Calorie Malnutrition Research Articles

Low serum 3, 5, 3′-triiodothyronine (T3) and raised 3, 3′, 5′-triidothyronine (reverse T3 or RT3) in diabetes mellitus: Normalization on improvement in hyperglycemia

In several pathophysiologic states, i.e., cirrhosis of liver, protein calorie malnutrition, starvation, carbohydrate deprivation, etc., thyroid hormone metabolism is reported to be altered with a decrease in serum T3 and a reciprocal increase in TR3. Uncontrolled diabetes mellitus is a similar state in which glucose does not enter the cells causing cellular starvation and hyperglycemia ensues. Therefore, serum T4, T3, RT3, T3-resin uptake, TSH, and glucose were determined after an overnight fast in 94 male diabetics (aged 28 to 85 years) during a routine follow-up visit to the outpatient clinic and 24 healthy male adults (aged 24 to 81 years). Glycosylated hemoglobin concentrations were measured as well in normal subjects and 16 newly discovered diabetics. In normal subjects, no significant relationships between fasting plasma glucose and T3 and RRT3 levels were observed. In diabetics there was a significant positive (r = 0.611; p less than 0.001) correlation between glucose and RT3. Similarly, a significant negative relationship was observed between glucose and T3 (r = 0.491; p less than 0.001). T4, free T4, T3-resin uptake, and TSH were normal in diabetics. In 16 newly discovered diabetics, with fasting plasma glucose greater than 200 mg/dl, serum T3 rose (96 +/- 5 to 128 +/- 5 ng/dl) and RT3 declined (26.3 +/- 10.4 +/- 1.4 ng/dl) on improvement of hyperglycemia (fasting plasma glucose less than 140 mg/dl) after intensive therapy for 6 to 8 weeks. Glycosylated hemoglobin levels declined as well (14.6 +/- 0.9% to 9.3 +/- 0.7%). These data indicate: (1) thyroid hormone metabolism may be altered in diabetes mellitus with a fall in serum T3 and a reciprocal rise in RT3; and (2) T3 and RT3 concentrations may serve as indicators of metabolic control in diabetes mellitus.

The effect of protein malnutrition on the copulatory behavior of the male rat

The copulatory behavior of male Sprague-Dawley rats reared under four dietary conditions was measured in three experiments at ages ranging from 95 to 325 days. Rats malnourished in preweaning stages of development were born to dams fed an 8% casein diet from 5 weeks before mating until weaning. Well-nourished rats were born to dams maintained on a 25% casein diet. At weaning half of the offspring in each group were switched to the other diet. In all three experiments rats subjected to the protein restriction in both pre- and postweaning periods, or in one period or the other only, were more effective copulators than well-nourished rats. The major differences between the protein-deprived and well-nourished rats were related to a diminished ability to intromit in the high-protein animals. Protein or protein—calorie malnutrition may enhance copulatory behavior in the male rat by retarding or prolonging several aspects of development, including body growth and changes in sex hormones.

IDLI, AN INDIAN FERMENTED FOOD: A REVIEW

ABSTRACTIdli is a fermented food of India which is prepared by steaming a fermented black gram (Phaseolus mungo L.) and rice (Oryza sativa L.) batter. It makes an important contribution to the diet as a source of protein, calories and vitamins, especially B‐complex vitamins, compared to the raw unfermented ingredients. It can be produced locally and used as a dietary supplement in developing countries to treat people suffering from protein calorie malnutrition and kwashiorkor. Other legumes such as soybeans and Great Northern beans could be substituted for black gram in preparation of a idli. Further research is needed regarding the increase of methionine content during idli fermentation, by which path way methionine is synthesized, and identification and isolation of microorganisms responsible for methionine production or synthesis.

Circulating gonadotropin profile in severe cases of protein calorie malnutrition

The circulating levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin (PRL) were studied in children of both sexes between 2 and 14 years of age who were suffering from severe protein calorie malnutrition (PCM), namely, kwashiorkor, marasmic kwashiorkor, and marasmus. LH and FSH levels in all the age groups and in all forms of PCM were found to be significantly lowered, thereby explaining the possible delay in the onset of puberty in these children. Circulating PRL levels, on the other hand, were significantly raised in all patients with PCM studied, with values in children with kwashiorkor and marasmic kwashiorkor higher than in children with marasmus, possibly accounting for the presence of edema in the former cases. The present work, therefore, proposes a possible correlation between gonadotropin levels and PCM in children.

