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What is it? Malnutrition is a disparity between the amount of food and other nutrients that the body needs and the amount that it is receiving. This imbalance is most frequently associated with undernutrition, the primary focus of this article, but it may also be due to overnutrition. Chronic overnutrition can lead to obesity and to metabolic syndrome, a set of risk factors characterized by abdominal obesity, a decreased ability to process glucose (insulin resistance), dyslipidemia, and hypertension. Those with metabolic syndrome have been shown to be at a greater risk of developing type 2 diabetes and cardiovascular disease. Another relatively uncommon form of overnutrition is vitamin or mineral toxicity. This is usually due to excessive supplementation, for instance, high doses of fat-soluble vitamins such as Vitamin A rather than the ingestion of food. Toxicity symptoms depend on the substance(s) ingested, the severity of the overdose, and whether it is acute or chronic. Undernutrition occurs when one or more vital nutrients are not present in the quantity that is needed for the body to develop and function normally. This may be due to insufficient intake, increased loss, increased demand, or a condition or disease that decreases the body’s ability to digest and absorb nutrients from available food. While the need for adequate nutrition is a constant, the demands of the body will vary, both on a daily and yearly basis. * During infancy, adolescence, and pregnancy adequate nutritional support is crucial for normal growth and development. A severe shortage of food will lead to a condition in children called marasmus that is characterized by a thin body and stunted growth. If enough calories are given but the food is lacking in protein, a child may develop kwashiorkor – a condition characterized by edema, an enlarged liver, apathy, and delayed development. Deficiencies of specific vitamins can also affect bone and tissue formation. A lack of Vitamin D, for instance, can affect bone formation, causing rickets in children and osteomalacia in adults, while a deficiency in folic acid during pregnancy can cause birth defects. * Acute conditions such as surgery, severe burns, infections, and trauma can drastically increase short-term nutritional requirements. Those patients who have been malnourished for some time may have compromised immune systems and a poorer prognosis. They frequently take longer to heal from surgical procedures and must spend more days in the hospital. For this reason, many doctors screen and then monitor the nutritional status of their hospitalized patients. Patients having surgery are frequently evaluated both prior to surgery and during their recovery process. * Chronic diseases may be associated with nutrient loss, increased nutrient demand, and/or malabsorption. Malabsorption may occur with chronic diseases such as celiac disease, cystic fibrosis, pancreatic insufficiency, and pernicious anemia. An increased loss of nutrients may be seen with chronic kidney disease, diarrhea, and hemorrhaging. Sometimes, conditions and their treatments can both cause malnutrition through decreased intake.. * Elderly patients require fewer calories but continue to require adequate nutritional support. They are often less able to absorb nutrients due in part to decreased stomach acid production and are more likely to have one or more chronic ailments that may affect their nutritional status. At the same time, they may have more difficulty preparing meals and may have less access to a variety of nutritious foods. Older patients also frequently eat less due to a decreased appetite, decreased sense of smell, and/or mechanical difficulties with chewing or swallowing. Signs and Symptoms General malnutrition often develops slowly, over months or years. As the body’s store of nutrients is depleted, changes begin to happen at the cellular level, affecting biochemical processes and decreasing the body’s ability to fight infections. Over time, a variety of symptoms may begin to emerge, including: * Anemia * Weight loss, decreased muscle mass, and weakness * Dry scaly skin * Edema * Hair that has lost its pigment * Brittle and malformed (spooned) nails * Chronic diarrhea * Slow wound healing * Bone and joint pain * Growth retardation (in children) * Mental changes such as confusion and irritability * Goiter Specific nutrient deficiencies may cause characteristic symptoms. For instance, vitamin B12 deficiency can lead to tingling, numbness, and burning in the hands and feet (due to nerve damage); a lack of vitamin A may cause night blindness and increased sensitivity to light; and a lack of vitamin D can cause bone pain and malformation. The severity of symptoms depends on the intensity and duration of the deficiency. Some changes, such as to bone and nerves, may be irreversible. Tests Malnutrition will often be noticeable to the doctor’s trained eye before it causes significant abnormalities in laboratory test results. During physical examinations, doctors will evaluate patients overall appearance: their skin and muscle tone, the amount of body fat they have, their height and weight, and their eating habits. In the case of infants and children, doctors will look for normal development and a normal rate of growth. If there are signs of malnutrition, the doctor may order general laboratory screening tests to evaluate a patient’s blood cells and organ function. Additional individual tests may be ordered to look for specific vitamin and mineral deficiencies. If general malnutrition and/or specific deficiencies are diagnosed, then laboratory testing may be used to monitor the response to therapy. A person who has malnutrition because of a chronic disease may need to have his or her nutritional status monitored on a regular basis. Hospitalized patients are often assessed for nutritional status prior to or at the time of admission. This may include a history, an interview by a dietician, and laboratory tests. If the results of these tests indicate possible nutritional deficits, patients may be provided nutritional support prior to a surgery or procedure and be monitored regularly during recovery. Laboratory tests may include: For general screening and monitoring: * Lipids * CBC (Complete Blood Count) * CMP (Comprehensive Metabolic Panel) * Albumin * Total protein For nutritional status and deficiencies: * Prealbumin (is decreased in malnutrition, rises and falls rapidly, and can be used to detect short-term response to treatment) * Iron tests (such as Iron, TIBC, and Ferritin) * Vitamin and minerals (such as B12 and Folate, Vitamin D, Vitamin K, Calcium, and Magnesium) Non-Laboratory Tests Imaging and radiographic scans may be ordered to help evaluate the health of internal organs and the normal growth and development of muscles and bones. These tests may include: * X-rays * CT (Computed Tomography) * MRI (Magnetic Resonance Imaging) Treatments Treatment of undernutrition includes: * Restoring the nutrients that are missing, making nutrient-rich foods available, and providing supplements for specific deficiencies. In someone who is severely malnourished, this must be done slowly until the body has had time to adjust to the increased intake and then maintained at a higher than normal level until a normal or near normal weight has been achieved. * Regular monitoring of those patients who have chronic malabsorption disorders or protein- or nutrient-losing conditions. Once the deficiencies have been addressed, putting a treatment plan into place is needed to prevent the malnutrition from recurring. How do you define severe acute malnutrition? Severe acute malnutrition is defined as: * Severe wasting, measured by weight-for-height <70% or <-3SD, or MUAC <110mm for children 6 – 59 months, or clinical signs of severe wasting * And/or oedema of both feet What should be done with children who are mild or moderately wasted? Children with mild or moderate wasting need building up. Since they are not severely wasted or oedematous, then the body’s metabolism will be reasonably intact and they should not need stabilising with F75. These children can be given frequent feeds of F100, RUTF, or any high energy, high protein diet that will provide the building blocks and energy for new tissue synthesis. In the community, children identified with moderate wasting can join a supplementary feeding programme (SFP) if one is available. Can weight-for-age be used to diagnose malnutrition? Low weight-for-age indicates a nutrition problem, but does not specifically identify acute malnutrition. A low weight may be due to stunting, and not wasting. So it is important to consider a child’s weight-for-height or thinness, rather than simply weight-for-age. Feeding can correct wasting but cannot easily correct stunting. |