause of death in infancy & childhood in this population.

PEM manifests as a range of clinical syndromes

Two ends of spectrum of syndromes▪Marasmus▪Kwashiorkor

Protein compartments

Somatic compartment• Proteins

in skeletal muscles

Visceral compartment• Protein

stores in visceral organs

MARASMUS

KWASHIORKOR

MARASMUS

Weight level falls to 60% of normal sex, height and age.

Growth retardation & loss of muscle mass as a result of protein catabolism.

Adaptive response to provide amino acids as alternate source

Serum albumin levels are either normal or only slightly reduced

Subcutaneous fat is also used as fuelLeptin

production low

Hypothalamic -

pituitary- adrenal axis stimulated

High cortisol

contributes to lipolysis

Extremities are emaciated

Marasmus. Note the loss of muscle mass and subcutaneous fat; the head appears to be too large for the emaciatedbody.

Anemia and manifestations of multivitamin deficiencies

Immune deficiency particularly of T cell mediated immunity.

Concurrent infections

KWASHIORKORProtein deprivation greater

Children who have been weaned too early

Prevalence high in impoverished countries

Less severe forms world wide Chronic diarrheal states Chronic protein loss

Hypoalbuminemia gives rise to generalised or dependant edema

Masks true loss of weight

Weight of children with severe Kwashiorkor 60-80 % of normal

Sparing of subcutaneous fat & muscle mass

Kwashiorkor. The infant shows generalized edema, seen as ascites and puffiness of the face, hands, and legs.

Alternating zones of hyperpigmentation, desquamation & hypopigmentation

“Flaky paint” appearance

Hair : alternating pale & dark color, staightening, loose attachment to scalp

Fatty liver

Vitamin deficiencies & Secondary infections

SECONDARY PEMIn chronically ill or

hospitalized patients.

Cachexia Severe form Advanced cancer patients Loss of appetite Proteolysis inducing factor {Cachectins}

Cytokines

ANOREXIA NERVOSA Self-induced starvation

causing marked weight loss.

In previously healthy young women who have developed an obsession with body image and thinness.

Clinical findings similar to those in severe PEM.

Amenorrhea : decreased secretion of GnRH, and subsequent decreased secretion of LH and FSH.

Decreased thyroid hormone release : Cold intolerance Bradycardia Constipation Changes in the skin and hair

Dehydration and electrolyte abnormalities

Bone density is decreased (low estrogen level)

Anemia, lymphopenia, hypoalbuminemia

BULIMIAPatient binges on

food and then induces vomiting.

Although menstrual irregularities are common, amenorrhea occurs in less than 50% of bulimic patients because weight and gonadotropin levels remain near normal.

I. Electrolyte imbalances (hypokalemia), which predispose the patient to cardiac arrhythmias

II. Pulmonary aspiration of gastric contents;

III.Esophageal and gastric rupture.

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