AAE350 Exam: Lecture 1 - 8

Kwashiorkor

1. "The illness of the dethroned child" 2. Low ENERGY-to-protein ratio 3. HYPOALBUMINEMIA 4. FATTY liver and edema 5. Caused through diet, infection, gut microbiome 6. Sufficient amount of carbs in diet but not enough protein. 7. Signs: soft pitting edema, DRY skin with lesions, brittle hair, loss of curls and color in hair. 8. Fat breakdown decreases and the action of insulin is enhanced because of the suppression of the inhibiting effects of free FATTY acids on the peripheral action of insulin. 9. Muscle protein breakdown decreases, and the pool of free amino acids decreases, leading to decreased visceral (non-muscular) protein SYNTHESIS. 10. The decreased SYNTHESIS of plasma proteins in the liver, albumin, reduces intravascular oncotic pressure leading to edema. 11. There is increased fat production in the liver from the excess carbs, impaired fat break down and reduced production of apo-B-lipoproteins for lipid transport leads to FATTY infiltration of the liver and enlargement of the liver. Perhaps also potassium DEFICIENT, since not all with decreased albumin levels get edema.

What is the nutrition transition? What DIETARY changes occur?

1. A model used to describe the shifts in diets, PHYSICAL ACTIVITIES and causes of disease that ACCOMPANY changes in economic development, LIFESTYLES, urbanization, and DEMOGRAPHY. 2. Refers to the change from traditional diets towards "Western" diets. High in fats, sugars, meat and HIGHLY processed foods. Low in fiber. Rise in SEDENTARY LIFESTYLES.

What are the issues associated with AVAILABILITY, intake, and absorption? (IODINE)

1. AVAILABILITY: 90% of the world is able to access iodized salt, but some places still lack resources to obtain it. How available it is depends on this, or on soil concentrations as well as seawater seafood and seaweed sources. 2. INTAKE: 200 million people around the world still suffer from goiter, meaning lacking AVAILABILITIES are still an issue. Goiter, therefore, can result from lacking iodine.

What are the issues associated with AVAILABILITY, intake, and absorption? (Vitamin A)

1. AVAILABILITY: VAD is a public health problem in more than half of all countries, ESPECIALLY in Africa and SE Asia. 2. Intake: Without intake of Vitamin A, night blindness, decreased resistance to infection, and other problems can occur. 3. Absorption: Vitamin A is a fat-soluble vitamin and is absorbed and transported with lipids. In animal sources, 90% of vitamin A is absorbed. ONLY 50% absorbed with plant-based products, which are sole options based on location.

What happens to the GASTROINTESTINAL SYSTEM during refeeding?

1. Activities of the brush border ENZYMES and pancreatic ENZYME secretion return to normal with refeeding. 2. Requires a period of re-adaptation to food to minimize GI complaints - Diarrhea, nausea and vomiting

What are the common chronic diseases? What common condition have MANY been linked to?

1. Cardiovascular disease 2. Cancer 3. Chronic RESPIRATORY disease 4. Diabetes

What are the major determinants of stunting? What is this linked to in adulthood?

1. Chronic low intake 2. Later deficits in cognitive abilities and mental development

What is a common complication of refeeding? WHY?

1. Congestive heart failure is a common complication of refeeding. 2. Cardiac output can't increase enough to meet the needs from the increased plasma volume, increased OXYGEN consumption and increases in blood pressure and heart rate.

What is the major effect of earlier life PEM?

1. Decreased brain growth 2. Nerve MYELINATION 3. Neurotransmitter production 4. VELOCITY of nervous conduction

How does the body adapt PHYSIOLOGICALLY to PEM?

1. Decreased nutrient demands and equilibrium compatible with available nutrients in store. 2. Insulin levels are low, which leads to hormonal changes that affect THYROXINE and lowers heat production and OXYGEN consumption. 3. Non-vital hormones, such as sex hormones, decrease. 4. Red blood cell production decreases. 5. Heart muscle reduces in size. 6. Cardiac output, blood pressure, and heart rate decrease. 7. Central circulation takes precedence, which allows heart to continue to function despite lack of OXYGEN.

