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1. PROTEIN-ENERGY
MALNUTRITION

2. INTRODUCTION
The most common cause of malnutrition worldwide is inadequate food supply, although in
industrialized countries, malnutrition usually reflects increased nutrient loss (e.g., malabsorption,
diarrhea, nephrotic syndrome), increased nutrient requirements (e.g., fever, cancer, infection, or
surgery), or both. Among patients admitted to surgical services in industrialized nations, 9% to
27% exhibit signs of severe malnutrition.
Around 45% of deaths among children under 5 years of age are linked to undernutrition. These
mostly occur in low- and middle-income countries. At the same time, in these same countries,
rates of childhood overweight and obesity are rising.
The developmental, economic, social, and medical impacts of the global burden of malnutrition
are serious and lasting, for individuals and their families, for communities and for countries.

3. Malnutrition
Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or
nutrients. The term malnutrition addresses 3 broad groups of conditions:
undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age)
and underweight (low weight-for-age);
micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of
important vitamins and minerals) or micronutrient excess; and
overweight, obesity and diet-related noncommunicable diseases (such as heart disease, stroke,
diabetes and some cancers).

4. Causes of malnutrition
Malnutrition in developed countries is unfortunately still more common in situations of poverty,
social isolation and substance misuse. However, most adult malnutrition is associated with
disease and may arise due to:
reduced dietary intake
reduced absorption of macro- and/or micronutrients
increased losses or altered requirements
increased energy expenditure (in specific disease processes)

5. THE FINDINGS
In children of developing nations, there are two distinct syndromes of protein energy
malnutrition:
Marasmus (profound weight loss, muscle wasting, and fat wasting)
kwashiorkor (abdominal distension, edema, and hypopigmented hair).
In industrialized countries, however, most malnourished patients have less dramatic symptoms
and present instead with combinations of low body weight, atrophy of muscle and subcutaneous
fat, weakness, and various laboratory abnormalities (e.g., low albumin or other serum proteins).

6. Marasmus and kwashiorkor
Marasmus is a severe form of malnutrition — specifically, protein-energy undernutrition. It
results from an overall lack of calories. Marasmus is a deficiency of all macronutrients:
carbohydrates, fats, and protein. People with marasmus are visibly depleted, severely
underweight and emaciated. Children may be stunted in size and development. Prolonged
marasmus leads to starvation.
Kwashiorkor, also known as “edematous malnutrition” because of its association with edema
(fluid retention), is a nutritional disorder most often seen in regions experiencing famine. It is a
form of malnutrition caused by a lack of protein in the diet. People who have kwashiorkor
typically have an extremely emaciated appearance in all body parts except their ankles, feet, and
belly, which swell with fluid.

7. Classification of PEM
It is easy to recognize gross abnormality in the severe forms of PEM. It is much more difficult to
decide the boundary between mild malnutrition and normal light weight or short stature.
Making distinctions between normality and malnutrition provides an area of great controversy
and an opportunity for a variety of classifications, none of which is entirely satisfactory.

8. ARM MUSCLE CIRCUMFERENCE
Arm muscle circumference (AMC) is a decades-old
anthropometric measurement of the amount of
muscle in the arm, which theoretically reflects the total
amount of muscle or protein in the body.
The clinician measures the upper arm circumference
(Ca, using a flexible tape measure) and the triceps
skinfold thickness (h, using calipers) and estimates
AMC with the following formula:
AMC =Ca −πh

9. Midupper Arm Circumference (MUAC)
MUAC is a measure of the sum of the muscle and subcutaneous fat in the upper arm. In severe
malnutrition both fat and muscle are reduced in the upper arm. Edema may increase a limb's
circumference but it is not usually a problem of the upper arm.
MUAC can be used as a indicator of body composition in adults and children.
Since MUAC increases little between the age of 6 months and 5 years, it can be used in
preschool children as an age-independent screening tool for severe malnutrition.
An MUAC less than 12.5 cm suggests malnutrition; an MUAC greater than
13.5 cm is normal.

