Mild pitting oedema

1) In the case study by Lunn et al (1998) the child is described as having “mild pitting oedema” and a moderately enlarged liver. Using appropriate literature briefly discuss the role of mechanisms that have been proposed to explain the development of these symptoms in subjects with kwashiorkor.

When diet is carbohydrate based, without appropriate protein intake, a form of malnutrition occurs which is called kwashiorkor. This condition can be specified mostly in developing countries where easily accessible grains are forming the primary diet (Pelletier et al, 1995). Since their primary diet is easily accessible grains, children starve from less protein intake even they have sufficient calorie intake. And this will affect their body's growth and digestive system (Hoffer 2001). This case, organs start to enlarge, especially in pancreas, fluid levels increase and this causes change in the cells like liver cells. %5 decrease in fat stores take place and this will also make liver to enlarge (Coward and Lunn 1981). This protein malnutrition also affects other parts and systems of the human body such as the endocrine system. In this system, there are some changes in the liver, lymphs and thyroids that will also cause swelling of the legs and ankles which is known as oedema (Lunn 1998). Oedema is also caused by the level of albumin concentration drop under 30g/l which turns out to have decreased amount of oncoitic pressure (Shah 2007). This happens when body cannot process purely carbohydrate diet. In this diet, there is less amount of protein which is not enough to build mass and to provide energy to the body (Lunn 1998). As it is known, the carbohydrate diet only affects glucose levels. This is due to the metabolism of carbohydrate has caused reliance on the sugars in the body. However there is some level of intolerance to the glucose in carbohydrates that explains the poisoning effects that result in the malnutrition, fatty liver and the close down of the digestive system (Hoffer ,2001).

How relevant are these mechanisms in the aetiology of the case of kwashiorkor described by Lunn et al (1998)?

In the case of kwashiorkor described by Lunn et al (1998), the diet of choice was carbohydrate based. Therefore, it shows that there are some parallels to the cases of kwashiorkor in the developing world. Some significant differences are taking places. These differences include the provision of pure glucose and the supplementing of vitamins. The result is same due to the absent of essential protein/carbohydrate balance. The case is classified as less severe and rapid stabilisation takes place when the patient has balanced diet. This case is missing in the developing countries and it is part of the parent's provision of essential vitamins and minerals.

2) What type of PEM is the patient in the case study by Hoffer (2001) suffering from?

In this case study by Hoffer(2001), the patient is suffering from the type of PEM which is called marasmus. The type of PEM can be moderate type because of the reversibility of the condition and decrease in BMI.

Explain, using appropriate literature, why this type of PEM is known as adaptive PEM. In your answer to this question do not rely solely on the information provided by Hoffer et al (2001) about adaptation. The biochemical basis for this adaptation must form part of your discussion.

The body will automatically try to compensate to continue its survival to be adaptive, if the body is malnourished. This way body will continue to function just to survive on a lower calorie intake. To achieve a zero protein and energy balance, body lowers its protein store and reduces its metabolic rate (Hoffer et al, 2001). If body does this successfully, then it can continue to survive in this adaptive state. To identify the type of PEM, patient's weight is important. For instance, reduced muscle mass, reduced but constant body weight, serum prealbumin and normal serum albumin will help to identify the adaptive PEM. The most significant indicator in all these is the serum albumin (Hoffer et al, 2001). When the organs and the body have managed to function in the lower nutritional state, albumin remains the same with no oedema developed (Morley, 1998). The reason of adaptive PEM having normal albumin and reduced prealbumin is that the prealbumin is directly related to protein intake. So, when protein intake decreases, prealbumin also decreases (Morley 1998, Hoffer et al 2001). The state of metabolism has changed to stop placing the stress and pressure on the main organs to continue surviving. Therefore, metabolism continues to progress. First, body minimizes the protein metabolizing mechanisms such as amino acids and diverts the energy to the mechanisms of the vital organs (Morley, 1998). After that, for producing fundamental protein need, liver reuse those amino acids. After this reusing, albumin is obtained and to encounter the increased probability of infections, gamma globulins are increased. Since there is no need to metabolize protein, the prealbumins are decreased (Morley, 1998). Whilst protein intake is increasing, the body starts to adapt its normal functions quicker . But if there is a metabolic stress, starvation or micronutrient deficiency, the body cannot continue to adapt and death is to be expected.

3) In the introduction to the case study by Lunn et al (1998) it states that: “The central role of dietary protein inadequacy particularly in the presence of an adequate intake of energy has been confirmed” (in the development of kwashiorkor). Using appropriate literature discuss the validity of this statement. In discussing the validity of this statement you must also address the conclusion made by Lunn et al (1998): “... and the term ‘kwashiorkor' limited to the metabolic disorder resulting primarily from dietary protein insufficiency in the presence of a relative adequacy of energy.”

