Severe Protein-energy Malnutrition Research Articles

Cranial MRI findings in children with protein energy malnutrition

In this study, cranial magnetic resonance imaging (MRI) findings were investigated in children with moderate and severe protein energy malnutrition (PEM) to determine cerebral abnormalities in malnutrition in childhood. A total of 20 children aged 3 months to 36 months were included in the study. Thirteen (65%) children had severe malnutrition and seven (35%) children had moderate malnutrition. Fifteen (75%) children had abnormal MRI findings: all of them had cerebral atrophy, and 10 (75%) children had cerebral atrophy plus ventricular dilatation. None of the children had abnormality in the brain stem or cerebellum. The authors did not find statistically significant differences between the groups when comparing the MRI findings for degree of malnutrition, head circumference, iron deficiency anemia, and serum albumin levels. In conclusion, the findings showed that most (75%) children with moderate/severe PEM had abnormal MRI findings. Therefore, it is suggested that children with PEM should be evaluated for cerebral atrophy.

Prevalence of Aflatoxins in Blood and Urine of Egyptian Infants with Protein–Energy Malnutrition

The aim of the present work was to study the presence of aflatoxins in blood and urine of infants with protein-energy malnutrition (PEM). The study was conducted on 60 infants, 30 with kwashiorkor and 30 with marasmus, with 10 age-matched healthy infants studied as a control group. Complete blood count, liver function tests, and determination of the level of aflatoxins (B1, B2, G1, G2, M1, M2, G2a, B3, GM1, P, and aflatoxicol R0) in blood and urine were carried out in all studied infants. Serum aflatoxins were detected in more infants with kwashiorkor (80%) than in those with marasmus (46.7%). The mean serum levels of total aflatoxins, AFB1, AFG1, and AFB2a, were significantly higher in infants with kwashiorkor (p <.001). Aflatoxin B1 (AFB1) was the most commonly detected type. The prevalence of aflatoxin excretion in the urine of infants with kwashiorkor was 80%, a higher value than that in infants with marasmus (46.7%). The mean urinary concentration of total aflatoxins followed the same pattern of distribution (p < .052). There were no significant differences between groups in the mean urinary concentrations of AFB1, AFG1, AFB2a, AFM1, and AFG2a. Aflatoxins were not detected in any of the serum or urine samples of the control group. Aflatoxins are highly prevalent in this study population and show a high degree of correlation with severe PEM.

A Critical Appraisal of Blood Urea and Electrolytes in Severe Primary Protein Energy Malnutrition: A Guide to Prevent Management Pitfalls

Blood urea and electrolytes were determined in 30 severely malnourished children and 10 well nourished children who acted as controls. The mean ages of the subjects were 1.44 and 1.55 years for PEM and controls respectively. The mean values for sodium, potassium and urea of the malnourished children were 129.9+9.7, 2.3+0.8 and 4.9+2.3 mmol/L respectively. The corresponding figures for the controls were 136.8+1.8, 3.9+0.3 and 6.2+1.1. All the differences were statistically significant (P < 0.001). Keywords: Malnutrition, Electrolytes, blood urea. Nigerian Medical Practitioner 46(2) 2004: 30-32

Socio-economic factors predisposing under five-year-old children to Severe protein energy malnutrition at the Moi teaching and referral hospital, Eldoret, Kenya

Malnutrition is one of the leading causes of morbidity and mortality in children aged five years and below. Risk factors for severe protein energy malnutrition (PEM) have been identified as ignorance, family size, mothers and fathers education, poverty, residence, chronic infections, and congenital defects or malformations. The role of such social factors as the caretaker, extended family, homestead surroundings, and family cohesiveness have not been studied in Kenya. To determine the social and economic factors that predispose children to severe PEM as seen at the Moi Teaching and Referral Hospital (MTRH), Eldoret. Prospective and case control study. The MTRH, Eldoret, Paediatric wards, outpatient and MCH clinics over a 12 month period (June 2001 to June 2002). Sixty six children aged 3 to 36 months with severe PEM attending the MTRH outpatient clinics and those admitted in the Paediatric wards were age-matched with 66 controls. A standard pretested questionnaire was used to interview caretakers with severely malnourished children and age-matched controls. The children were weighed after interviewing the caretakers. The data was entered on a computer and analysed using the statistical package for social sciences (SPSS) programme. The social risk factors for PEM were single mothers (Odds Ratio) OR 14.93, p= 0.00001), young mothers aged 15-25 years (OR 3.95, p= 0.00020), the child's living conditions such as living in a temporary house (OR 3.627 p= 0.00257), caretaker who was not married to the child's parent (OR 0.10, p= 0.00005) and not staying with both parents in the past six months (OR 0.28606, p=0.00101). The economic risk factors were father's lack of ownership of land (OR 0.401, p= 0.01732), cattle (OR 0.24, p=0.00022), not growing maize (OR 0.15, p=0.00013), not growing beans (OR 0.36, p=0.00484) and ownership of small piece of land by grandfather (OR 6.00, p= 0.02274). Other risk factors were incomplete immunization (OR 3.87, p= 0.00151) and female sex (p=0.03721). Poverty, social conditions under which the child was living, sex of the child and incomplete immunizations were risk factors for the severe protein energy malnutrition.