What is the significance of thiamin deficiencies in refeeding?

1. Deficiencies might contribute to refeeding syndrome functions as a cofactor in INTERMEDIARY CARB metabolism. 2. Amount needed depends on carbs ingested, so feeding carb without adequate thiamin supplementation can lead to DEFICIENCY SYMPTOMS: - Mental confusion, ataxia, muscle weakness, edema, muscle wasting, TACHYCARDIA and CARDIOMEGALY - Wernicke's ENCEPHALOPATHY can be brought on BY carb feeding in thiamine-deficient patients

Describe the changes in the use of carbs, fat, and protein during starvation.

1. During starvation, when carbs are not available, protein is broken down to produce glucose, as fat cannot be converted to carbs. About 75 g. of muscle (protein) are used per DAY. This process is called gluconeogenesis. 2. Glucagon is also produced during starvation, which mobilizes and uses fat stores for ENERGY. However, to be able to convert fat into ENERGY, some carbs must available. 3. EVENTUALLY, once carbs/glucose levels are depleted, ketones are derived from fat breakdown instead and used for all tissues except CNS, RBC, and WBC.

What is environmental ENTEROPATHY and what is its proposed mechanism?

1. Environmental ENTEROPATHY is a small intestine disorder triggered via constant ingestion of feces via contaminated food and water. 2. It can be a causative disorder for SECONDARY malnutrition, and it results in a leaking of bacteria through the intestinal walls into the bloodstream. 3. It also results in low-grade infections that require more nutrients and ENERGY to fight, leaving fewer nutrients for growth.

What happens to the RESPIRATORY SYSTEM during refeeding?

1. Excess carbon dioxide production and increased OXYGEN consumption can result from giving too much glucose and overfeeding. 2. A person with malnutrition-induced RESPIRATORY muscle wasting can get short of breath. 3. Can't sustain an increased VENTILATORY drive. 4. PULMONARY edema might develop in some due to increased water load.

What is food INSECURITY, and how does it relate to malnutrition?

1. Food INSECURITY is not having PHYSICAL and economic access to sufficient, safe, and nutritious food that meets DIETARY needs for an active and HEALTHY life. It comes in three forms: - Mild (worried about abilities to obtain food) - Moderate (comprising and reducing food intake) - Severe (experiencing effects of hunger) 2. It relates to malnutrition as its precursor. If one experiences food INSECURITY, it's probable that THEY will or are also experiencing malnutrition in the form of undernutrition, as malnutrition can also refer to overnutrition, or too much food and not enough exercise.

What are the good and bad parts of this?

1. Good: Less undernutrition and communicable disease 2. Bad: Higher risk of OBESITY and chronic disease

What happens to the functional CAPACITY of the heart during PEM? The lungs?

1. Heart: Cardiac function is reduced in proportion to the smaller size of the ventricles with reduction in cardiac output and stroke volume occurring at the same time. Cardiovascular reflexes are altered, which can lead to postural HYPOTENSION and decreased venous return. 2. Lungs: Exhalation and inhalation muscles are catabolized and diaphragmatic mass is proportional to the loss of weight. Decreased RESPIRATORY muscle strength, max VOLUNTARY ventilation, vital capacities, max inhalation pressure. More CO2 in the blood due to lowered BMR. Deterioration and EMPHYSEMA. Decreased surfactant SYNTHESIS, storage and secretion. Increase in infection.

How did the subjects in KEYS STUDY adapt to semi-starvation?

1. High loss of lean BODY mass 2. Loss of BODY fat made up 1/3 of weight change 3. Decreased BMR due to less lean BODY mass 4. Reduced weight 5. Reduction in tissue metabolism 6. Reduction in PHYSICAL activities

What happens to cardiovascular SYSTEM during refeeding?