10. GRIP STRENGTH
Grip strength is a measure of muscular strength or the maximum force/tension generated by
one's forearm muscles. It can be used as a screening tool for the measurement of upper body
strength and overall strength. It is most useful when multiple measurements are taken over time
to track performance.
Based on the hypothesis that malnutrition influences the outcome of surgical patients and that
muscle weakness is an important sign of malnutrition, Klidjian et al. in 1980 investigated 102
surgical patients and demonstrated that hand grip strength accurately predicts postoperative
complications.In their method, the patient squeezes a simple handheld spring dynamometer 3
times, resting 10 seconds between each attempt, and the clinician records the highest value
obtained. (Patients with arthritis, stroke, or other obvious causes of weakness are excluded.)

11. GRIP STRENGTH
Grip strength is often used in medicine as a specific type of hand strength. The purpose of this
testing is diverse, including to diagnose diseases, to evaluate and compare treatments, to
document progression of muscle strength, and to provide feedback during the rehabilitation
process as a measure indicating the level of hand function.
In medicine, doctors sometimes use grip strength to test a patient's mentality, as grip strength
directly correlates to mental state. Grip strength is also used to measure the degree of
rehabilitation from injuries;
Additionally, grip strength can be used to determine a patient's physical stability. Measuring this
in intervals allows a doctor to determine if a patient is making progress or if different methods
need to be used. There is a direct correlation between grip strength of older people and their
overall body strength. This correlation helps doctors with treating the elderly a lot, because it
allows doctors to see how well an elderly person is functioning.

13. Consequences of malnutrition
Malnutrition affects the function and recovery of every organ system.
Muscle function
Weight loss due to depletion of fat and muscle mass, including organ mass, is often the most obvious sign
of malnutrition. Muscle function declines before changes in muscle mass occur, suggesting that altered
nutrient intake has an important impact independent of the effects on muscle mass.
Cardio-respiratory function
Reduction in cardiac muscle mass is recognised in malnourished individuals. The resulting decrease in
cardiac output has a corresponding impact on renal function by reducing renal perfusion and glomerular
filtration rate. Micronutrient and electrolyte deficiencies may also affect cardiac function. Poor
diaphragmatic and respiratory muscle function reduces cough pressure and expectoration of secretions,
delaying recovery from respiratory tract infections.

14. Consequences of malnutrition
Gastrointestinal function
Adequate nutrition is important for preserving GI function: chronic malnutrition results in changes in
pancreatic exocrine function, intestinal blood flow, villous architecture and intestinal permeability. The
colon loses its ability to reabsorb water and electrolytes, and secretion of ions and fluid occurs in the
small and large bowel. This may result in diarrhoea, which is associated with a high mortality rate in
severely malnourished patients.
Immunity and wound healing
Immune function is also affected, increasing the risk of infection due to impaired cell-mediated
immunity and cytokine, complement and phagocyte function. Delayed wound healing is also well
described in malnourished surgical patients.
Psychosocial effects
In addition to these physical consequences, malnutrition also results in psychosocial effects such as
apathy, depression, anxiety and self-neglect.

15. WEIGHT LOSS
Involuntary weight loss reflects diuresis, decreased caloric intake, or the increased caloric
requirements of malabsorption, glucosuria, or a hypermetabolic state.
Organic disease is diagnosed in 65% of patients presenting with involuntary weight loss exceeding
5% of their usual weight (most commonly cancer and gastrointestinal disorders, although
virtually any chronic disease may cause weight loss), and psychiatric disorders are diagnosed in
10% of patients (depression, anorexia nervosa, schizophrenia). In 25% of patients, the cause
remains unknown despite at least 1 year of follow-ups