Rabies post-exposure prophylaxis in malnourished children exposed to suspect rabid animals

Over half of the world's malnourished children live in Asia where more than 90% of reported human rabies deaths occur. In order to determine the effect of malnutrition on the immune response to rabies post-exposure prophylaxis (PEP), 45 children with moderate to severe protein energy malnutrition (PEM) who were exposed to potentially rabid animals were enrolled in a clinical trial. Patients received purified chick embryo cell rabies vaccine (PCECV) on days 0, 3, 7, 14 and 30. Blood was drawn on days 0, 14 and 30 and evaluated for the presence of rabies virus neutralizing antibody. All children that met the protocol criteria developed rabies virus neutralizing antibody titers above the acceptable level of 0.5 IU/mL by day 14 and no serious adverse events were reported. We conclude that children in this study that received four or five doses of rabies vaccine intramuscularly developed an acceptable immune response despite their severe degree of protein energy malnutrition.

Nutritional support with nucleotide addition favors immune response in severely malnourished infants

Background Adequate nutritional support of severe primary protein energy malnutrition (PEM) is indispensable for achieving normal immune response. However, an ideal dietetic criterion has not yet been established or accepted by the majority of health professionals caring for malnourished infants. Our objective was to demonstrate improvement in immune response in infants with PEM who received starting infant formula with nucleotides. Methods Twelve malnourished infants 3–18 months of age were included in our study and were fed through a nasogastric tube with infant formula (3.35 kJ/mL) for 2 weeks and ad libitum for an additional 2 weeks. Anthropometric measurements and immunologic indicators such as phagocytosis, microbicidal activity, chemotaxis, and cell proliferation index were determined. The sample was divided into two groups; group 1 ( n = 6) was fed formula with nucleotides added, while group 2 ( n = 6) was fed a formula with no nucleotides. Paired t test was used to determine differences between initial and final results for each group for comparison between group 1 vs. group 2; a nonparametric Mann–Whitney U test was used for immunologic indicators. Results Comparison of immunologic indicators showed no significant difference between groups. Groups 1 and 2 showed improvement in phagocytosis and microbicidal activity (p <0.05) and group 2 additionally showed improvement in cell proliferation index. Conclusions Infant formula with intake of 837 kJ/kg/d (200 kcal/kg/d) and proteins of 4 g/kg/d in infants with PEM had a favorable impact on immunologic indicators regardless of addition of nucleotides.

Detection of severe protein-energy malnutrition by nurses in The Gambia

Aim: To test whether nurses can use the WHO integrated management of childhood illness (IMCI) nutrition algorithm to identify reliably severe protein-energy malnutrition in children. Methods: Nurses were trained to...

Intraerythrocytic potassium levels and early insulin release in children with moderate malnutrition.

Potassium deficiency and insulin releasing defect in severe protein-energy malnutrition (PEM) have been reported previously. The aim of this study was to investigate the existence of potassium deficiency and early insulin releasing defect in moderate PEM, which is more common in children. This study was carried out prospectively in the Pediatrics Department at Trakya University. The study group comprised 30 children with moderate PEM who were also classified as stunted, wasted, and stunting-wasting. Thirty healthy children were selected as controls. Although there was no statistical difference between the study and control groups in terms of serum potassium and initial insulin levels, intraerythrocytic potassium and early insulin release in patients were significantly lower than in controls. The stunting-wasting cases had the lowest intraerythrocytic potassium and early insulin response to intravenous glucose administration. This study suggests that it is appropriate to evaluate moderate PEM cases for intraerythrocytic potassium deficiency and early insulin releasing defect. Potassium supplements should be given if necessary.