1. Increases in heart rate, blood pressure, OXYGEN consumption, cardiac output and an expansion of plasma volume are seen. 2. Response is dependent on amount of calories, protein and sodium given. 3. The malnourished heart can EASILY be given a metabolic demand that is too high for it to SUPPLY.

What is the KEY indicator of malnutrition?

1. Infant MORTALITY Rate (defined as number of children per 1,000 live births who die before their 1st BDAY)

What happens METABOLICALLY during refeeding?

1. Insulin release is stimulated BY the presence of carb and protein in the gut 2. KEY role in the switch from using up BODY stores to using food 3. Stops the release of fat from stores and production of glucose from protein 4. Stops sodium excretion 5. Causes fluid retention in the first few DAYS of refeeding and when the caloric intake is increased

Which nutrient deficiencies are associated with decreased cognitive abilities? WHY?

1. Iodine deficiencies are associated with decreased cognitive abilities because it PLAYS a vital role in cell replication (i.e., brain growth and function). 2. Iron deficiencies prevent O2 from reaching the brain; decreased amount of neurotransmitters.

What are the 4 major micronutrient deficiencies in the world?

1. Iron 2. Iodine 3. Vitamin A

What are the issues associated with AVAILABILITY, intake, and absorption? (IRON)

1. Iron depletion. Decrease of stores (ferritin). Iron deficient ematopoiesis. Iron stores depleted with insufficient absorption to counteract normal losses. Leads to decreased hemoglobin production. Iron deficient anemia. Hemoglobin falls below a set standard. Amount of iron in a food and ABSORBABILITY can be different in plant foods. 2. Concurrent intake of Vitamin C can enhance absorption of nonheme iron up to 6-fold. 3. "Meat factor" also increases absorption of non-heme (and heme) iron, as heme iron is taken into the bloodstream much more EFFICIENTLY than non-heme iron. 4. Fiber, PHYTATE, tannins and oxalate bind iron and prevent absorption. Milk, calcium products can decrease absorption.

What are SYMPTOMS of deficiencies?

1. Iron: Cognitive defects, poor motor development, maternal deaths due to severe anemia, decreased PRODUCTIVITY. 2. Vitamin A: impaired immune function, night blindness, DRY and hard skin, DRY cornea and eventual blindness. 3. Iodine: impaired THYROID function, goiter, birth defects in newborns, cretinism, PSYCHOMOTOR deficits

What are the DIETARY sources for these nutrients?

1. Iron: HEME iron is found in almost all meats, whereas non-heme iron is found in grains, LEAFY green vegetables, legumes, and meat and is absorbed at about half (or less) the rate of heme iron. 2. Iodine: Iodized salt 3. Vitamin A: Beef liver, carrots, muster greens, egg YOLKS

Who is most LIKELY to be deficient in each of these nutrients?

1. Iron: Women of reproductive age 2. Vitamin A: People who don't eat DAIRY, young children and pregnant women in low-income countries 3. Iodine: Adults, kids within two YEARS of age, unborn kids, people who don't use iodized salt, people who live in regions farther from the sea and at high altitudes

What is the result of the changes in the immune SYSTEM during PEM?

1. LYMPHOCYTES deplete from the THYMUS gland as it atrophies. 2. Cells from the T-LYMPHOCYTE regions of the spleen and LYMPH nodes are depleted. T cells GENERALLY have defects. 3. Immune function decreases. 4. PHAGOCYTOSIS, chemotaxis, and intracellular killings are also impaired. 5. Production of B-LYMPHOCYTES and T-LYMPHOCYTES might be limited. 6. Alteration in monokine metabolism.

What problems might stunted women have during PREGNANCY and DELIVERY?

