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The clinical manifestations of protein energy malnutrition range from mild growth retardation and weight loss to a number of distinct clinical syndromes Children in the developing world manifest marasmus and kwashiorkor In secondary protein energy malnutrition as seen in industrialized nations, clinical manifestations are affected by the degree of protein and energy deficiency, the underlying illness that resulted in the deficiency, and the patient s nutritional status prior to illness Progressive wasting that begins with weight loss and proceeds to more severe cachexia typically develops in most patients with marasmus-like secondary protein energy malnutrition In the most severe form of this disorder, most body fat stores disappear and muscle mass decreases, most noticeably in the temporalis and interosseus muscles Laboratory studies may be unremarkable serum albumin, for example, may be normal or slightly decreased, rarely decreasing to < 28 g/dL In contrast, owing to its rapidity of onset, kwashiorkorlike secondary protein energy malnutrition may develop in patients with normal subcutaneous fat and muscle mass or, if the patient is obese, in patients with excess fat and muscle The serum protein level, however, typically declines and the serum albumin is often < 28 g/dL Dependent edema, ascites, or anasarca may develop As with primary protein energy malnutrition, combinations of the marasmus-like and kwashiorkor-like syndromes can occur simultaneously, typically in patients with progressive chronic disease in whom a superimposed acute illness develops
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The treatment of severe protein energy malnutrition is a slow process requiring great care Initial efforts should be directed at correcting fluid and electrolyte abnormalities and infections Of particular concern are depletion of potassium, magnesium, and calcium and acid base abnormalities The second phase of treatment is directed at repletion of protein, energy, and micronutrients Treatment is started with modest quantities of protein and calories calculated according to the patient s actual body weight Adult patients are given 1 g of protein and 30 kcal/ kg Concomitant administration of vitamins and minerals is obligatory Either the enteral or parenteral route can be used, although the former is preferable Enteral fat and lactose are withheld initially Patients with less severe protein calorie undernutrition can be given calories and protein simultaneously with the correction of fluid and electrolyte abnormalities Similar quantities of protein and calories are recommended for initial treatment Patients treated for protein energy malnutrition require close follow-up In adults, both calories and protein are advanced as tolerated, adults to 15 g/kg/d of protein and 40 kcal/kg/d of calories Patients who are re-fed too rapidly may develop a number of untoward clinical sequelae During refeeding, circulating potassium, magnesium, phosphorus, and glucose move intracellularly and can result in low serum levels of each The administration of water and sodium with carbohydrate refeeding can overload hearts with depressed cardiac function and result in congestive heart failure Enteral refeeding can
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Excess adipose tissue, resulting in BMI > 30 Upper body obesity (abdomen and flank) of greater health consequence than lower body obesity (buttocks and thighs) Associated with multiple metabolic and structural disorders, including diabetes mellitus, hypertension, and hyperlipidemia
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Obesity is one of the most common disorders in medical practice and among the most frustrating and difficult to manage Little progress has been made in prevention or treatment, yet major changes have occurred in our understanding of its causes and its implications for health
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Obesity is defined as an excess of adipose tissue Accurate quantification of body fat requires sophisticated techniques
Nutritional Disorders
not usually available in clinical practice Physical examination is usually sufficient to detect excess body fat More quantitative evaluation is performed by calculating the BMI The BMI closely correlates with excess adipose tissue It is calculated by dividing measured body weight in kilograms by the height in meters squared The National Institutes of Health (NIH) define a normal BMI as 185 249 Overweight is defined as BMI = 25 299 Class I obesity is 30 349, class II obesity is 35 399, and class III (extreme) obesity is BMI > 40 Factors other than total weight, however, are also important Upper body obesity (excess fat around the waist and flank) is a greater health hazard than lower body obesity (fat in the thighs and buttocks) Obese patients with increased abdominal circumference (> 102 cm in men and 88 cm in women) or with high waist hip ratios (> 10 in men and > 085 in women) have a greater risk of diabetes mellitus, stroke, coronary artery disease, and early death than equally obese patients with lower ratios Further differentiation of the location of excess fat suggests that visceral fat within the abdominal cavity is more hazardous to health than subcutaneous fat around the abdomen Current US survey data demonstrate that 65% of Americans are overweight and 304% are obese Women in the United States are more apt to be obese than men, and AfricanAmerican and Mexican-American women are more obese than whites The poor are more obese than the rich regardless of race
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