Serum leptin concentrations in children with mild-to-moderate protein-energy malnutrition.

The aim of the present study was to clarify the relationship between nutritional anthropometric parameters and serum leptin concentrations in otherwise healthy children with mild-to-moderate protein-energy malnutrition (PEM) secondary to inadequate energy intake. Eighty-one otherwise healthy children with poor appetite and inadequate energy intake were enrolled in the study. The anthropometric values were evaluated in all subjects. Fasting serum leptin concentrations were assessed. Of the 81 otherwise healthy children, 30 were found to have mild-to-moderate PEM. The control group consisted of 51 healthy children who had normal anthropometric values, even though they had inadequate energy intake. There was a significant difference in serum leptin concentrations between the two groups (P < 0.01). Furthermore, there was a positive correlation between mean serum leptin concentrations and percentage of standard weight for height in the patient and the control group (P < 0.05). Multiple linear regression analysis indicated that percentage of standard BMI was the best predictor for serum leptin concentrations (P < 0.05). In addition to BMI, percentage of standard weight for height is a valuable nutritional anthropometric parameter for serum leptin concentrations in PEM and inadequate energy intake. However in the present study, percentage of standard BMI was the best predictor for serum leptin concentrations. Serum leptin concentrations are low not only in severe PEM, but also in children with mild-to-moderate PEM without chronic disease.

Role of long-chain polyunsaturated fatty acids in infant nutrition.

To review briefly the influence of dietary long-chain polyunsaturated fatty acids (LC-PUFA) on tissue composition and functionality in early infancy. Moreover, the influences of LC-PUFA sources on plasma composition as well as the effects of these fatty acids on intestinal repair after malnutrition are discussed. Human milk not only supplies essential fatty acids but also contains up to 2% of the total fatty acids as LC-PUFA, of which arachidonic acid (AA) and docosahexaenoic acid (DHA) are considered the most important. Plasma and erythrocyte levels of both AA and DHA are decreased in infants fed artificial standard milk formulae. However, the supplementation of formulae with these fatty acids in amounts close to that of human milk leads to tissue LC-PUFA patterns similar to those of breast-fed infants. However, the bioavailability of LC-PUFA depends on the typical LC-PUFA source; egg phospholipids increases both AA and DHA in plasma phospholipids and HDL more than a mixture of tuna and fungal triglycerides. Dietary LC-PUFA affects positively the growth and development of the infant and ameliorates the visual and cognitive functions, particularly in preterm infants. Likewise, LC-PUFA improves intestinal repair in severe protein-energy malnutrition; therefore, its qualitative and quantitative dietary supply should be considered.

The Effect of Drought in South East Ethiopia: Study of Pediatric Admissions to Gode Hospital

BACK GROUND: The East African region of the continent, particularly Ethiopia experienced prolonged drought during 1997-2000 resulting in severe food shortage especially in southeast part of the country. As a result people, mostly children suffered from malnutrition, which is associated cause of death for more than half of all underfive mortality in developing countries. The aim of this study was to describes the profile and outcome of pediatric admissions to Gode Hospital during the relief activities in the year 2000. PATIENTS AND METHODS: A cross-sectional study was conducted on 323 children admitted to Gode Hospital, Somali regional state, during April to August 2000 with the objective of analyzing the profile and outcome of pediatric admissions among people with long standing food shortage in drought affected area. RESULTS: A total of 323 children were admitted to the ward during the stated period of which 98% were under-five children with male to female ratio of 1.4:1; 23% percent of the admissions were underweight and 64% severely malnourished. Females were more prone to severe protein energy malnutrition than males. Pneumonia, gastroenteritis and sepsis were common related diseases complicating protein energy malnutrition in 51%, 32% and 28% of admitted children respectively. All were managed in the ward with a specialized case management for malnourished children and discharged after a median hospital stay of 12 days. The over all mortality was 18% with case fatality rate of 23% for severe protein energy malnutrition. CONCLUSION: It is clear from this study that children aged 2 years and below, moreover girls, were affected and died from severe forms of protein energy malnutrition. Compared to high case fatality rate (49%) in previous reports, it is shown as well a specialized management somehow decreased deaths in severely malnourished children complicated by infections and other diseases. Ethiop J Health Sci . Vol. 13, No. 2 July 2003