1. Linear growth of adolescent girls has been shown to stop when pregnant - An extra 1 cm of adult height will be added for each YEAR that median age of first PREGNANCY can be DELAYED beyond age 15 - Taller women have bigger babies 2. Food supplementation of the adolescent pregnant for the first time does not improve BW - Growth hormones favor growth of mother instead 3. Control of anemia can improve birth weight - Best WAY to improve BW is to DELAY PREGNANCY until 18

What are other metabolic consequences of refeeding? (Magnesium)

1. Magnesium - Goes into the cell from the blood with refeeding and new tissue SYNTHESIS - Important cofactor in MANY ENZYME SYSTEMS involving ENERGY storage and utilization and protein SYNTHESIS - Important for the proper functioning of the CNS, the peripheral neuromuscular SYSTEM, and the cardiovascular SYSTEM - Low blood magnesium levels might cause irregular heart RHYTHM, HYPOCALCEMIA, muscle weakness, and neurologic SYMPTOMS

What are the two kinds of PEM? What has been linked to the microbiome? What is the proposed manner to change the microbiome?

1. Marasmus 2. Kwashiorkor 3. Kwashiorkor has been linked to the microbione. The decreased SYNTHESIS of plasma proteins in the liver, albumin, reduces intravascular oncotic pressure leading to edema.

How do bodies' metabolisms adapt to malnutrition?

1. Negative nitrogen balances occurs within 5-7 DAYS. 2. Gluconeogenesis occurs (breakdown of protein via skeletal muscle). 3. After 1 month of malnutrition, 2-4 g. of nitrogen lost p/d, and gluconeogenesis decreases, producing glucose ONLY for cells that MUST have it, including CNS, red blood cells, and white blood cells. 4. At that point, fat breakdown and metabolism provide ketones instead of constant gluconeogenesis. 5. Serum FATTY acid levels increase and serum albumin is normal until late in the process of malnutrition/starvation. 6. Weight loss occurs, but in the first week, it is, for the most part, salt and water loss. In addition, the basal metabolic rate and total ENERGY expenditure decrease. More sleep is needed, and BODY temperature decreases.

How is nutritional status assessed? What is the result of good nutrition?

1. Nutritional status is assessed through anthropometric assessment, measuring height, weight, BMI, BODY composition, and MUAC (mid-upper arm circumference). 2. The result of good nutrition is growth, ACTIVITY, PRODUCTIVITY, and chronic disease prevention.

What is ORS and what is it used for?

1. ORS is an oral REHYDRATION solution and its used for treating acute diarrhea. It contains sodium, glucose and ELECTROLYTES.

What are other metabolic consequences of refeeding? (Phosphorus)

1. Overfeeding carbs can result in high blood sugars and dehydration 2. Phosphorous - Blood levels might decrease in the first few DAYS - Moves into cells from blood because of need in making PHOSPHORYLATED compounds in the cell. - Insulin promotes uptake in liver and muscles - VERY low levels can lead to RESPIRATORY, cardiac, nervous SYSTEM, and red and white blood cell DYSFUNCTION.

What is a problem in both industrialized and developing countries and WHY?

1. Overnutrition is a problem in both industrialized and developing countries because people might not have access to the proper resources needed to learn about proper nutritional requirements. 2. Parasitic infection, and therefore, SECONDARY malnutrition. Due to PLAYING outside where STRAY cat and dog feces infested with hookworms might lie.

What are the 4 kinds of malnutrition? What causes each?

1. Overnutrition, caused with excessive food intake in relation to ENERGY requirements. BASICALLY, when people eat too much and exercise too little. 2. SECONDARY malnutrition, not caused via diet but simultaneous health conditions/concerns that lead to changes in normal nutrient intake. 3. Micronutrient malnutrition, caused with DIETARY deficiencies in vitamin A, iodine, iron (*MAIN THREE), as well as zinc, vitamin D, C, and B. 4. Protein Calorie (ENERGY) Malnutrition, caused via severe DIETARY deficiencies of protein and calories.

What were the PHYSICAL and PSYCHOLOGICAL SYMPTOMS exhibited during the semistarvation in KEYS' STUDY?

1. PHYSICAL: fatigue, muscle soreness, hunger pains, decrease in heart rate and muscle tone, lacking sex drive. 2. PSYCHOLOGICAL: lack of ambition, self-discipline, poor concentration, irritable, depressed, emotional.

