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Malnutrition, Starvation and Refeeding Syndrome

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Iatrogenic. Gastrointestinal losses. Copper Deficiency. Infants recovering from malnutrition. Iatrogenic. Vitamin D deficiency. Dietary. Malabsorption. Lack of sun ... – PowerPoint PPT presentation

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Title: Malnutrition, Starvation and Refeeding Syndrome


1
Malnutrition, Starvation and Refeeding Syndrome
  • Khursheed Jeejeebhoy

2
Starvation and Semi-starvation
  • State of Negative Protein-Energy Balance
  • Absence of nutrient intake
  • Intake below requirements

3
Metabolic Adaptation to Starvation
Post Absorptive state --- Overnight fast after a
meal
Fast lasting 12-24 Hours
Fast lasting gt 3days
Prolonged Starvation
4
Post-Absorptive State
  • The Brain Must receive Glucose
  • Insulin levels fall
  • Glucose delivery to Tissues 8-10 g/hr
  • Increased Glycogenolysis 50
  • Continued Gluconeogensis 50
  • Lactate and Pyruvate 50
  • Amino acids 50
  • Muscle uses mainly fatty acids
  • 2/3 fuel oxidation is derived from fatty acids

5
Fasting 2-4 days
  • Liver glycogen depleted
  • Insulin levels fall
  • Glucose production by Gluconeogenesis
  • Lactate and Pyruvate
  • Amino acids
  • Nitrogen loss from amino acid is 10-12 g/day
  • Branched chain aminoacids released by muscle and
    oxidized
  • Ketone production increases
  • Brain reduces glucose utilization and increases
    Ketone body oxidation

6
Prolonged Starvation
  • Metabolic rate falls
  • Nitrogen losses decrease to 4-5 g/day
  • Brain now uses ketones as the sole source of
    energy
  • Muscle uses fatty acid and spares branched-chain
    amino acid oxidation

7
Clinical Effects of Starvation
  • Resting Energy Expenditure fall by about 25-35
    by 3 weeks
  • Serum Albumin Concentrations remain normal
  • Serum Prealbumin falls
  • Death occurs when body fat is depleted
  • Obese persons can withstand prolonged starvation

8
Clinical effects of Fasting Weight loss
9
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10
Weight and Sodium loss
  • Fall in insulin level reduces sodium reabsorption
    by the kidney
  • Increased sodium excretion
  • Diuresis
  • Reduced sodium intake increases negative sodium
    balance
  • Water loss main cause of rapid weight loss seen
    early in starvation

11
Malnutrition
  • Malnutrition is a condition in which there is
    unbalanced deficiency of nutrients.
  • Causes are
  • Macronutrient deficiency
  • Protein-energy malnutrition
  • Protein deficiency
  • Energy deficiency
  • Micronutrient deficiency
  • Electrolyte
  • Potassium
  • Magnesium
  • Phosphorus
  • Trace element
  • Zinc
  • Copper
  • Chromium
  • Selenium
  • Vitamin Deficiency
  • Fat soluble - Vitamin D
  • Water soluble - Thiamine

12
Protein-Energy MalnutritionReduced intake of
both Protein and energy
  • 1944-46 32 volunteers reduced their intake from
    2400 kcals/d to 1600 kcals/day (Keys Minnesota
    study)
  • Lost 70 body fat and 24 FFM
  • New equilibrium at 24 weeks into the diet.

13
PEM Nitrogen adaptation Martin and Robison 1922
Neg N balance
Pos. N balance
14
Nitrogen Adaptation
  • Loss of labile nitrogen pool reduces nitrogen
    output
  • Equilibrium restored unless protein intake fall
    below lt 37 mg/Kg/day on a diet meeting energy
    requirements

15
Energy Adaptation
  • Body reduces energy requirements by
  • Reduced metabolic rate of the body cell mass.
  • Reduced body cell mass.
  • Body weight equilibrates approximately at
  • 28-30 kcal/kg/day

