 Parenteral Nutrition

 Malnutrition
 Protein energy malnutrition
 Obesity
 Intravenous provision
of all nutritional
requirements
without the use of
the GIT
 2 types- Total PN
(Central Venous
catheter- s/c vein) &
Peripheral PN
(peripheral vein)
 Indications
 Poor nutritional status(more
than 10% weight loss in 6
months), intestinal fistula, Infl
bowel disease, intestinal
resection (↓100cm small bowel
remains), cancer cachexia

 Water, electrolytes, 10-30%

glucose, 1-1.5g/kg body wt
protein, a fat emulsion
containing 1-4g fat/kg body
wt, multivitamins, minerals
 Absence of a balanced diet

 General term for a medical condition caused

by an improper or insufficient diet

 Most often refers to under-nutrition but also

encompasses over nutrition
1. Cardiovascular disease- ↑ingestion of
saturated fat, trans fats, cholesterol
2. Cancers: Colon- processed/ non-veg food
liver & oesophageal cancer- alcohol
3. Obesity/ Diabetes mellitus/ insulin
resistance: ↑ingestion of saturated fat,
trans fats, cholesterol AND sugar
4. Hypervitaminosis A- eating liver of
animals, treatment for wrinkles, pimples
5. Vitamin B6- treatment for pre-menstrual
syndrome, hyperemesis gravidarum
6. Iron overload disorder- dietary iron
overload
1. Protein Energy Malnutrition- Protein and/calories
2. Scurvy- Vit C
3. Beri beri- Thiamine
4. Pellagra- Niacin
5. Rickets- Vit D
6. Osteoporosis- calcium deficiency
7. Iodine deficiency- goitre
8. Microcytic hypochromic anaemia- iron, copper, Vit
B6, Zinc
9. Macrocytic anaemia- Folic acid & Vit B12
10. Normocytic anaemia- Protein and/calories
1. Spectrum/Group of clinical conditions that result from varying
degree of protein lack and energy(calorie) inadequacy
2. Old terminology is Protein Calorie Malnutrition
3. 57 million children in India are underweight
4. >50% of deaths betwn 0-4 years

TWO MAJOR
CLINICAL FORMS
OF PEM
Type of PEM % of body weight Oedema Deficiency in
compared to weight for
standard weight height
Kwashiorkor 80-60 + +
Marasmic <60 + ++
kwashiorkor
Marasmus <60 Nil ++
Nutrional <60 Nil Nil
dwarfism
Underweight 80-60 Nil Nil
child
 “to waste” in Greek
 Predominantly calorie
inadequacy & secondary
protein deficiency
 “sickness that the older child gets
when the next child is born” Ga
tribe
 PEM that results from predominant
protein deficiency with adequate
calorie intake
 MARASMUS KWASHIORKOR
Age of Onset ↓1 year 1-5 years
Predominant Deficiency Calorie Protein
Cause Early weaning, repeated Starchy diet after
infection weaning
Body weight <60% of Normal 60-80% of normal
Growth retardation Marked Mild
Oedema, Absent, Pitting oedema on face &
Abdomen Lower Limb
Shrunken Protruding
 MARASMUS KWASHIORKOR
Attitude Irritable Lethargic, dull & listless
Appearance Like old mans face/ little Moon face;
monkey facies;
Muscle wasting- weak & muscle wasting with
atrophic retention of s/c fat
Appetite Hungry craves for food Anorexia
 MARASMUS KWASHIORKOR
Skin Dry & atrophic Crazy pavement
dermatosis, flaky paint
dermatosis-
hyperpigmentation
intervened by raw skin
due to pealing, cracking
& denudation
Hair No characteristic change Hypochromotrichia,
Sparse, soft, thin, flag
sign, easy pluckability
Vitamin deficiencies Present Present
 MARASMUS KWASHIORKOR
Associated features Other nutritional def, Angular stomatitis,
Watery diarrhoea cheilosis, watery
diarrhoea
Shrunken liver; serum Fatty liver due to ↓
lipids not much affected lipoprotein synthesis
Serum albumin 2-3g/dL <2g/dL
Serum Cortisol ↑ Normal/↓
FBS Decreased Normal
Serum K+ & Mg2+ Normal Decreased
 High Protein, High energy diet
 150-200kcal/kg body weight energy
 3-4g/kg body weight proteins, vitamin & mineral supplements
 Small amt of food at frequent intervals
 Mixture of 3 parts of vegetable proteins(bengal gram or
peanuts) + 1 part milk protein
 Roasted wheat flour (30 parts), green gram flour (20 parts),
groundnut (8 part) and sugar or jaggery (20 parts) has been
developed by National Institute of Nutrition, Hyderabad. The
food contains about 12.5 percent proteins.
 Dissappearance of oedema, rise in serum albumin level and
gain in weight
 Obesity is a medical condition in which excess
body fat has accumulated to the extent that it
may have an adverse effect on health, leading to
reduced life expectancy and/or increased health
problems
 Indicator for obesity is Body Mass Index(BMI)
 Wt in kg
BMI= -----------------------
 Height in m2

Grade BMI
GRADE 3 >40
GRADE 2 30-40
GRADE 1 25-29.9
NON OBESE <25
 Increase in the number and size of
adipocytes

 Increases risk for

 Metabolic syndrome, heart disease, type 2
diabetes, obstructive sleep apnea, certain
types of cancer, and osteoarthritis.

 Most commonly caused by a

 combination of excessive food energy intake,
lack of physical activity, and genetic
susceptibility (50%), endocrine disorders
(hypothyroidism, Cushings Syndrome),
medications or psychiatric illness.
 Hypothalamus- control center for appetite

 Appetite increasers are neuropeptide Y,

ghrelin, insulin, cortisol

 Appetite decreasers are Leptin, melanocyte

stimulating hormone and serotonin
 Leptin is a hormone secreted by adipocytes
 167AA, 16kDa
 Regulates energy intake, energy expenditure
 Lep gene on chr 7
 Fasting/Very Low Cal diet lowers leptin levels
 Satiety signal- ↑ energy levelsleptin
↑ suppresses food intake
 Inhibits neuropeptide Y secretion, decreases
appetite when fat is ↑
 Mutation of leptin or its receptoruncontrolled
eating and obesity
 Lifestyle modification- stress free, alcohol
free, quit smoking
 Physical activity
 Reduced intake of calories and fat
 Frequent small meals, rich in dietary fiber,
low glycemic index
 Diet
 Low carbohydrate diet promoted by Dr.
Robert Atkins
 Allowed 20g of carbs/day(120g/ day
normally)
 Unlimited fat and protein consumption
 ↓glucose ↓ insulin, ↑GH, epinephrine,
glucagon Lipolysis, keto genesis -
ketolysis, gluconeogenesis (AA)
 Onset of hunger is delayed
 Benefits- weight loss (6-12 weeks),
maintenance of low weight, decreased
craving, good health
 Ill effects- difficult to avoid carbs for long
(tiredness and weakness), bad breath,
constipation, ↓antioxidants, ↓calcium (no
fruits, vegetables), kidney stones, ulcers,
kidney infections, stones, CHD(saturated
fats)
 Increased olive oil,
unrefined cereals,
fresh fruits and
veggies, nuts,
moderate fish
intake, moderate
wine consumption,
low consumption of
meat
 Increased salt,
decreased Ca, Fe