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MALNUTRITION

and its
CONSEQUENCES

Course On Medical Nutrition & Treatment


OBJECTIVES

1.To describe the prevalence of malnutrition


2.To describe the types of malnutrition
3.To describe the pathophysiology of malnutrition
4.To describe clinical manifestation of malnutrition
5.To explain the consequences of malnutrition
6.To describe the effect of nutrition therapy on
malnutrition
1

PREVALENCE
OF
MALNUTRITION
Prevalence of Malnutrition in
Hospitalized Patients

10%
Severely Malnourished

21%
Moderately
69% Malnourished
Adequate
Nutritional
State

Detsky et al. JPEN


Prevalence of Malnutrition in
Hospitalized Patients

In a published British study:


46% of general medicine patients
45% of patients with respiratory problems
27% of surgical patients
43% of elderly patients
Percentage of malnourished patients at time of
admission

McWhirter et al. Br Med J 1994


PREVALENSI MALNUTRISI DI
INDONESIA

Riskesdas 2007 menunjukkan bahwa


sebanyak 19 provinsi mempunyai
prevalensi Gizi Buruk dan Gizi Kurang diatas
prevalensi nasional sebesar 18,4%.
SCREENING OF NUTRITIONAL STATUS USING
MALNUTRITION INFLAMMATION SCORE (MIS)
IN CHRONIC HEMODIALYSIS PATIENTS IN BANDUNG
Roesli RMA & Abdurachman AM
PROPORTI
PROPORTION OF MIS
ON OF MIS
; > 6; 40,7;
41%

≤6

PROPORTI >6
ON OF MIS
; ≤ 6; 59,3;
59%

PROPORTION OF MODERATE TO SEVERE MALNUTRITION 40.7


% IN CHRONIC HEMODIALYSIS PATIENT IN BANDUNG

NO CORRELATION BETWEEN MIS EITHER WITH ETIOLOGY


NOR DURATION OF HEMODIALYSIS
Hospital Malnutrition:
Critical Evidence

The Skeleton in the Hospital Closet


• Height not recorded in 56% of cases
• Body weight not recorded in 23% of cases
• 61% of those whose weight was recorded lost > 6 kg
• 37% had albumin < 3.0 g/dL
“I am convinced that iatrogenic malnutrition has become a significant
factor in determining disease outcomes in many patients.”

Butterworth CE. Nutr Today 1974


TYPES OF MALNUTRITION
2
DEFINITIONS
 MALNUTRITION
WHO defines Malnutrition as "the cellular
imbalance between the supply of nutrients and
energy and the body's demand for them to ensure
growth, maintenance, and specific functions.“

Malnutrition is the condition that develops when the body


does not get the right amount of the vitamins, minerals,
and other nutrients it needs to maintain healthy tissues
and organ function.

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Women
TYPES OF MALNUTRITION

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
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Women
MARASMUS
 The term marasmus is derived from the Greek
word marasmos, which means withering or
wasting.

 Marasmus is a form of severe protein-energy


malnutrition characterized by energy deficiency
and emaciation.

 Primarily caused by energy deficiency,


marasmus is characterized by stunted growth
and wasting of muscle and tissue.
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Women
KWASHIORKOR
 The term is taken from the Ga language of Ghana
and means "the sickness of the weaning”.
 Williams first used the term in 1933, and it refers
to an inadequate protein intake with reasonable
caloric (energy) intake.
 Kwashiorkor, also called wet protein-energy
malnutrition, is a form of PEM characterized
primarily by protein deficiency.

St.Ann's Degree College for


Women
Malnutrition in emergencies
 Protein-energy malnutrition (PEM)
– Marasmus
– Kwashiorkor
– Marasmic kwashiorkor

 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 :

[] Starvasi sederhana ( simple starvation) akibat


tidak terpenuhinya kebutuhan energy dan
protein (protein-energy malnutrition), tipe ini
menjurus ke malnutrisi tipe marasmus

[] Starvasi stress (stress starvation) diakibatkan


terutama karena kebutuhan protein yang tidak
terpenuhi, tipe ini menjurus ke malnutrisi tipe
Kwashiorkor.
DEFINISI
MALNUTRISI
MENURUT ASPEN
3

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)

Carbo-hydrates: 680 carbohydrates: 700


(brain) (80%)
lipids : 100 000 lipids: 860

Proteins: 25 000 proteins: 240

But : 1g of carbohydrates = 4 Kcal


To store 1g of carbohydrate 1g of lipids = 9 Kcal
2.5 g of water must be stored! 1g of proteins = 7 Kcal

Hence, lipidic storage is clearly advantageous”


Component Mass Energy Availability
(kg) (kcal) (days)

Body water and minerals 49 0 0


Protein 6 24.000 13
Glycogen 0.2 800 0.4
Fat 15 140.000 78
Total : 70 164.800 91.4

Data adapted from Cahill GF N Engl J Med 1970;282-668-75


Availability is the duration for which the energy supply would last based upon an
1800 kcal/day resting energy consumption
Konsumsi
INTAKE
berkurang PUASA (1-2 hari)

Sumber energi 144 g


Protein
Otot Glukosa
AA Glikogen
75 g 180 g
Jaringan
Glukoneogenesis hemopoi-
etik
Gliserol 36 g
TG 16 g
Jaringan Laktat + Piruvat
40 g
Lemak Keton Jantung
160 g 60 g
FA Ginjal
160 g 120 g Otot
INTAKE
Sangat berkurang
PUASA (5-6 minggu)
Keton 47 g
Sumber energi
44 g
Protein
Otot Glukosa 80 g
AA Glikogen
20 g Jaringan
36g
GLUKONEOGENESIS hemopoi-
etik
Gliserol 50 g
15 g
TG Laktat + piruvat
Jaringan 36 g Keton
lemak 57 g
Jantung
150 g FA Ginjal
150 g Otot
112 g
0-6 hours after eating 6-72 hours after eating