The correctability of the nutritional, immune, and hematopoietic manifestations of protein calorie malnutrition in the elderly.

Protein calorie malnutrition is being recognized with greater frequency in the hospitalized patient. This report describes the clinical presentation and response to nutritional therapy in nine elderly malnourished patients ranging from 73 to 95 years. Clinical features of malnutrition include weight loss, confusion, hypoalbuminemia (mean 2.8 gm/dl), a low total iron binding capacity (TIBC) (mean 192 micrograms/dl), anergy, lymphocytopenia (mean 1 X 10(3) cells/microliter) and an anemia (mean 9.0 gm/dl). Our subjects were followed for 42 days. In two, hyperalimentation was achieved by voluntary food intake and polymeric dietary supplements. In seven, feeding for 21 days via nasogastric tube was required. After three weeks, weight gain, decreased confusion, improved appetite and mobility, and significant increases in serum albumin and TIBC were seen. At that time, no subject was anergic and lymphocyte counts increased significantly. Increase in the serum iron and percent saturation was noted, and by day 42, a significant elevation in the hemoglobin occurred. As a measure of stem cell function, the committed granulocyte/macrophage progenitor cell (CFU-C) was quantitated in four subjects prior to and following 21 days of nutritional support. A marked increase in CFU-C number from a mean of 0.1 X 10(7) cells/kg to a normal value of 0.85 X 10(7) cells/kg was seen. Thus in addition to correcting the nutritional deficit, hyperalimentation returned immune and hematopoietic abnormalities to near normal levels. While improvement could reflect recovery from an associated disease, it is just as likely that correction of malnutrition, a well-recognized cause of these immunologic and hematopoietic abnormalities, accounted for the response. These observations emphasize the importance of recognizing malnutrition in the elderly and highlight the need for a careful nutritional assessment prior to ascribing hematologic and immunologic abnormalities to the aging process.

Trichotillometry: the quantitation of hair pluckability as a method of nutritional assessment

In protein-calorie malnutrition, particularly kwashiorkor, ease of hair pluckability is frequently observed. In an attempt to quantitate this manifestation of the disease a calibrated mechanical instrument, referred to as a trichotillometer, was devised and used to determine the force required to epilate individual hairs in 17 adult hospitalized patients with evidence of protein calorie malnutrition and in 16 well-nourished patients. Nutritional status was examined by measuring body weight, triceps skinfold thickness, arm muscle circumference, serum albumin, lymphocyte count, hematocrit, beta-carotene, vitamin nutriture, and hair shaft diameter. Average epilation force was significantly lower in the malnourished patients than in the well nourished group (17.0 g +/- 11.8 versus 38.2 g +/- 11.4, p less than 0.001), with the lowest mean value found in patients categorized as having kwashiorkor (14.8 g). Plucking force correlated significantly and positively with serum albumin, hair shaft diameter, triceps skinfold, arm muscle circumference, weight, hematocrit, beta-carotene; it did not correlate with vitamin status. In order to determine the effect of acute stress on epilation force a subgroup of 18 patients was evaluated before and 1 and 4 days after surgery. Within this time interval epilation force was not significantly altered by the stress of surgery.

Nutritional assessment: An integral part of the preoperative pediatric surgical evaluation

Comprehensive nutritional assessment in adults has revealed that 50% of hospitalized patients suffer from acute protein calorie malnutrition (PCM), a state which correlates with increased surgical morbidity and mortality. We report our results examining the same question in children, and on the basis of these data suggest that nutritional assessment be a routine part of the preoperative evaluation of all pediatric surgical patients. We studied 198 children and found that the overall prevalence of acute PCM was 54%; but if premature and term infants less than three months of age are selected, the prevalence of acute PCM was a striking 63%. If only surgical patients are considered, the prevalence of acute PCM among patients hospitalized for trauma or burns was 31%, for elective operation 39%, and for acute but complex operative procedures 64%. These data demonstrate that a remarkably high prevalence of acute PCM exists among hospitalized pediatric and pediatric surgical patients. Whether aggressive perioperative nutritional support can reverse such acute PCM and favorably influence morbidity and mortality is currently speculation, but that acute protein calorie malnutrition is far more prevalent among hospitalized pediatric patients than is generally realized, and that comprehensive nutritional assessment is essential to identify the “at risk” nutritionally deprived pediatric surgical patient, have now been proven.