16. CLINICAL SIGNIFICANCE:
Weight loss is rarely due to occult disease, and most diagnoses are made during the initial evaluation,
including the patient interview, physical examination, and basic laboratory testing.
In patients with involuntary weight loss, the presence of alcoholism and cigarette smoking increase the
probability that an organic cause will be discovered during a 6-month follow-up, whereas prior psychiatric
disease and a normal initial physical examination decrease the probability of discovering organic disease.
Also, the patient’s perceptions of the weight loss— whether he or she significantly underestimates or
overestimates it—help predict the final diagnosis.
The patient is asked to estimate his or her weight before the illness (W) and the amount of weight lost
(E). The observed weight loss (O) is the former weight (W) minus the current measured weight.
Significant underestimation of weight loss, defined as (O − E) greater than 0.5 kg, predicts an organic
cause of weight loss.
Significant overestimation of weight loss, defined as (E − O) greater than 0.5 kg, predicts a nonorganic
cause of weight loss.

17. Obesity
Obesity increases the risk of coronary artery disease, diabetes, hypertension, osteoarthritis,
cholelithiasis, certain cancers, and overall mortality. Clinicians have recognized the hazards of
obesity for thousands of years (according to one Hippocratic aphorism, “Sudden death is more
common in those who are naturally fat than in the lean”). Two-thirds of US adults are overweight
or obese.
Several different anthropometric parameters have been used to identify those patients at
greatest risk for medical complications due to obesity. The most important ones are body mass
index (BMI), skinfold thickness, waist-to-hip ratio (WHR), waist circumference, and abdominal
sagittal diameter.

18. BODY MASS INDEX
THE FINDING BMI (or the Quetelet index) is the patient’s
weight in kilograms divided by the square of his height in
meters (kg/m2).
BMI was derived by a 17th-century Belgian mathematician
and astronomer, Lambert-Adolphe-Jacques Quetelet, who
discovered that this ratio best expressed the natural
relationship between weight and height

19. CLINICAL SIGNIFICANCE
BMI is an easy and reliable measurement that correlates well with precise measures of total
body fat much better than other formulas of weight (W) and height (H). BMI also correlates
significantly with a patient’s cholesterol level, blood pressure, incidence of coronary events, and
overall mortality
The arbitrary cutoff of 25 kg/m2 was chosen in part because it reflects the level at which there is
a significant increase in mortality. Many studies of BMI and mortality revealed a J-shaped
relationship (i.e., both lean and overweight patients have increased mortality), but the increased
risk of lean individuals is likely explained by cigarette use, short duration of follow-up, and
illness-related weight loss.

20. SKINFOLD THICKNESS
Another measure of obesity is total skinfold thickness, which is
estimated by adding together the skinfold thickness (measured with
calipers) of multiple sites .
Skinfold measurement is a technique to estimate how much fat is on
the body. It involves using a device called a caliper to lightly pinch the
skin and underlying fat in several places. This quick and simple method
of estimating body fat requires a high level of skill to get accurate
results.

21. WAIST-TO-HIP RATIO
WHR is the circumference of the waist divided by that of the hips. It is based on the premise that
the most important characteristic of obesity is its distribution, not its quantity.
Abdominal obesity has a much worse prognosis than gluteal-femoral obesity (also called gynoid,
lower body, or pear-shaped obesity). Most authorities measure the waist circumference at the
midpoint between the lower costal margin and the iliac crest and the hip circumference at the
widest part of the gluteal region. Adverse health outcomes increase significantly when WHR
exceeds 1 in men and 0.85 in women, values that are close to the top quintiles in
epidemiological studies.
The French diabetologist Jean Vague is usually credited with making the observation in the
1940s that abdominal obesity, more common in men, is associated with worse health outcomes
than obesity over the hips and thighs, more common in women.

22. how measure waist to hip ratio?
to measure it yourself:
Stand up straight and breathe out. Use a tape measure to check the distance around the
smallest part of your waist, just above your belly button. This is your waist circumference.
Then measure the distance around the largest part of your hips — the widest part of your
buttocks. This is your hip circumference.
Calculate your WHR by dividing your waist circumference by your hip circumference.
In both men and women, a
WHR of 1.0 or higher
increases the risk of heart
disease and other conditions
that are linked to having
overweight.