Expression of messenger ribonucleic acid and production of cytokines in children with malnutrition

The aim of this study was to determine the IL2 and IL4 mRNA expression by antigen/mitogen stimulated lymphocytes and IL2, IFN-γ, IL4, IL5 and IL10 protein secretion from the culture supernatant obtained from children suffering from severe protein energy malnutrition (PEM) and compare with the responses of normal healthy children. Twelve children aged between 3 and 5 years hospitalised for rehabilitation of severe PEM manifesting as marasmic kwashiorkor were investigated at the time of hospitalisation and 8 were retested 30 days after nutritional rehabilitation. Ten age matched healthy children served as controls. Three normal adult volunteers were also investigated for validating Reverse Transcription–Polymerase chain reaction (RT-PCR) results obtained in children. mRNA expression for IL2 and IL4 by in vitro cultured peripheral blood mononuclear cells (PBMC) stimulated by PHA/PPD was determined using RT-PCR technique following established procedures. mRNA was quantified using Dipstic™ kit. Concentrations of IL2, IL4, IFN-γ, IL5 and IL10 were determined from the culture supernatant using ELISA technique. Lymphocytes from adult volunteers expressed clearly both IL2 and IL4 mRNA with PHA as well as PPD. Four out of the 10 control children had clear mRNA band for IL2 while the other six had faintly visible bands with PHA. IL4 mRNA bands were clearly visible in 9 out of 10 children with both PHA and PPD. Mean (± SE) concentrations of mRNA from PHA stimulated systems for IL2 and IL4 were significantly lower in children compared to adults. All the children with PEM had very faint mRNA bands for IL2 before as well as 1 month after rehabilitation while IL4 mRNA expression was clear. Mean mRNA concentration for IL2 was significantly ( P < 0.05) lower (81.2 ± 16.06 ng/1 ×10 6 cells) than in control children (127.1 ± 26.24 ng/1 × 10 6 cells) with no significant change after rehabilitation. IFN-γ, IL4, IL5 and IL10 cytokine profile of children with PEM before as well as after rehabilitation was similar to that of the control children. These observations suggest that Th1 subset responses are lower in children compared to adults. IL2 response is impaired in children suffering from severe PEM. Short term nutritional rehabilitation has no impact on these immune responses.

IgE responses in mice fed moderate protein deficient and high protein diets.

While severe protein energy malnutrition (PEM) has been known to depress several immune functions, allergies are suppressed by decreasing IgE and impairing vascular permeability and mast cell functions. To address the effect of moderate protein malnutrition without growth arrest and protein hypernutrition on type I allergy, we examined the effect of various levels of protein nutrition on allergy at humoral immunity and the regulation of Th cell function levels. Mice fed 100 g/kg (moderate protein malnutrition; MPM), 200 g/kg (normal protein nutrition; PN) and 400 g/kg (protein hypernutrition; PH) protein diets were intraperitoneally sensitized to ovalbumin (OVA) in aluminum hydroxide. Higher elevations of OVA-specific IgE and total IgE in the serum were observed in the PH group as compared to the PN group. However, OVA-specific IgE in the MPM group was not significantly different from that in the PN group, although the former appeared higher than the latter. While CD3, CD4, CD8 and B220 expressions in the splenic lymphocytes were decreased in the MPM group, B220 expressions were increased in the PH group. Splenic lymphocyte proliferative responses to OVA were augmented in the PH group and depressed in the MPM group. IFN-gamma production from splenic lymphocytes was significantly decreased; however, IL-4 production was not affected significantly in the MPM group, and increased in the PH group. These findings suggest that immune functions to specific antigens in the MPM state are depressed at the cytokine level but not in terms of IgE responses. They also suggest that immune functions become Th2-predominant in the PH state, resulting in an increased risk of type I allergy.

Urinary tract infection in severely malnourished children at the University of Maiduguri Teaching Hospital.