Malnutrition and the intake of carbohydrates are related to term kwashiorkor which was developed in 1933. It has been emphasized where the foods are poor in protein which is also found out from misunderstanding breastfeeding in the developing world (Lunn, 2008). Since in the developing world, mother eating less protein intake, therefore children have higher instances of malnutrition. This is caused by the changed patterns in breastfeeding by Western norms (Pelletier et al 1995). Weaning has also less protein intake and causes starvation and malnutrition even its diet is carbohydrate rich. In the developing world, Kwashiorkor examples are more noticeable where grains are easily accessible and proteins are too expensive to produce (Pelletier et al, 2005). As it has been shown, lack of protein is the main sign of kwashiorkor. If comparison is needed, longer breastfed baby has more chances to the early weaner than other babies (Lunn et al, 1998). Also, Lunn (1998) stated that limited protein resulting in lack of energy that causes starvation or adaptation is the way of understanding the kwashiorkor. Therefore, it is important to know what the causes are to figure out the kwashiorkor. In addition, there is a connection between kwashiorkor and marasmus and the reason is that they both are different stages of protein malnutrition. Marasmus is the stage where body is adapted to the protein malnutrition and it is also known as kwashiorkor-marasmus. However, the treatments and biomedical traits are specific for each stage of protein malnutrition (Lunn et al, 1998).

4) The case study by Hoffer (2001) briefly discusses the impact of some malignancies on body weight and the role of cytokines and acute phase proteins. Using appropriate literature critically discuss the role of cytokines and acute phase proteins in contributing to the PEM you have identified in your answer to the first part of question 2. Include in your answer how such a factor, malignancy, can contribute to failed adaptation to PEM. In addition, your discussion must also address the role of other factors that may contribute to PEM associated with malignancy.

The increase and decrease in albumin is caused by the biomedical functions such as the cytokine. Also, some transport proteins such as prealbumin are primary indicator.It is used to see if the patient is responding to the treatment (Morley 1998). It increases because prealbumin is also related to cytokines' increase and decrease. On the other hand, like albumin depends on cytokine, cytokine depends on the protein level. For instance, cytokine decreases when protein level decreases which also causes the decrease in food intake (Hoffer et al, 1998). When the person causes a chemical depression because the food is not appealing, it results in the body causing a decreased food intake. This is a big cause of malnutrition and it is known as therapeutic diets (Morley, 1998). This malnutrition is also caused by carbohydrate heavy diet which also turns into starvation in the developing world (Pelletier et al, 2005). Therefore, cytokine reduction helps body to leave the starvation mode and move to the survival mode. This process is shown in the case of Hoffer et al (2001) where patient was in a starvation mode and prealbumin reduction and albumin stabilisation took place which depends on cytokines to produce the survival mode. However, even if the measurement of cytokine is difficult in both albumin and prealbumin levels, patient can be helped to start surviving (Hoffer et al 2001, Morley 1998). Since older patients have hard time to adjust their food intake because of an increased malnutrition and PEM, cytokine plays an important role in the feeling of satiation. This may also reflective in the depressed patient syndrome where their body is unable to regulate its intake therefore patient has failure to eat (Morley 1998). To specify the biomedical and clinical difference between the adaptive and maladaptive states of PEM, understanding the cytokine process and its indicators such as albumin and prealbumin is important (Hoffer et al. 1998).

REFERENCES:

Coward, W. A. and Lunn, P. G.(1981) Biochemistry and Physiology of Kwashiorkor and Marasmus. British Medical Bulletin,37 (1), 19-24.

Hoffer LJ. (2001) Clinical Nutrition: 1. Protein-energy malnutrition in the inpatient. Canadian Medical Association Journal 165(10),1345-1349.

Lunn, PG., Morely, CJ. & Neale, G. (1998) A case of kwashiorkor in the UK. Clinical Nutrition 17, 131-133.

Morley, J. E., (1998) Protein Energy Malnutrition in older subjects. Proceedings of fhe Nutrition Society, 57,587-592

Pelletier, D. L. , Frongillo, E. A. , Schroeder, D. G. and Habicht, J. P.(1995)The effect of malnutrition on child mortality in developing countries. Bull World Health Organ, 73(4), 443-448.

Shah, S., Kannikeswaran, N. And Kamat, D. (2007) Patient Report. Clinical Pediatrics , 46(7), 650-654.

Susan, B. R., Fuss, P., Heyman, M. B., Evans, W. J., Tsay R., Rasmussen, H., Fitarone, M., Cortiella, J., Dallal, G. E. and Young, V. R. (1995) Control of Food Intake in Older Men. JAMA, 273 (9) 1601-1606.

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