In developing countries, lack of food and poor usage of the available food can result in protein-energy malnutrition ( PEM). About 50 million pre-school African children have PEM.I n developed countries excess food is available and the most common nutritional problem is OBESITY.
Diet and disease are interrelated in many ways. Excess energy intake, particularly when high in animal fat content, is said to contribute to a number of disease including ischemic heart disease and diabetes: A relationship between food intake and cancer has been found in many epidemiological studies, an excess of energy –rich foods often with physical inactivity, plays a role in the development of certain cancers while diets high in vegetables and fruits reduce the risk of most epithelial cancers.
The proportion of processed foods eaten may affect the development of disease. A number of processed foods eaten may affect the development of disease .A number of processed convenience foods have a higher sugar and fat content and therefore predispose to dental caries and obesity respectively.
Protein contains many amino acids of which nine are indispensible (essentials).These amino acids cannot be synthesized and must be provided in the diet. The dispensable (non-essential) amino acids can be synthesized in the body but some may still be needed in the diet. Animal proteins, such as in milk, meat and eggs are of high nutritional value as they contain all indispensable amino acids.
In developing countries, adequate protein intake is achieved mainly from vegetable proteins, combining food stuffs with different low concentrations of indispensable amino acid (maize with legumes) Protein intake can be adequate provided enough vegetables are available.
Loss of protein in the body occurs not only because of inadequate protein intake but also owing to inadequate energy intake. When there is loss of energy from the body more protein is directed towards oxidative pathways and eventually gluconeogenesis for energy.
The term” protein – energy malnutrition” covers the spectrum of clinical conditions seen in adults and children.
Maramus is the childhood form of starvation which is associated with obvious wasting. Maramus is the type of severs PEM seen most commonly .A child looks emaciated; there is obvious muscle wasting and loss of body fat. There is no Oedema; the hair is thin and dry. The child is not so apathetic or anorexic as with Kwashiorkor.Diarrhoea is frequently present and signs of infection must be looked for carefully.
Kwashiorkor occurs typically in a young child displaced from breast feeding by a new baby and fed a diet with very low protein content relative to energy such as cassava. Kwashiorkor shows the child to be apathetic and lethargic with severe anorexia. There is generalized Oedema with pigmentation and thickening. The hair is dry sparse and may become reddish owing to hepatomegaly. Serum albumin is always low.
Many children in developing countries are underweight, the under nourished child is very susceptible to respiratory and gastrointestinal infections leading to an increased mortality in this group.
- BLOOD TESTS:
- Anaemia due to folate, iron and copper deficiency is often present, but the heamatocrit (PCV) may be high owing to dehydration.
- Eosinophila disturbances are common
- Malaria parasites should be looked for.
- HIV test.
- Stools should be examined for parasitic infections
- Chest x-ray- tuberculosis is common
Protein and energy supplement must be provided and infection must be controlled.
RESUSTICATION: The severly ill child will require correction of fluid and electrolyte abnormalities, but intravenous therapy should be avoided if possible because of the danger of fluid overload. Glucose- electrolyte mixtures are sometimes necessary.
Diarrhea is often due to bacteria or protozoa overgrowth metronidazole is very effective.
REFEEDING: During the initial treatment of the acute situation a balanced diet with sufficient energy is to maintain steady states. Large increases in energy lead to heart failure, circulatory collapse and death. Supplements of vitamin A, D, B, and C should always be given together with folic acid and iron. Many children are deficient in minerals such as zinc, copper and selenium and supplements should be given if deficiency is suspected.
Rehabilitation: As the child improves more energy can be given and during rehabilitation maximum weight gain is achieved in the shortest time by extra calories.
PROGNOSIS: Children with extreme malnutrition have a mortality of over 50%. By careful management this can be reduced significantly to 1-2 % depending on the availability of facilities. Brain development takes place in the first years of life, a time when severe PEM frequently occurs. There is evidence that intellectual impairment and behavioral abnormalities occur in severely affected children. Physical growth is also impaired. Probably both of these effects can be alleviated if it is possible to maintain a high standard of living with a good diet and freedom from infection over a long period.
Prevention of PEM depends not only on adequate nutrient being available but also on education of both government and individual in the importance of good nutrition and immunization. Bad feeding practices and infections are more prevalent than actual shortage of food in many areas of the world, However good surveillances is necessary to avoid periods of famine. Food supplements should be given to ‘at-risk’ groups by adding high-energy food (eg milk powder, meat concentrates) to the diet. Pregnancy and lactation are times of high energy requirement and supplements have been shown to be beneficial.