1. PCM affects ~ 1 billion individuals world-wide
Malnutrition
Definition: loss of the lean body mass and adipose tissue due to insufficient dietary supply
PCM affects ~ 1 billion individuals world-wide
30-50% of hospitalized patients are will be malnourished.

2. Malnutrition
1.primary : inadequate or poor-quality food intake (starvation due to war or famine).
2.secondary : from diseases that alter food intake or nutrient requirements, metabolism, or absorption.
Two forms of starvation
kwashiorkor(selective protein loss with edema)
marasmus (marked loss body fat and protien)

3. CAUSES OF malnutrition
Decreased the energy intake
( hypo metabolism)
Economic : poverty, famine
anorexia : nervosa, dementia ,depression cancer , renal failure
Abdominal pain: pancreatitis, intestinal ischemia

4. CAUSES OF malnutrition Decreased the energy intake ( hypo metabolism)
Impaired diet transit : benign and malignant esoph.or gastric obstruction
Maldigestion: chronic pancreatitis, short bowel syndrome
Malabsorption : small intestinal disease celiac disease

5. Causes of malnutrition
Increased energy expenditure (hyper metabolism)
Increased BMR: (thyrotoxicosis , fever, cancer trauma , sepsis, surgery,burn)
Excessive physical activity( marathone runner )
Acute and chronic inflammation : T.B ,collagen diseases.
Energy loss :(e.g. glycosuria in diabetes)

6. Causes of malnutrition
Mixed mechanisms
Disseminated cancer
Chronic inflammatory bowel disease (crohns disease

7. Consequences of malnutrition
Wt loss Weakness Loss of cell
mediated immunity Bronchopneumonia
Too weak to walk Urinary tract infection
Too week to sit Bed sore death

8. Malnutrition in Hospitalized Pts
Consequences for hospitalized pts:
poor wound healing
higher rate of infections
greater length of stay
greater costs
Increased morbidity and mortality

9. Metabolic response to Starvation
First day
Circulating glucose and FA and TGs
decrease in insulin, increase in glucagon
release of glucose from liverglycogen(1200Kcal)
Lipolysis release and oxidation of fatty acids (65% of energy source )

10. Metabolic response to Starvation
More than 24 hr.
Further decrease in insulin, increase in glucagon
Lipolysis increase and ketone body production increase
Gluconeogenesis
Proteolysis and release of amino acids from muscle as a source of fuel (70 g),

11. Metabolic response to Starvation
2 weeks-30 days
Decreased metabolic rate
decreased activity, body temperature
Lipolysis continue 150g/day (90% on fat)
Muscle PTN breakdown decrease(20g/day)

12. Metabolic response to stress
High catecholamines ,glucagon , cortisol cytokines , TNF , interlukine
hypercatabolic state with increased RMR
Insulin resistance, hyperglycemia
Skeletal and visceral PTN catabolism (150 g/d)
50 % of body protein stores within 3 weeks

13. Physiological consequences
1. GIT :
Villous atrophy of small IN. mucosa
Gastric and pancreatic secretion
Volume of bile and conjugated bile acids decrease
Carbohydrate. and fat malabsorption decrease.

14. Physiological consequences
2.CVS:
Myocardial Mass and function decrease
decreased cardiac output
bradycardia, hypotension
3.Immune system:
Total lymphocyte count decrease
Delayed skin hypersensitivity (anergy)
Decrease production of Abs
increased infection rate (pneumonia)

15. Physiological consequences
4.Respiratory:
Structural and functional atrophy
Decrease the inspiratory and vital capacity
5.Bone marrow:
Decrease lymphocyte and WBC and RBC
6.Renal :
Decrease mass and function

16. Physiological consequences
7.Skin and hair:
Dry ,thin, wrinkled , hyperkeratosis
Wound healing
8.Endocine
Low insuline
Increase cortisol
Increase growth homone
T3and T4 decrease
Primary gonadal dysfuction

17. Clinical features
WT loss
Weakness and, craving for food
muscle wasting (temporal, upper arm, thigh)
Loss of subcutaneous fat
Leg edema and ascites
Skin dry pale lax, easy packable thin hair

18. Clinical features amenorrhea or impotence
Bradycardia, Cold cyanosed extremities, pressure sores
distended abdomen, with diarrhea
apathy, depression, loss of the initiative
Features of associated vitamins deficiency
susceptibility to infections

19. PCM – in Hospitalized Patients
Temporal wasting observed with ageing and reduced intake
Temporal
wasting

20. PCM in Hospitalized Patients
Loss of Skinfold Thickness

21. INFECTIONS ASSOCIATED WITH PEM Patient
Gastroenteritis
Gram-negative septicemia
Respiratory infections (bronchopneumonia )
viral infection :herpes simplex
Tuberculosis
Streptococcal and staphylococcal skin infections
Helminthic infestation

22. Nutritional Assessment
History
Physical examination
Anthropometric measurements
Laboratory investigations
Functional test

23. Nutritional Assessment
History
Dietary Analysis
Dietary history Review foods eaten
Review preparation methods
Evaluate digestive and absorption adequacy
Review supplements taken
Significant weight loss within last 6 months
> 10% loss of body weight
<90% 0f ideal body weight
Specific symptoms

24. Nutritional Assessment
Physical Examination
Evidence of muscle wasting
Depletion of subcutaneous fat
Peripheral edema, ascites
Skin changes (easily plucked hair)
Features of Vitamin deficiency
e.g. nail and mucosal changes

25. Nutritional Assessment
Anthropometry
Weight for Height comparison
Body Mass Index (BMI)
BMI = Weight (kg)/ Height (m²)
Triceps-skin fold
< (6mm for the men), <(8mm for the women)
Mid arm muscle circumference
<(20cm for the men),<(18.5cm for the women)

26. BODY MASS INDEX (WEIGHT/HEIGHT2) BMI (kg/m2) classification > 25 obese >20 Adequate nutrition Marginal < 18.5 Malnutrition Mild Moderate < 16 Severe

27. Nutritional Assessment
Lab investigations
1. Serum visceral protein:
albumin
transferrin
pre-albumin

28. Nutritional Assessment
2. vitamin and minerals assays:
tests reflecting specific nutritional deficits
e.g. prothrombin time
3.Assessment of immune function:
Total lymphocyte count < 1800 / mm3
Skin anergy testing
Nutritional Assessment

29. Nutritional Assessment
Functional test
Hand grip dynamometry

30. Nutritional Assessment
Other
Urinary creatinine excretion:
1g of urine creatinine:18.5g of FFM
23mg/kg of ideal body wt./men
18mg/kg of ideal body wt./women
bioelectric impedance analysis

31. Thanks