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and its
CONSEQUENCES
PREVALENCE
OF
MALNUTRITION
Prevalence of Malnutrition in
Hospitalized Patients
10%
Severely Malnourished
21%
Moderately
69% Malnourished
Adequate
Nutritional
State
≤6
PROPORTI >6
ON OF MIS
; ≤ 6; 59,3;
59%
Consumption of
too many
calories
OBESITY
OVERNUTRITION
TYPES OF MALNUTRITION
UNDER-NUTRITION
Micronutrient
Malnutrition
Protein Energy
Malnutrition
• Most
important
PROTEIN ENERGY MALNUTRITION
(protein- calorie wasting, protein-energy wasting)
It is a group of body depletion disorders which
include kwashiorkor, marasmus and the
intermediate stages
MARASMUS
Represents simple starvation . The body adapts to a
chronic state of insufficient caloric intake
KWASHIORKOR
It is the body’s response to insufficient protein intake
but usually sufficient calories for energy
St.Ann's Degree College for
Women
MARASMUS
The term marasmus is derived from the Greek
word marasmos, which means withering or
wasting.
Micronutrient malnutrition
– Vitamin A deficiency (xerophthalmia)
– Thiamin (B1) deficiency (beriberi)
– Niacin (B3) deficiency (pellagra)
– Vitamin C deficiency (scurvy)
– Iron deficiency (anemia)
– Iodine deficiency (goiter, cretinism)
– Riboflavin (B2) deficiency (ariboflavinosis)
TYPE APPEARANCE CAUSE
Acute Wasting or Acute inadequate nutrition leading to rapid
malnutrition thinness weight loss or failure to gain weight normally
Chronic Stunting or Inadequate nutrition over long period of time
malnutrition shortness leading to failure of linear growth
Acute and Underweight A combination measure, therefore, it could
chronic occur as a result of wasting, stunting, or both
malnutrition
ESPEN =
European Society of Perenteral-Enteral Nutrition :
PATHOPHYSIOLOGY
OF
MALNUTRITION
LIPIDS
adipose tissue
Long PROTEINS GLYCOGEN
fat stores Term muscle storage liver storage
energy
few hours
carbohydrate
short term energy
ENERGY
1g of carbohydrates = 4 Kcal
1g of lipids = 9 Kcal
1g of proteins = 7 Kcal
Body storage Daily
(Kcal) consumption
(Kcal/J)
8 Normal Range
4 Partial Starvation
Total Starvation
0
10 20 30 40
Days
Long CL et al. JPEN 1979;3:452-456
PERUBAHAN PROSES METABOLISME PADA STARVASI PENDEK DAN STARVASI PANJANG
Starvasi pendek (< 72 jam) Starvasi panjang (> 72 jam)
Protein
Glukosa
Otot AA Glikogen 320 g
180 g
Glukoneogenesis 8g
76g
Ginjal
Gliserol
30 g
130 g
TG
Jaringan
Lemak LUKA
160 g
Laktat
104g
KEBUTUHAN Konsumsi
bertambah
SEPSIS BERAT
Protein
Otot Glukosa
AA Glikogen 360 g
250 g
Glukoneogenesis 8g
76g
Ginjal
Gliserol
30 g
170 g
Jaringan Massa
Lemak radang
Asam lemak
Laktat 136g
RESPON NEUROENDOKRIN
TERHADAP STRES
Post Starvasi Reaksi
Prandial lama Stress METABOLISME
GLUKOSA PADA
Glukoneogenesis STARVASI DAN
Glikolisis PENYAKIT KRITIS
Oksidasi
asam amino
PROTEIN METABOLISM DURING INJURY
METABOLIC RESPONSE
AFTER TRAUMA
Energy
Temperature Ebb Phase Flow Phase
O2 Consumption
Anabolism
Catabolism
Death
Injury
28
24
Nitrogen Excretion (g/day)
20
16
12
8
4
0
10 20 30 40
Days
BODY
PROTEIN
DIETARY
PROTEIN
STORE
PROTEIN PROTEIN
DEGRADATION SYNTHESIS
WASTE
PRODUCT NITROGEN
BALANCE NITROGEN BALANCE
Negative Positive
Comparison Between protein synthesis
and breakdown in various conditions
Normal Mild trauma Severe trauma Starvation
Baseline
CLINICAL MANIFESTATION
OF
MALNUTRITION
Kapan pasien dicurigai PEM ?
MALNUTRISI KRONIK (marasmus) ditandai dengan
adanya defisiensi kalori berat, berat badan < 80% berat
badan ideal, tebal lipatan kulit (trisep) <3mm, lingkar
lengan atas <15cm, yang ditemukan pada pasien kanker,
PPOK, atau anoreksia nervosa. Tidak didapatkan adanya
gangguan pada sistem imun.
•Decreased subcutaneous tissue: Areas that are most affected are the
legs, arms, buttocks, and face.
•Edema: Areas that are most affected are the distal extremities and
anasarca (generalized edema). See the image below.
•Oral changes
•Cheilosis
•Angular stomatitis
•Papillar atrophy
•Abdominal findings
•Abdominal distension secondary to poor abdominal
musculature
•Hepatomegaly secondary to fatty infiltration
•Skin changes
•Dry peeling skin with raw exposed areas
•Hyperpigmented plaques over areas of trauma
•Nail changes: Nails become fissured or ridged.
•Hair changes: Hair is thin, sparse, brittle, easily pulled
out, and turns a dull brown or reddish color.
NUTRITIONAL PARAMETERS:
CHANGE PER TYPE OF MALNUTRITION
Chronic Acute
Malnutrition Malnutrition Mixed
Weight
Mid-arm Circumference
Albumin
Lymphocyte Count
Immune Function
5
CONSEQUENCIES
OF
MALNUTRITION
MALNUTRITION
Malnutrition AND ITS
and Increased
CONSEQUENCES
Complications
THE EFFECT OF
NUTRITION THERAPY
ON MALNUTRITION
Menilai status Nutrisi dan kondisi klinis penderita
350 65
Pre-albumin Levels
63
250
62
200 61
0 2 4 6 8 10 12
10
0 n = 28 n = 32 n = 9 n = 15 n = 25 n = 27
n = Number of hip fracture patients
Delmi M et al. Lancet
1990
Nutrition Therapy Affects Outcomes:
Early Nutrition
80
76 Days
Length of Stay
40
(days)
30 Days
0
Fed at 3 At 7 days
days Garrel et al. J Burn Rehabil 1991
Overview of MICRONUTRIENT deficiency
disorders and clinical signs
Iron Anemia
Iodine Iodine Deficiency Disorders (IDD)
Vitamin A Xeropthalmia
Zinc Multiple disorders
Overnutrition Undernutrition
OBESITY MALNUTRITION
Macronutrient Micronutrient
Malnutrition Malnutrition
Protein Energy
Malnutrition Malnutrition
(kwashiorkor) (marasmus)
Protein - Energy
Malnutrition SUMMARY
… never let
the
nutrition
status
of your
patient
.. like this
take home
message