What are other metabolic consequences of refeeding? (Potassium)

1. Potassium - Refeeding causes a shift of potassium into the cells from the blood and the rebuilding of proteins also incorporates potassium into the cell protoplasm - Low blood potassium levels might result - Can cause irregular heart RHYTHM

What is RUTF, under what circumstances is it used, and what are the advantages of it?

1. RUTF is READY-TO-USE therapeutic food and a home-based treatment for severe acute malnutrition in children who have no medical complications and still have an appetite. 2. Provides foods that are safe to use at home and ensure rapid weight gain. 3. RUTF is a paste in packets that doesn't need to mixed with water. Based on peanut butter mixed with dried skimmed milk and vitamins and minerals. 4. Can be stored for 3 to 4 months without refrigeration and is similar in nutrient composition to F100.

Marasmus

1. Severe protein and ENERGY deficit. Not enough calories in diet. 2. Signs: wasted appearance, marked growth failure, sparse hair that's thin, DRY, and comes out without pain, skin dries and wrinkles, faces are apathetic and anxious. 3. Sunken cheeks due to loss of Bichat pads, or the last adipose depots to disappear, which leads to looking like an older person. 4. Large amounts of food not tolerated--vomiting and diarrhea ensue.

Which anthropometric measures reflect acute undernutrition? Chronic undernutrition?

1. Stunting reflects chronic undernutrition. 2. Wasting reflects acute undernutrition.

What is stunting? Wasting? Underweight?

1. Stunting: Low height for age 2. Wasting: Low weight for height 3. Underweight: Low weight for age

What besides nutrients must be part of the THERAPY for malnourished children?

1. Tender loving care 2. A cheerful, stimulating environment 3. Structured PLAY THERAPY for 15-30 minutes a DAY 4. PHYSICAL ACTIVITY as soon as the child is well enough 5. Maternal involvement as much as possible (e.g. comforting, feeding, bathing, PLAY)

What is the best WAY to feed an infant? For how long? What actions have been recommended supporting this?

1. The best WAY to feed a newborn child is with breast milk, for at least the first 6 months of their life because... -Infant doesn't compete with food SUPPLY for FAMILY -Breast milk is a clean food SUPPLY in a clean container -Breast milk has immunologic benefits so disease decreases 2. The actions that have been recommended supporting this include to breast feed until at least six months, then ween afterwards in the second 6 months.

What sign indicates that a child is entering the rehabilitation phase? What is encouraged at this point?

1. Their appetite returns. 2. At this point, high intakes are recommended to support weight gain.

What is the effect of ELECTROLYTE changes on muscle tissue?

1. Total potassium is reduced in PEM 2. Decreased amounts of ATP 3. Serum potassium is stable 4. Na-K-ATP pumps potassium into and out of cells 5. Intracellular overHYDRATION

What are modifiable risk factors for chronic disease?

1. UNHEALTHY diet 2. PHYSICAL INACTIVITY 3. Tobacco use 4. Harmful use of alcohol

What is a major issue with EARLY PREGNANCY in undernourished girls?

1. Undernourished girls grow for a longer period of time, so might not be finished growing before the 1st PREGNANCY. 2. This leads to smaller infants due to competition for nutrients and poorer placental function. 3. Calcium a special concern since bones of adolescents have not reached maximum DENSITY. 4. Higher maternal and infant MORTALITY and pre-term deliveries with adolescent pregnancies.

How long did it take participants to recover from the STUDY?

33 weeks.

What happens in the adolescent period that challenges nutrition?

Adolescent hormonal changes accelerate growth. Therefore, one requires more nutrition to grow at an average rate.

When should COMPLEMENTARY foods be introduced and WHY?

After 6 months in order to provide adequate nutrition and stimulate development.

What improves learning in children?

Alleviating hunger.

How MANY people in 2021 could not afford a HEALTHY diet?

An estimated 3 billion.

WHY is good nutrition important for older adults?

