This document discusses different types of malnutrition including primary and secondary malnutrition. It describes the clinical syndromes of marasmus and kwashiorkor that represent the two extremes of protein-energy malnutrition (PEM). Marasmus is characterized by loss of muscle and fat mass while kwashiorkor presents with edema and skin changes. Anorexia nervosa, bulimia, cachexia and starvation are also summarized as forms of self-induced malnutrition.

1. PEM
ANOREXIANERVOSA
BULIMIA

2. Healthy diet provides
Sufficient
energy
Essential as
well as
nonessential
amino acids &
fatty acids
Vitamins &
minerals

3. PRIMARY MALNUTRITION:
• One or all of these
components are missing from
the diet
SECONDARY
MALNUTRITION:
• Dietary intake of nutrients is
adequate, and malnutrition
develops frommalabsorption,
impaired utilizationor
storage, excess loss or
increased requirements

4.  Common in poor countries.
 Malnutrition is the major cause of deathin infancy &
childhood in this population.
 PEMmanifests as a range of clinical syndromes
 Two ends of spectrumof syndromes
▪ Marasmus
▪ Kwashiorkor

5. Protein
compartments
Somatic
compartment
• Proteins in
skeletal muscles
Visceral
compartment
• Protein stores in
visceral organs
MARASMUS KWASHIORKOR

6.  Weight level falls to 60%of normal sex, height andage.
 Growth retardation & loss of muscle mass as a result of
protein catabolism.
 Adaptive response to provide amino acids as alternate
source

7.  Serumalbumin levels are either normal or only slightly
reduced
 Subcutaneous fat is also used as fuel
Leptin production low
Hypothalamic -
pituitary-
adrenal axis
stimulated
High cortisol
contributes to
lipolysis
 Extremities are emaciated

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

9.  Anemia and manifestations of multivitamin
deficiencies
 Immune deficiency particularly of T cell mediated
immunity.
 Concurrent infections

10.  Protein 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

11.  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

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

13.  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

14.  In chronically ill or hospitalized patients.
 Cachexia
 Severe form
 Advancedcancer patients
 Loss of appetite
 Proteolysisinducingfactor{Cachectins}
 Cytokines

16.  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.

17.  Decreasedthyroidhormonerelease:
 Cold intolerance
 Bradycardia
 Constipation
 Changes in the skinand hair
 Dehydration and electrolyte abnormalities
 Bonedensityis decreased(lowestrogenlevel)
 Anemia, lymphopenia, hypoalbuminemia

18.  Patient 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.

19. I. Electrolyte imbalances (hypokalemia), which
predispose the patient to cardiac arrhythmias
II. Pulmonary aspiration of gastric contents;
III. Esophageal and gastric rupture.