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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