Because malnutrition can lead to impairments in... 1. PSYCHOMOTOR speed and coordination 2. MOBILITY 3. ABILITIES to complete activities of DAILY living INDEPENDENTLY 4. Positive mental health (Depression can ensue) 5. Sarcopenia

What is the link between POVERTY AND OBESITY?

Because nutritious food is so expensive, those who lack financial resources might be more prone to purchasing cheaper food with no nutritional value, thus contributing to lacking ENERGY to perform PHYSICAL activities and an UNHEALTHY diet, leading to overnutrition and therefore, OBESITY and the potential to develop chronic disease.

Who is affected BY chronic disease?

Chronic disease affects all genders across all countries and socioeconomic demographics. Those with less access to resources meant to combat chronic disease might be at higher risk, however.

WHY is there diarrhea with severe PEM?

Due to GI tract changes and irregular MOTILITY/GI growth, people might have diarrhea when fed. Low blood protein levels leads to intestinal edema which decreases luminal absorption which leads to diarrhea

WHY must refeeding be done SLOWLY?

Effects most significant in first few DAYS of refeeding and it might take 1 week to adapt to the increase OXYGEN demand.

What causes diarrhea in refeeding?

GI and it's ENZYMES must have time to readapt.

What nutrient is required for ENERGY production and where does it comes from when not in the diet?

Glucose is required for ENERGY production. When not in diet, protein is broken down instead during the process of gluconeogenesis.

What is the relationship between toilets and stunting?

In some places around the world, open defecation is commonplace. However, refraining from SANITARY waste disposal can sometimes lead to causative conditions, such as parasitic infections, for SECONDARY malnutrition in children, and thus, stunting.

What has been HYPOTHESIZED regarding in utero malnutrition and health in later life?

In utero malnutrition can lead to health problems later in life.

WHY should prevention focus on the LIFECYCLE and not just with fetal and EARLY childhood malnutrition?

Intervening at each point in the life CYCLE will accelerate and consolidate positive change.

WHY is EXPLORATORY behavior so important in children? What fuels it?

It is so important because it stimulates the brain and allows for greater PHYSICAL ACTIVITY throughout the DAY. It is fueled with proper nutrition, as a malnourished child will exhibit less EXPLORATORY behavior.

WHY is it important to FREQUENTLY weigh and measure a child?

It's important to ensure that THEY'RE not stunting or wasting and thus, have greater potential for increased cognitive and PHYSICAL development.

What is the double burden of malnutrition?

Malnutrition + rapid upsurge of risk factors for chronic disease such as overweight and OBESITY.

What is the effect of maternal nutrition on the fetus?

Maternal malnutrition can lead to... 1. Increased rate of fetal loss and malformations 2. Low birth weight 3. Child with little/no iron stores 4. Increased maternal MORTALITY 5. Cretinism (in the case of iron deficiencies) 5. Intra uterine growth retardation (IUGR)

What nutrient has been supplemented in the diet via salt? Sugar?

Salt: Iodine Sugar: Vitamin A

What must people have to make good choices about diet?

The correct information regarding DIETARY needs and financial resources to be able to acquire nutritious foods.

How does the cost of a HEALTHY diet compare to a nutrient adequate diet or ENERGY sufficient diet?

The cost of a HEALTHY diet is 60% higher than the cost of a nutrient adequate diet and about 5 times the cost of an ENERGY sufficient diet.

WHY are continuing studies on children who have been treated for malnutrition of interest?

These studies are of interest because child malnourishment has been linked to increased probabilities of chronic disease as an adult.

What nutrient deficiencies have a decrease in immune function before the presentation of more obvious clinical signs?

Vitamin A deficiencies

What DIETARY recommendations have been made to decrease risk?

WHO Technical Report 916 (see Lecture 8 slides)

What might happen to the CAPACITY to work with undernutrition?

With undernutrition, the capacities to work will be limited. With the limited ENERGY stores that result from undernutrition, being able to complete strenuous PHYSICAL and mental tasks becomes more challenging.

What decreases with malnutrition in adults?

Work CAPACITY AND PRODUCTIVITY