Protein-energy malnutrition (BEM) is a pathological condition characterized by a deficiency of nutrients, energy and negatively affects the work of all body systems. The main signs of pathology are the loss of more than 10% of the initial weight in a short time, asthenovegetative syndrome, dryness and pallor of the skin. Diagnostic search involves performing physical examination and laboratory tests to assess the patient’s condition, instrumental methods to establish the root cause of nutritional deficiency. Treatment consists in the appointment of high-protein and high-calorie enteral, probe or parenteral nutrition.
E44 Protein-energy malnutrition of moderate and mild degree
Protein-energy malnutrition (nutritional deficiency) is a global medical problem. The most vulnerable categories of the population are children and the elderly. According to WHO, more than 17% of children under the age of 5 suffer from various degrees of BEM, the bulk of them live in Africa, Pacific island countries. About 50% of elderly patients who are admitted to the hospital have signs of chronic malnutrition. It was found that 25% of the Russian population experience nutritional deficiency, and 85% have various manifestations of hypovitaminosis.
Causes of protein-energy malnutrition
The widespread nutritional and energy malnutrition is primarily due to socio-economic factors. Pathology is typical for residents of low-income countries who cannot afford sufficient caloric and vitamin content of food. The growth of protein-energy malnutrition is observed in regions with frequent natural disasters, war zones. A number of medical causes of the disease have been established:
- Insufficient intake of nutrients. This category includes iatrogenic factors of fasting: strict diets for gastroenterological and metabolic diseases, the transition to parenteral nutrition in severe patient condition. Often the cause of nutritional deficiency is anorexia nervosa, psychosis.
- Increased catabolic processes. Symptoms of protein-energy malnutrition develop against the background of normal caloric intake. Metabolic disorders are caused by increased breakdown of nutrients, which is caused by thyrotoxicosis, type 1 diabetes mellitus, oncological diseases.
- Digestive disorders. Nutritional deficiency is formed by malabsorption and maldigestion of various genesis. Often its causes are chronic gastroenteritis, a decrease in the external secretory function of the pancreas (pancreatic steatorrhea), biliary disorders.
- Intoxication. Metabolic disorder occurs in patients who are forced to take strong medications for a long time. The situation is aggravated by polypragmasia, especially in geriatric practice. The violation is detected in almost all sufferers of chronic alcoholism.
For the elderly, the main predisposing factor is neurodegenerative processes — Alzheimer’s disease, Parkinsonism. The structure of the etiology of protein-energy malnutrition in children is dominated by congenital causes:
- malformations of development;
- neuromuscular pathologies;
- genetically determined problems — cystic fibrosis, metabolic disorders.
Risk factors for EB in children include prematurity, intrauterine hypoxia, alcohol and narcotic substances used by a pregnant woman.
With nutritional deficiency, all organs and systems are involved in the pathological process. The degree of impairment depends on the duration and severity of malnutrition. With a small lack of calories, there is a breakdown of glycogen in the liver, due to which the body receives a sufficient amount of energy. There is a mobilization of fat reserves, an increase in the level of amino acids in the blood.
Tissues and organs that acted as depots of carbohydrates and lipids are reduced in volume. With nutritional failure of the diet, the weight of the liver decreases by an average of 50%, other digestive organs lose from 30% to 60% of weight. The muscles suffer the most — they atrophy first, with prolonged fasting, only 25-30% of the original musculature remains. Dystrophy of bone tissue is characteristic, due to a deficiency of calcium and vitamins.
The contractility of the heart muscle decreases sharply, blood output decreases. Over time, myocardial atrophy develops, severe heart failure. The defeat of the respiratory system is characterized by a decrease in the vital capacity of the lungs, the minute volume of respiration, a violation of the function of the atrial epithelium. As a result of the lack of vitamins and protein, the functional activity of lymphocytes decreases.
Depending on the prevailing symptoms, clinicians distinguish 3 syndromes of deficient nutritional pathology: marasmus (or “dry” form), kwashiorkor (“wet” form) and a mixed variant. A mild degree of severity is established with a weight deficit of up to 20%, an average of 21-30%, a severe degree is a lack of weight of more than 30% of the norm. In practice, the systematization of protein-energy malnutrition by etiology is widely used, according to which there are 3 types of BEM:
- Primary. Occurs in the absence of a sufficient amount of food of proper quality and normal functioning of the gastrointestinal tract. It is typical for developing countries, mainly formed in children and the elderly.
- Secondary. It is caused by damage to the digestive system, other oncological, endocrine or infectious diseases. It can start at any age.
- Combined. The most severe variant of the disease, involving a combination of the two forms listed above. The combined form of pathology usually has a severe course, is prognostically unfavorable.
