Undernutrition

Tory Davis, PA-C

Malnutrition Undernutrition and overnutrition

Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss of nutrients due to diarrhea, or increased nutritional requirements (as in cancer or infection).

Stages of Undernutrition Each takes time to develop First, nutrient levels in blood and

tissues change Second, intracellular changes in

biochemical functions and structure Finally, signs and symptoms

Risk Factors Ages and stages Social circumstances: poverty Medical conditions

Infancy and Childhood High demands for:

– Vit E– Energy– Essential nutrients

Nutrients req’d for nl body fxn that we can’t produce – must be obtained by diet

Vegan mother breastfeeding B12 deficiency

Adolescence Anorexia Rapid growth

Pregnancy Fe deficiency anemia Folate deficiency anemia Pica – seen more in pregnancy – want

to eat things that aren’t normally considered food – sometimes to replace nutrional deficit

Old Age Sarcopenia (progressive loss of lean

body mass) begins at 40! physical activity food intake

– Anorexia cytokine levels androgen levels Basic metabolic rate

Disorders/Procedures DM – can’t absorb GI Tract disorders

– Malabsorptions, IBD,Bowel resection– Impaired absorption of fats. Fat-sol

vitamins, B12, Ca, Fe Liver d/o

– Impair metabolism of vit A, B12, protein

Disorders/Procedures Renal disorders

– Deficiencies of protein, vit D, Fe

Increased metabolic demands– Infection, trauma, fevers, burns

Diets Vegetarian

– B12 in vegans– Fe defic in ovo-lacto– Protein

Fad diets– Protein, vit, minerals– Ask Liberace

Diet Meds/drugs/supplements

– Alter appetite– Alter absorption and metabolism

Etoh/Drugs– Neglect of nutritional needs– Etoh deficiencies of Mg, Zinc, thiamine

Thus the “banana bag (mg, zinc thiamine + others).” Why? – see note below

Diagnosis of Undernutrition

Hx: dietary intake, weight change, above risk factors

SHx: money for food? Able to prepare meals? Think elders!

PE: BMI, look for signs of deficiencies OR conditions that could predispose to undernutition.– Like what? Jaundice, spoon nails, wasted, pale

(sign of anemia), hair loss or thinning, etc MNA- Mini Nutritional Assessment

Testing- Labs Serum albumin as indirect measure

– May indicate protein deficiency

Other testing-– Vitamin/mineral levels as specific tests

PEM Protein Energy Malnutrition Energy deficit secondary to chronic

deficiency of all macronutrients Graded mild to severe, based on

percentage of expected wt Primary- inadequate intake Secondary from drug or d/o that

interferes with nutrient use

PEM Developing countries:

– Children who can’t consume enough protein and calories

Lack of access Developed countries:

– Institutionalized elderly– Abuse (child or elder)– Pts with decreased appetite or impaired

digestion/absorption/metabolism

Vitamins Organic compound required as

nutrient in tiny amounts but can’t be synthesized by the organism and must be obtained via diet.

See posted vitamin chart for sources, functions, effects of deficiencies

Vitamin Deficiencies in developed countries

Poverty Food faddism Drugs (ie drug/vit interactions) Alcoholism Parenteral nutrition (prolonged or with

inadequate supplementation)

S/S Nutritional Deficiency: General

Wasting Cachexia

Energy deficiency

Skin Rash

– many vits (usually def), zinc, fatty acids

Rash in sun-exposed areas– Niacin (pellagra)

Easy bruising– Vit C or K

Hair/nails Thinning or loss of hair

– Protein Premature whitening of hair

– Selenium Spooning of nails

– Iron

Eyes

Impaired night vision and Corneal keratomalacia

– Vit A

Mouth Cheilosis (angular cheilitis) and

glossitis– Riboflavin, niacin, pyridoxine, iron

Bleeding gums– Vitamin C, riboflavin

Extremities Edema

– Protein def

Why?

Neuro Stocking/glove paresthesias and

numbness– Thiamin

Tetany– Ca, Mg

Cognitive and sensory deficits– Thiamin, niacin, B12

MSSK Wasting

– Protein Bony deformities

– Vit D, Ca Bone tenderness

– Vit D Joint pain/swelling

– Vit C

GI Diarrhea

– Protein, niacin, folic acid, B12 Diarrhea with dysgeusia

– Zinc Dysphagia/odynophagia (Plummer-

Vinson syndrome)– Iron

Endo

Thyromegaly– Iodine