One hundred and ninety-four children with severe protein energy malnutrition were investigated for urinary tract infection in this prospective study. The prevalence of urinary tract infection was found to be 11.3 per cent. There was no difference either between the sexes or the different categories of malnutrition. The commonest isolates were Gram-negative organisms predominantly Escherichia coli. The antibiotic sensitivity pattern of the organisms in this study differs from other reports. In this study, we observed poor sensitivities of organisms especially the Gram negatives to the second and third generation cephalosporins. We therefore conclude that regular surveillance of urinary tract infection pathogens and their antibiotic sensitivity patterns should be carried out.

Response of splanchnic and whole-body leucine kinetics to treatment of children with edematous protein-energy malnutrition accompanied by infection

Although the reduction in whole-body protein turnover and net protein loss induced by protein-energy malnutrition (PEM) has been well documented, it is unclear whether the protein-sparing mechanisms elicited by chronically inadequate intakes of dietary protein and energy are affected by the protein catabolic response to infection. The objective of this study was to determine whether the presence of infection alters the PEM-induced reduction in whole-body protein metabolism. We determined whole-body leucine kinetics in 4 boys and 3 girls aged 6-15 mo with edematous PEM and infection approximately 3 d after admission (study 1), when they were both infected and malnourished; approximately 11 d after admission (study 2), when infection had resolved but they were still anthropometrically malnourished; and at recovery (study 3), when weight-for-length was at least 90% of that expected. The children had significantly less leucine flux in both study 1 and study 2 than they had in study 3. There were no significant differences in the amount of leucine released from protein breakdown or used for protein synthesis between study 1 and study 2. There were no significant differences in leucine balance or in either the amount or percentage of enteral leucine extracted by the splanchnic tissues among the 3 studies. When subjects are in the fed state, severe PEM induces a marked reduction in whole-body protein synthesis and breakdown rates, and the presence of infection does not alter this adaptation and hence the overall protein balance. A corollary is that children with severe PEM do not mount a protein catabolic response to infection.

Effect of renutrition on natural and cell-mediated immune response in infants with severe malnutrition.

The purpose of this study was to evaluate whether a 4-week nutritional recovery period with a starting infant formula and 3.35 kJ/mL energy density would favorably affect the natural and cell-mediated immune response in infants with severe and primary protein-energy malnutrition. The study included 12 severely malnourished infants, 3 to 18 months of age. For 2 weeks, infants were fed a starting infant formula, with energy density increased to 0.8 kcal/mL, through a nasogastric tube. Infants were fed "ad libitum" for 2 more weeks. On the fifth day, 837 kJ/kg and 4 g/kg protein were given daily. At the beginning and at the end of the 4-week period, weight, length, phagocytosis, microbicidal activity, chemotaxis, and cell proliferation indices were measured. Null hypothesis was rejected with a paired t test and a P value less than 0.05. After the 4-week period of nutritional recovery, the weight and length indicators and the four immunologic assays showed significant increase (P < 0.005). The study demonstrated that a 4-week nutritional recovery period with a starting infant formula and 0.8 kcal/mL energy density favorably affected the natural and cell-mediated immune response in infants with severe protein-energy malnutrition.

A case of kwashiorkor in a child with congenital hypothyroidism

A 12-year-old Indonesian girl with the body weight of 9.8 kg and length 78 cm was admitted to the Department of Child Health, Manado General Hospital with kwashiorkor and congenital hypothyroidism. The main complaint was edema starting 3 weeks before admission. Physical examination showed body weight for age (BW/A) 14.3%, body weight for body length (BW/BL) 66.0% and body length for age (BL/A) 49.1%. On admission she looked severely ill, apathetic, with hypothermia and hypotonia. Almost all signs and symptoms of kwashiorkor and congenital hypothyroidism were found accompanied bronchopneumonia and dermatologic problems. Laboratory findings showed severe anemia, leukocytosis, hypoproteinemia, hyponatremia, hypokalemia, elevated thyroid stimulating hormone and low level of Thyroxine-4. Bone age equaled to a newborn baby bone age. There was no thyroid tissue on thyroid ultrasound examination. The patient was treated for severe protein energy malnutrition and ThyraxR. Problems of kwashiorkor could been solved well but not with the congenital hypothyroidism. She was discharged from hospital after 2 months treatment and till now at 14th year of age with her developmental milestones equals to that of 8 month old baby.