23. PATHOGENESIS
The main contributor to abdominal obesity is visceral fat (i.e., omental, mesenteric, and
retroperitoneal fat), not subcutaneous fat. Visceral fat is metabolically active, constantly
releasing free fatty acids into the portal circulation, which probably contributes to
hyperlipidemia, atherogenesis, and hyperinsulinemia.
Gluteal-femoral fat, on the other hand, is metabolically inactive except during pregnancy and
the postpartum period, which has led some to suggest that the role of lower body fat is to help
guarantee the survival of the species by providing a constant source of energy to the lactating
female even when external nutrients are unavailable.

24. WAIST CIRCUMFERENCE
Waist circumference is simply the numerator of WHR calculation. It has the advantages of being
simpler to measure and avoiding any consideration of the hips, which, because they encompass
bone and skeletal muscle as well as fat, should have no biologically plausible relationship to
diabetes, hypertension, and atherosclerosis. Recommended cutoffs for increased health risk are
a waist circumference >102 cm (>40 inches) for men and >88 cm (>35 inches) for women.
Waist circumference is strongly associated with risk of death, independent of BMI. Waist
circumference is also a criterion for the metabolic syndrome (defined as the presence of three or
more of the following five variables: large waist circumference, hypertension, elevated
triglycerides, reduced HDL cholesterol, and elevated fasting glucose).

25. SAGITTAL DIAMETER
Because waist circumference encompasses both subcutaneous and visceral fat, investigators have
looked for better anthropometric measures of just visceral fat.
One proposed measure is the sagittal diameter, which is the total anterior-posterior distance
between the anterior abdominal wall of the supine patient and the surface of the examining table.
Sagittal abdominal diameter (SAD) is a measure of visceral obesity, the amount of fat in the gut
region. SAD is the distance from the small of the back to the upper abdomen. SAD may be measured
when standing or supine.
SAD is a strong predictor of coronary disease, with higher values indicating increased risk
independent of BMI.
For persons of normal BMI, SAD should be under 25 centimetres. The amount this measure exceeds
30 centimetres (12 in) correlates to increased cardiovascular risk and insulin resistance. SAD measure
of men in their 40s, greater than 25 cm, also predicts significantly higher risk of Alzheimer's disease
30 years later.

26. Cushing Syndrome
Cushing syndrome refers to those clinical findings induced by excess circulating glucocorticoids,
such as hypertension, central obesity, weakness, hirsutism (in women), depression, skin striae,
and bruises.
The most common cause is exogenous administration of corticosteroid hormones. Endogenous
Cushing syndrome results from pituitary tumors producing the adrenocorticotropic hormone
ectopic production of ACTH, adrenal adenomas (10% of cases), or adrenal carcinoma (5% of
cases).
Cushing disease and the ectopic ACTH syndrome are referred to as ACTH-dependent disease,
because the elevated cortisol levels are accompanied by inappropriately high ACTH levels.
Adrenal tumors are indicative of ACTH independent disease.
The bedside findings of Cushing syndrome were originally described by Harvey Cushing in 1932.
Corticosteroid hormones were first used as therapeutic agents to treat patients with rheumatoid
arthritis in 1949; within 2 years, clear descriptions of exogenous Cushing syndrome appeared.

27. What are the symptoms of Cushing's syndrome?
Upper body obesity with thin arms and legs
Round face
Increased fat around neck or a fatty hump
between the shoulders
Reddened, thin, fragile skin that is slow to heal
Reddish-blue stretch marks on the underarms,
belly, thighs, buttocks, arms, and breasts
Bone and muscle weakness
Severe tiredness (fatigue)
High blood pressure
High blood sugar
Irritability and anxiety or depression
Extra facial and body hair growth in women
Irregular or stopped menstrual cycles in
women
Reduced fertility in men
Each person may have symptoms in a different way. These are the most common
signs and symptoms:

28. BODY HABITUS
Patients with Cushing syndrome develop central obesity (also known as truncal obesity or
centripedal obesity), a term describing accumulation of fat centrally on the neck, chest, and
abdomen, which contrasts conspicuously with the muscle atrophy affecting the extremities.
There are three definitions of central obesity:
1) Obesity sparing the extremities (a subjective definition and also the most common one).
2) The central obesity index, a complicated ratio of the sum of 3 truncal circumferences (neck,
chest, and abdomen) divided by the sum of 6 limb circumferences (bilateral arms, thighs, and
lower legs). Values higher than 1 are abnormal.
3) Obesity as defined by an abnormal waist-to-hip circumference. The abnormal waist-to-hip
circumference is not recommended because there are many false positives (i.e. for Cushing
syndrome).

29. characteristic features of the Cushing
body
Other characteristic features of the Cushing body habitus are accumulation of fat in the
bitemporal region (moon facies), between the scapulae and behind the neck (buffalo hump), in
the supraclavicular region (producing a “collar” around the base of the neck), and in front of the
sternum.
Many experts state that the buffalo hump is not specific to Cushing syndrome but accompanies
weight gain from any cause;this hypothesis has not been formally tested. Morbid obesity is rare
in Cushing syndrome.
The truncal obesity of Cushing syndrome reflects increased intra-abdominal visceral fat, not
subcutaneous fat,probably from glucocorticoid-induced reduction in lipolytic activity and
activation of lipoprotein lipase, which allows tissues to accumulate triglyceride

30. HYPERTENSION
Hypertension is one of the most distinguishing features of endogenous Cushing’s syndrome (CS), as it is
present in about 80% of adult patients whereas in children its prevalence is about 47%.
Glucocorticoids cause hypertension through several mechanisms:
1. their intrinsic mineralocorticoid activity;
2. through activation of the renin-angiotensin system;
3. by enhancement of vasoactive substances, and
4. by causing suppression of the vasodilatory systems.
In addition, glucocorticoids may exert some hypertensive effects on cardiovascular regulation through the CNS
via both glucocorticoid and mineralocorticoid receptors.
Hypertension in CS usually resolves with surgical removal of the tumor, but some patients require
pharmacological antihypertensive treatment both pre- and postoperatively.

31. SKIN FINDINGS
The characteristic skin findings associated with Cushing syndrome are thin skin, striae, plethora,
hirsutism (in women), acne, and ecchymoses.
Significant thinning of the skin probably arises from corticosteroid-induced inhibition of
epidermal cell division and dermal collagen synthesis. To measure skin thickness, many experts
recommend using calipers (either skinfold calipers or electrocardiograph calipers) on the back of
the patient’s hand, an area lacking significant subcutaneous fat and thus representing just
epidermis and dermis.
In women of reproductive age, this skinfold should be thicker than 1.8 mm. Precise cutoffs have
not been established for men, whose skin is normally thicker than women’s, or for elderly
patients, whose skin is normally thinner than younger patients

32. SKIN FINDINGS
The striae in patients presenting with Cushing syndrome are wide (>1 cm) and colored deep red
or purple, in contrast to the thinner, paler pink or white striae that occur normally during rapid
weight gain of any cause.
Striae are usually found on the lower abdomen but may occur on the buttocks, hips, lower back,
upper thighs, and arms. In one of Cushing’s original patients, wide striae extended from the
lower abdomen to the axillae.
Pathologically, striae are dermal scars, with collagen fibers all aligned in the direction of stress,
covered by an abnormally thin epidermis.
The pathogenesis of striae is not understood, but they may result from rupture of the weakened
connective tissue of the skin, under tension from central obesity, which leaves a thin translucent
window to the red and purple colored dermal blood vessels. Striae are more common in
younger patients with Cushing syndrome than in older patients

33. SKIN FINDINGS
Plethora is an abnormal, diffuse purple or reddish color of the face.Hirsutism and acne occur
because of increased adrenal androgens.
Ecchymoses probably appear because the blood vessels, lacking connective tissue support and
protection, are more easily traumatized. The severity of striae, acne, and hirsutism correlates
poorly with cortisol levels, indicating that other factors—temporal, biochemical, or genetic—
play a role in these physical signs.