16
Hormonal response
  • Insulin levels fall promoting release of glucose
    and free fatty acids for energy
  • T3 levels reduced resulting in a lower metabolic
    rate
  • IGF -1 levels fall with starvation reducing
    protein synthesis

17
Hypoproteinemia
  • Low prealbumin levels can be due to
  • Protein deficiency
  • Protein loss
  • Acute Phase reaction
  • Low Albumin levels are
  • ?Low protein with high energy intake
  • Protein loss
  • Acute Phase reaction
  • Hypoalbuminemia is a sign of disease not
    malnutrition

18
Micronutrient deficiency
  • Iron deficiency
  • Blood loss due to disease
  • Dietary deficiency
  • intake of cereal iron (India)
  • Magnesium Deficiency
  • Dietary Alcoholism
  • Renal
  • Endocrine metabolic
  • Malabsorption
  • Short Bowel
  • Iatrogenic
  • Phosphorus deficiency
  • Iatrogenic
  • Alcoholism
  • Recovery from diabetic ketoacidosis
  • Zinc Deficiency
  • Iatrogenic
  • Gastrointestinal losses
  • Copper Deficiency

19
Micronutrient deficiency
  • Vitamin A deficiency
  • Dietary deficiency in developing countries
  • Iatrogenic
  • Thiamine deficiency
  • Alcoholism
  • Iatrogenic
  • Diuretics
  • Folate deficiency
  • Alcoholism
  • Malabsorption
  • Vitamin B12 Deficiency
  • Vegans
  • Malabsorption
  • Poor intake in an ageing population

20
Refeeding Syndrome
  • Refeeding a malnourished patient results in
  • Rise of insulin levels
  • Sodium and water retention
  • Potassium retention
  • Phosphorus retention
  • Magnesium retention
  • Refeeding may cause serious
  • Hypokalemia
  • Hypophosphatemia

21
Refeeding Syndrome
  • Refeeding a malnourished patient can result in
    Heart failure due to
  • Atrophic myocardium in malnutrition
  • Muscle depletion of Mg, K, P
  • Sodium and water overload
  • Increased metabolic rate

22
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23
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24
REFEEDING EDEMA CARDIAC FAILURE
36 year old Anorexia fed by NG 3200 kcal/d
25
Micronutrient DeficienciesIn Malnutrition and
the Heart
MICRONUTRIENT SYNDROME Thiamine deficiency
Heart Failure Magnesium Deficiency
Arrhythmias Phosphorus Deficiency
Cardiomyopathy Selenium Deficiency
Cardiomyopathy Potassium Deficiency
Arrhythmias Myocardial injury
26
Refeeding Syndrome
  • High CHO intake exacerbates the refeeding
    syndrome
  • Low protein High energy diet causes fat gain but
    not lean tissue
  • High protein diet can reduce nitrogen loss even
    if energy deficient
  • Exercise important to regain muscle mass

27
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28
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29
Relationship of Protein and Energy to Nitrogen
retention
Energy intake kcal/d
30
Refeeding SyndromeJournal of Internal Medicine
2005 257 461468
  • Case controlled study in Geriatric ward
  • 325 had hypophosphatemia
  • 326 normal plasma phosphorus levels

31
Refeeding SyndromeJournal of Internal Medicine
2005 257 461468
32
Refeeding SyndromeJournal of Internal Medicine
2005 257 461468
33
Refeeding SyndromeAm J Clin Nutr 197932981-91
  • Severely starved men fed 27 g/day protein 2250
    Kcal/d
  • Weight gain
  • Increased Cholesterol
  • Albumin levels fell
  • Nitrogen balance 0
  • Protein intake increased to 100 g/day
  • Positive nitrogen balance
  • Rise in serum albumin

34
Refeeding SyndromeAm J Clin Nutr 197932981-91
  • Refeeding of malnourished patients
  • 20 kcal/kg/day and 1.5-2.0 g/protein/day
  • Low CHO and higher fat
  • Monitor K, P, Mg and weight gain
  • Diuretics if rquired
  • Gradually increase energy intake depending on
    response.
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