Nutritional support of hospitalized patients.

AS limits of nutritional-support programs are tested, the tendency is to simplify regimens for nutrition, to exhaust means of enterai and peripheral-vein supplementation before resorting to central parenteral nutrition, and to scrutinize the advocacy of some uses of total parenteral nutrition; these policies guide our practice. Our chief index for advising nutritional support sufficient to meet or exceed a patient's basal energy requirements is the common definition of caloric malnutrition: loss of 10 per cent of usual weight, coupled with inability to eat or absorb enough food to reverse the depleted state.Although otherwise normal patients might be expected to . . .

34 IMPAIRED ANTIGEN RECOGNITION IN PROTEIN CALORIE MALNUTRITION

Top of pageAbstract The in vitro proliferative response of lymphocytes to alloantigens, PPD and PHA was studied in 17 severely marasmic infants aged 4 to 13 months. Twenty one well-nourished infants served as controls. All infants had been vaccinated with BCG at birth and had a BCG scar. Proliferation was measured by tritiated thymidine incorporation and results expressed as the stimulation ratio (S.R.):c.p.m. in stimulated cultures/c.p.m. in unstimulated cultures. The response to alloantigens was studied in one way mixed lymphocyte cultures (MLC) using irradiated leukocytes from three non-related donors.The table shows geometric mean and range: There were no significant differences in the S.R. of tuberculin positive marasmic and control infants nor of tuberculin negative marasmic and control infants. There were significant differences between the two groups in the response to PHA with a geometric mean SR of 27 and range 4-64 vs 101 and 61-203 in the controls (p < 0.01).These results suggest that recognition of foreign antigens is depressed in protein calorie malnutrition, as evidenced by the lymphocyte response to alloantigens and PHA. Lymphocytes of malnourished infants sensitized to PPD in the period of adequate nutrition responded to it normally.

34 THYROID HORMONES IN MALNOURISHED CHILDREN

In a study of hormonal adaptations, we determined serum levels of thyroid-stimulating hormone (TSH) (4.14 ± 2.01 uU/ml), thyroxine (T-4) (6.43 ± 0.93 ug/100 ml) and triiodothyronine (T-3) (160.61 ± 28.28 ng/100 ml) in 27 normal children. Five marasmic and five kwashiorkor children on the 1st, 7th, 14th and 21st days of adequate feeding were also studied. Low serum levels of T-4 (2.23 ± 1.79 ug/100 ml), and T-3 (56.0 ± 17.9 ng/100 ml) were observed in malnourished children with decreased levels of albumin. After seven days of adequate food intake these values returned to the normal range. These low levels revealed a relationship between thyroid hormone and poor protein and calorie ingestions. These probably reflects and adaptation in protein caloric malnutrition.

EFFECTS OF MALNUTRITION, AGE, AND CHOLERA TOXIN ON GLUCOSE-STIMULATED WATER ABSORPTION

Oral administration of glucose-containing solutions reduces net stool output in patients with cholera. Since malnutrition is frequently associated with diarrhea, we examined the influence of malnutrition on intestinal response to glucose in experimental cholera. Water fluxes (Jv) were determined by weighing intestinal fluid at different times in isolated ligated loops of jejunum. The effects on Jv of glucose and mannitol (30mM + Ringer) were compared in loops with and without (C) cholera toxin (CT), in 20 adult control rats, 20 adult rats with protein caloric malnutrition (PCM), 10 adult rats on a protein-free diet (APM), and 10 growing rats on a protein-free diet (YPM). Glucose stimulated water absorption (expressed in μ1/10 min cm2) equally in control loops and in CT loops in all four groups studied. The C and CT values for Jv were respectively 36.2 ± 7.5 and 39.6 ± 11.9 in control rats, 64.4 ± 8.3 and 73.8 ± 10 in PCM, 37.1 ± 8.1 and 41 ± 5.2 in APM, and 18.9 ± 3.5 and 18.1 ± 2.6 in (YPM). Similarly, CT did not modify the fluxes of Na, C1, HCO3 and glucose. The relationship between Jv, JNa and Jglucose remained unchanged. The effect of glucose on water fluxes in intestine was therefore not influenced by cholera toxin, but greatly depended on the type of malnutrition and on the age of the rats. In addition, the present results suggest that the intestinal secretion induced by cholera toxin is independent of the intestinal absorption stimulated by glucose.