Protein-energy malnutrition symptoms
The main manifestation of energy malnutrition is a rapid weight loss of more than 10% of the initial value. The thickness of subcutaneous fat decreases, the ribs and pelvic bones are well contoured. Muscle atrophy gradually occurs. The skin becomes pale and cold to the touch, sometimes brown pigment spots appear. At a late stage, edema forms. The hair is brittle and dull, diffuse alopecia is observed.
With protein-energy malnutrition, weakness and apathy increase. Sometimes, due to a decline in strength, a person cannot even get out of bed. Sensitivity to cold increases, due to microcirculation disorders, limbs remain cold even in a warm room. Due to the nutritional inferiority of the diet, menstruation stops in women, impotence develops in men.
Severe digestive disorders are characteristic. Appetite gradually decreases, nausea and vomiting may occur. There are violations of the stool by the type of alternation of diarrhea and constipation. Feces contain a large amount of undigested food particles, neutral fat. Nutritional deficiency pathology, which began in childhood, is characterized by a combination of these manifestations with a violation of neuropsychic development.
All patients with nutritional deficiency have severe hypovitaminosis. With BEM, retinol deficiency, group B vitamins are more common. Conditions caused by a lack of vitamins appear — folate deficiency or B12 deficiency anemia, peripheral polyneuritis, twilight vision disorders. Against the background of calcium deficiency, pathological bone fractures and muscle cramps occur.
A frequent consequence of protein-energy malnutrition is infectious processes that occur in 70-80% of patients. The complication is caused by immunological disorders — insufficiency of T-lymphocytes and a decrease in the production of immunoglobulins. Infections are extremely severe with a high risk of local inflammation turning into sepsis. In surgical patients, a decrease in calorage by 10 kcal / kg per day increases the risk of death by 30%.
The manifestations of protein-energy malnutrition are faced by doctors of all specialties, but the identification of the initial forms of pathology is most often dealt with by a general practitioner. For diagnostics, it is very important to collect information about the nature of human nutrition, material and living conditions. To verify the diagnosis of nutritional deficiency, the following studies are conducted:
- Assessment of anthropometric indicators. Height and body weight are measured, BMI is calculated. If the weight has decreased by more than 10% in the last 2 months, the doctor is highly likely to suspect a protein-energy malnutrition. To estimate the amount of fat in the body, the thickness of the skin-fat fold on the abdomen or above the triceps is measured.
- Blood test. In the clinical analysis, the level of hemoglobin was reduced, the number of red blood cells was reduced, their shape and size were changed. In the biochemical study of blood, there is a sharp hypoproteinemia, hypokalemia, hypocalcemia.
- Special laboratory methods. An immunological study is necessarily prescribed: with marasmus, T-lymphocytes mainly decrease, with kwashiorkor, there is a deficiency of T- and B-lymphocytes. The diagnostic criterion of protein-energy malnutrition is a drop in the absolute number of leukocytes less than 2000 cells in 1 µl.
- Abdominal ultrasound. A simple non-invasive method is recommended if a secondary form of the disease is suspected and allows you to identify problems with the gastrointestinal tract. When pathological changes are detected on ultrasound, radiography of the barium passage, ERCP and other diagnostic methods used in clinical gastroenterology are shown.
Protein-energy malnutrition treatment
Treatment approaches are determined taking into account the stage of nutritional deficiency. With mild to moderate severity, if patients can take food on their own, therapy consists in the selection of a rational diet. The diet increases the protein content to 1.5-2 g / kg of weight, increases the total caloric content of the diet. With a sharply reduced appetite, violation of the processes of chewing or swallowing, liquid nutrient mixtures are prescribed.
A more serious task is the treatment of severe BEM. As a rule, patients are not able to eat food on their own, therefore, probe feeding with balanced mixtures or parenteral nutrition is required. In addition to filling the energy deficit, water-electrolyte mixtures are introduced to correct homeostasis disorders. With a secondary form of protein-energy malnutrition, a gastroenterologist selects a treatment regimen for the underlying disease.
Prognosis and prevention
With early diagnosis and timely treatment of protein-energy malnutrition, it is possible to achieve regression of symptoms, restoration of functional activity of organs. The prognosis is less favorable for young children and the elderly who suffer from a severe degree of nutritional deficiency. Intellectual disabilities that have arisen in young children, in rare cases, remain for life.
Prevention involves improving the socio-economic living conditions of the population, providing food and vitamin supplements to people below the poverty line. Medical preventive measures are aimed at identifying and treating gastroenterological diseases, eliminating pathologies that are accompanied by accelerated metabolism.
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