0-6 hours after eating


our bodies start to break down glycogen to
produce glucose. Glucose is our primary fuel
source; in storage mode. Glucose gets
packed into our liver and muscle, with the
fatty acids getting stored around our body
for (potential) future use.
6-72 hours after eating
enter into a state of ketosis the first
significant metabolic phase shift as you
enter into starvation. At this point, all your
glycogen stores will have been exhausted,
and your body start hitting the fatty acids for
energy. During lipolysis, fatty acids are
directly broken down to produce ketone
bodies.
Energy Expenditure in Starvation
12
Nitrogen Excretion (g/day)

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)

Starvasi pendek (< 72 jam) Starvasi panjang (> 72 jam)


KEBUTUHAN
bertambah
TRAUMA MAYOR
Sumber energi 114 g

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

Sumber energi 114 g

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 glukosa   


Siklus glukosa   

Post Starvasi Reaksi


Prandial lama Stress METABOLISME
Proteolisis    PROTEIN PADA
STARVASI DAN
Proteosintesis    PENYAKIT KRITIS

Oksidasi
  
asam amino
PROTEIN METABOLISM DURING INJURY
METABOLIC RESPONSE
AFTER TRAUMA

EBB & FLOW


PHASES

Energy
Temperature Ebb Phase Flow Phase
O2 Consumption
Anabolism

Catabolism

Death

Injury

Minutes Hours Days…………………Weeks


Metabolic Response to Trauma
Long CL, et al. JPEN 1979;3:452-456

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

N-balance Negative Negative Slightly Negative


N-balance N-balance N-balance
Synthesis Breakdown VINNARS; 1984
4

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.

MALNUTRISI AKUT (kwashiorkor) peningkatan kebutuhan


protein pada kondisi trauma berat atau kerusakan jaringan
akut atau pada keadaan hipermetabolik. Status gizi pasien
biasanya masih baik, namun didapatkan tanda berupa
rambut mudah rontok, edema, serum albumin <2,8g/dL,
TIBC <200 g/dL, limfosit total < 1500/mm3.

MALNUTRISI KOMBINASI adalah kondisi malnutrisi


kronik yang diperberat oleh malnutrisi akut / inflamasi.
MARASMUS
( starvation)
 Defisiensi kalori berat
 Tampak kurus
 Berat badan < 80%
 TSF < 3 mm
 MAMC < 15 cm
 Penyakit: Kanker, COPD,
anorexia nervosa
 Sistem imun tidak tertekan
seperti pada Kwashiorkor
KWASHIORKOR
(stress/ injury)
 Kebutuhan protein pada
keadaan stres
 Dapat terjadi dalam beberapa
minggu
 Terlihat gizi baik; Rambut mudah
rontok, Edema
 Serum albumin < 2,8 g/dl
 TIBC < 200 g/dl
 TLC < 1500/mm3
 Anergi
 Luka sukar sembuh
MARASMIC KWASHIORKOR
 Bila stres akut seperti pembedahan, trauma dan
infeksi dialami oleh pasien yang sudah starvasi
kronis
 Bentuk paling berat dan mengancam jiwa
 Marasmic kwashiorkor bersifat hipometabolik
dan memiliki risiko bila mendapat nutrisi
berlebihan
 DIFFERENCE IN
 CLINICAL FEATURES BETWEEN
 MARASMUS
 AND
 KWASHIORKOR

St.Ann's Degree College for


Women
Malnutrition Clinical Presentation
PHYSICAL FINDINGS that are associated with PEM include the following:

•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

Many studies have shown that complications


are 2 to 20 times more frequent in
malnourished patients than in well-nourished
patients.

Buzby et al. Am J Surg 1980


Hickman et al. JPEN 1980
Klidjian et al. JPEN 1982
MALNUTRITION AND ITS
CONSEQUENCES
Changes in intestinal barrier Loss of weight
Reduction in glomerular Slow wound healing
filtration Impaired immunity
Alterations in cardiac function Increase in length of
Altered drug hospital stays
pharmacokinetics Increased treatment
costs
Increase in mortality
Roediger 1994; Green 1999; Zarowitz 1990
5

THE EFFECT OF
NUTRITION THERAPY
ON MALNUTRITION
Menilai status Nutrisi dan kondisi klinis penderita

Hitung kebutuhan nutrisi


(energi, protein, lemak, elektrolit, dll)

Memilih Komposisi Terapi Nutrisi

Menentukan Teknik & Skema


Pemberian terapi Nutrisi

Monitor : Efek & Komplikasi terapi Nutrisi


ASPEN
Nutrition Therapy Affects Outcomes:
Improvement in Pre-albumin with PEG
Pre-albumin Body weight

350 65
Pre-albumin Levels

Body Weight (kg)


64
300
(mg/kg)

63

250
62

200 61
0 2 4 6 8 10 12

Weeks of Radiation Therapy


Fietkau et al. Recent Results Cancer Res
1991
Nutrition Therapy Affects Outcomes:
Fewer Complications
1st hospitalization 2nd hospitalization At 6 months
15 With Nutrition Therapy
Without Nutrition Therapy
Number of Complications

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

anemia goiter xeropthalmia Zinc deficiensies


MALNUTRITION

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

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