Cell-mediated immune defects and infection. A study of malnourished hospitalized children.

Severe protein calorie malnutrition in children in developing countries has been characterized by noticeable depression of cell-mediated immunity and an increased manifestation of infectious illnesses. We studied 23 hospitalized US children whose admitting diagnoses included severe malnutrition to see if similar findings existed. Children were divided into two groups based on the percentage of E rosettes (T cells) prior to nutritional therapy. Those with E rosette values less than 50% were considered to have noticeably abnormal cell-mediated immunity. Eleven of the 23 patients who had rosette values less than 50% had 18 clinical infections, including four episodes of sepsis. One of the 23 children with normal (> 50%) E rosettes had one minor infection. It was concluded that depressed cellular immunity as measured by E rosette is associated with an increased incidence of infectious illness in the malnourished hospitalized pediatric patient in the United States. Other defects in host defenses, ie, defects in complement and phagocytic function, may also have contributed to the increased number of clinical infections noted in these patients.

Pyruvate kinase activity in the lymphocytes of malnourished, anergic patients

Intralymphocytic pyruvate kinase (PK) has been reported to have decreased activity in protein calorie malnutrition. We studied the activity of this enzyme in the lymphocytes of normal, nonhospitalized individuals (Group 1: n = 14) and malnourished, anergic patients on the surgical ward (Group 2: n = 17). The mean activity in Group 2 (0.12 ± 0.02 U/10 7 cells) was significantly decreased ( P < 0.001) from that in Group 1 (0.28 ± 0.03 U/10 7 cells). Five of the patients in Group 2 were studied following return to normal skin reactivity and prior to discharge from hospital; their mean activity had returned to the normal range (0.32 ± 0.08; P < 0.005). Kinetic studies of the enzyme in normal, nonhospitalized controls (Group 3: n = 7) and malnourished, anergic patients (Group 4: n = 5) showed a significant reduction in V max of Group 3 (0.51 ± 0.02 U/10 7 cells) as compared to Group 4 (0.35 ± 0.03 U/10 7 cells), P < 0.005, K m in Group 4 showed a significant increase (1.59 ± 0.26 m M) as compared to Group 3 (0.71 ± 0.09), P < 0.005. These studies show that significant changes occur in intralymphocytic PK activity, V max and K m in the malnourished, anergic patient and suggest that examination of this enzyme may help to define the lymphocytes of malnourished, anergic patients.

Protein-calorie malnutrition and cutaneous anergy in hemodialysis maintained patients

In 52 unselected patients maintained in intermittent hemodialysis, protein calorie malnutrition was present in 10 patients (19%). Complete cutaneous anergy to four intradermal skin antigens. (Candida, tuberculin, Streptokinase-dornase, and mumps) and failure to respond to contact sensitization to dinitrochlorobenzene was present in 60% of the patients. No correlation between cutaneous anergy and protein calorie malnutrition could be demonstrated.

Improvement of uremic hypogeusia by zinc: a double-blind study

Diminished taste acuity may account for the persistence of protein and caloric malnutrition observed in a majority of hemodialysis patients inspite of liberalization of the prescribed amount of dietary protein. Twenty-two patients undergoing thrice weekly hemodialysis for more than 6 months were tested for taste acuity and plasma zinc concentration, after which a double-blind study was instituted using a zinc supplement (50 mg of elemental zinc as zinc acetate per day) or a placebo. The threshold of taste detection and recognition for salt (NaCl), sweet (sucrose), and bitter (urea) but not for sour (HCl) improved significantly in all patients on zinc supplementation. None of these parameters improved in those taking placebo. During the study period, the mean plasma zinc level increased from 75 +/- 8 to 97 +/- 10 microgram/dl (P less than 0.001) in patients receiving zinc acetate. There was not significant change in plasma zinc level in the placebo group (75 +/- 15 to 80 +/- 15). The results of this study show that uremic hypogeusia improved in association with zinc supplementation and elevation of plasma zinc concentration.