34. PROXIMAL WEAKNESS Painless proximal weakness of the legs is common and prominent in
Cushing syndrome, especially in elderly patients.Because this weakness is a true myopathy,
patients lack fasciculation, sensory changes, or reflex abnormalities.
DEPRESSION Patients with Cushing syndrome present with crying episodes, insomnia,
impaired concentration, difficulty with memory, and suicide attempts. The severity of
depression correlates with the cortisol level,and unless the depression antedates the
endocrine symptoms by years, it usually improves dramatically after treatment

35. PSEUDO-CUSHING SYNDROME
Several disorders, including chronic alcoholism, depression, and HIV infection, may mimic the
physical and biochemical findings of Cushing syndrome and can thus be categorized as pseudo-
Cushing syndrome.
Patients with chronic alcoholism may develop the physical findings or the biochemical
abnormalities associated with Cushing syndrome, or both, most likely due to the overproduction
of ACTH by the hypothalamic-pituitary axis, an abnormality that resolves after several weeks of
abstinence.
Depressed patients may have the biochemical abnormalities of Cushing syndrome, but they
usually lack the physical findings.
Patients with HIV infection, particularly if they are receiving protease inhibitors, may develop
some of the physical findings (especially the buffalo hump and truncal obesity) but rarely the
biochemical abnormalities

36. The findings that significantly increase the
probability of Cushing syndrome are thin
skinfold, ecchymoses , central obesity , and
plethora
The findings that decrease the probability of
Cushing syndrome are generalized obesity
absence of moon facies , absence of central
obesity , and normal skinfold thickness

37. ETIOLOGY OF CUSHING SYNDROME AND
BEDSIDE FINDINGS
Patients who take exogenous corticosteroids have the same frequency of central obesity, moon
facies, and bruising as patients with endogenous Cushing, but a significantly lower incidence of
hypertension, hirsutism, acne, striae, and buffalo humps.
Patients with the ectopic ACTH syndrome from small cell carcinoma are more often male, have
Cushing syndrome of rapid onset (over months instead of years), and present with prominent
weight loss, myopathy, hyperpigmentation, and edema. The irregular hepatomegaly of
metastatic disease may suggest this diagnosis.
In studies of patients with ACTH-dependent Cushing syndrome, two findings increase the
probability of ectopic ACTH syndrome: weight loss and symptom duration less than 18 months.
Hirsutism and acne may occur in any woman with endogenous Cushing syndrome, but the
presence of virilization (i.e., male pattern baldness, deep voice, male musculature,
clitoromegaly) argues strongly for adrenocortical carcinoma

38. How is Cushing's syndrome diagnosed?
24-hour urinary test to measure the level of corticosteroid hormones
CT scan. This scan uses X-rays and computer technology to make detailed images of the body.
MRI. This scan creates detailed pictures of internal organs and structures.
Dexamethasone suppression test. This test can tell whether your body is making more cortisol
than normal. If so, you would need more tests. You might also need more tests to tell if the extra
amount of hormones is coming from the pituitary gland or from a tumor elsewhere in your body.
Other lab tests. These should include a late evening salivary cortisol level and an ACTH level.

39. Treatment
Treatment depends on what is causing Cushing's syndrome. may need surgery to remove tumors
or the adrenal glands. Other treatments may include:
Radiation
Chemotherapy
Certain hormone-inhibiting medicines

40. Key points about Cushing's syndrome
Cushing's syndrome often happens when pituitary gland makes too much adrenocorticotropin
hormone. That causes the adrenal glands to make too many corticosteroids.
Cushing's syndrome is fairly rare. It most often affects adults who are 20 to 50 years old.
Symptoms may include upper body obesity, round face, and thin skin with bruising.
Treatment depends on the cause. It may include surgery, radiation, chemotherapy, or medicines.