Protein-Calorie Malnutrition in a Community Hospital

An assessment of protein-calorie status was performed on 200 consecutive adult nonobstetric admissions to a private hospital from two group family practices. Anthropometric measurements, serum albumin level, and total lymphocyte count were determined at admission and weekly if the patient remained in the hospital. Nonnutritional factors affecting muscle protein stores and serum albumin level were taken into account. A total of 63 patients (31.5%) were found to be malnourished. The most common conditions associated with decreased protein stores were hypoxic cardiopulmonary disease, gastrointestinal disease, neuromuscular or arthritic impairment, organic brain syndrome, and febrile illness. Although nonnutritional factors accounted for many instances of protein depletion, expecially milder degrees of depletion, nevertheless protein calorie malnutrition was highly prevalent in this population.

Skeletal maturation of hands and wrists in normal and malnourished children

The skeletal development along with other physical parameters appears to be a useful and reliable indicator of growth and development. 1 The hand and wrist arc a fair index of the maturity of the entire skeleton of a healthy child, z Extensive data exist on the appearance of ossification centres in the bones of hand and wrist of healthy children of various racial groups, a-5 However, there is less information on the effects of long standing protein calorie malnutrit ion on the normal time of appearance of ossification r of bone growth. ]he present study compares the skeletal maturat ion of healthy children, to those with protein calorie malnutrition.

Causes of Hypothermia

To the Editor. —TheArchivesarticle entitled "Thermoregulatory Failure Secondary to Acute Illness" (139:418-421, 1979) by Drs Whittle and Bates deserves two comments. First, except possibly for case 3, the 26-year-old man admitted to the hospital following a chlorpromazine hydrochloride overdose, all other patients described were suffering from an acute illness superimposed on chronic organic diseases such as chronic obstructive lung disease (case 1), chronic renal failure (case 2), chronic renal failure and cerebrovascular disease (case 5), diabetes mellitus (case 4), and severe congestive heart failure (case 6). Therefore, the discussion may apply to chronically ill medical patients who become decompensated and not necessarily to acute medical illness. Hypothyroidism is, in our experience also, an uncommon cause of hypothermia. In fact, in our intensive care unit the most common cause of hypothermia is sepsis in association with chronic renal failure, protein calorie malnutrition (PCM), cirrhosis, and immunoincompetence. The second point

Clinical aspects of protein deficiency with special reference to protein calorie malnutrition (PCM) in children.

We have investigated the pathophysiology and optimum treatment of PCM in Northern Thai children over the past 10 years and have developed what we consider to be an improved scoring system for the diagnosis of the three major forms of severe protein calorie malnutrition, namely: marasmus, marasmic kwashiorkor, and kwashiorkor. We feel that it gives a more definitive classification of these subgroups of PCM than any other system. It takes into account anthropometric and laboratory parameters, as well as clinical ones, and permits hospitals and metabolic units in various parts of the world to make better comparisons of their results.Various aspects of the pathophysiology of PCM have been studied, including hematopoietic, endocrine, and metabolic aspects. We have developed a plan of therapy which has reduced mortality to 6-7%. In support of our plan of treatment, we have presented the clinical and biochemical data, and have demonstrated the protein and calorie requirements for the optimum treatment of severe protein calorie malnutrition.The distribution of the three forms of protein calorie malnutrition clearly differs widely in affected countries throughout the world. In some, marasmus is more prevalent; in others, kwashiorkor. Investigators not familiar with the global distribution of the types of the disease may be regarding their particular population of children in a special way.

Metabolism of sulfadiazine in children with protein calorie malnutrition.

6 children with protein calorie malnutrition (PCM) and 5 control children received a single dose of sulfadiazine (25 mg/kg body weight). Absorption rate constant in the control group was 0.735 +/- 0.058 h-1 and in PCM 0.519 +/- 0.03 h-1. Peak blood levels of the drug were similar in both groups. However, the time to reach the peak was shorter in the control than in the PCM group. Elimination rate constant and half life of the drug were 0.0233 +/- 0.0026 h-1 and 31.78 +/- 3.82 h, respectively, in the PCM group and 0.0332 +/- 0.0022 h-1 and 21.27 +/- 1.51 h, respectively, in the control group. These values differ significantly from each other. The area under the blood concentration-time curve was more than double in the PCM group as compared to the control group. Urinary excretion of the drug in 48 h was significantly more in control (19.3 +/- 1.4 mg/kg body weight) in comparison to the PCM group (13.6 +/- 1.7 mg/kg body weight). However, the free drug concentration in urine/kg body weight was not altered in the PCM group. There was a significant decrease in quantity of acetylated drug in the PCM group as compared to the controls. In view of these observations, therapy with sulfadiazine in children suffering from PCM requires reconsideration.