Human growth in southern Zambia: a first study of Tonga children predating the Kariba Dam (1957-1958).

During the late 1950s the Kariba hydro-electric dam was constructed on the border of Zambia and Zimbabwe forcing the relocation of 57,000 people, mainly Tonga. As part of a larger study to assess the effects of the relocation, research into the human biology of the Tonga people was conducted. The research reported here provides a basis for comparison with long-term follow-up data on growth and physical status of Gwembe Tonga to determine the effects of resettlement. The sample consists of 303 schoolchildren, 7 to 13 years, from two schools that were not relocated and three schools that were to be relocated. Homogeneity of the two groups led us to combine them as a single baseline sample before relocation. Comparisons with NCHS (National Center for Health Statistics) reference data and with contemporary urban data from southern Zambia indicate sub-optimal nutritional status. After ages 6 and 7, height-for-age and weight-for-age Z-scores of boys decline steadily towards -2.0 SD throughout the 12th year, whereas mean Z-scores of girls decline markedly from 8 years on. Mean HAZ (Height-for-age-Z-score) of girls falls below -2.0 SD by 11 years and approaches -3.0 SD by 13 years. Thirty-nine percent of males and 47% of females in the baseline sample showed effects of moderate or severe protein energy malnutrition at the time of relocation. Because these children were from a school sample, gender differences in opportunity to attend school may be a factor in what appears to be gender bias, favoring the status of boys. This sample provides a baseline for assessing the long-term impact of forced relocation on the Gwembe Tonga.

Impact of protein energy malnutrition on thyroid size in an iodine deficient population of Gujarat (India): Is it an aetiological factor for goiter?

To assess the severity of protein energy malnutrition (PEM) in iodine deficient subjects and to assess the impact of PEM on thyroid size. 1002 subjects (530 school-aged children and 472 adults) were assessed for PEM by direct anthropometric measurements of height, weight, triceps skinfold (TSF) thickness, mid upper arm circumference (MUAC) and thigh circumference (TC), and derived indices of body surface area (BSA), body mass index (BMI), and Z-scores for weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ). Severity of PEM was based on the World Health Organization (WHO) criteria and the threshold on the Waterlow classification. Thyroid size was measured by ultrasonography to determine the thyroid volume (TV). Linear regression analysis was performed between TV and anthropometric parameters. Children had severe PEM as evident from the WHO percentage prevalence of stunting (HAZ<-2SD)=64% (where <-2SD is the Z-score deficit), wasting (WHZ<-2SD)=43%, underweight (WAZ<-2SD)=82% and BMI<16 kg/m=90%. Waterlow classification showed that children were either stunted or wasted, or stunted and wasted, or stunted and obese. Nearly 100% (529/530) of the children had goiter as evidenced from enlarged TV-for-BSA when compared with the WHO reference. There was a weak but statistically significant (P<0.05) positive correlation between TV and BSA, weight, height, MUAC, TC and HAZ but a negative correlation between TV and WHZ, BMI and TSF (r=-0.1-0.2). Adults had PEM as evident from BMI<18.5 kg/m in 54% subjects. Median MUAC=22.7 cm reveals prolonged severe PEM. Eighty-two percent had enlarged TV (>20 ml). There was a significant (P=0.01) negative correlation between TV and MUAC. (i) The severity of acute (wasting) and chronic (stunting) PEM is very high in Gujarati children. They are stunted or wasted, or stunted and wasted, or stunted and obese. Gujarati adults are thin with low protein and fat reserves. (ii) Anthropometric parameters showed a significant (P<0.001) correlation (r=0.1-0.2) with thyroid size. (iii) Higher prevalence of goiter may be due to macro-nutrient malnutrition (PEM) in the face of micro-nutrient malnutrition (iodine deficiency disorders, IDD).

Hospital admission and mortality rates in anorexia nervosa: experience from an integrated medical-psychiatric outpatient treatment.

To evaluate the effectiveness of an integrated medical-psychiatric treatment of major eating disorders. Historical cohort study. Outpatient Unit for Protein Energy Malnutrition of the Department of Clinical and Experimental Medicine, "Federico II" University of Naples, time of study: January 1994 to December 1997 PARTICIPANTS: 147 female patients with restrictive or bulimic anorexia nervosa (mean age 19.8 +/- 13.7, BMI 14.7 +/- 2.1 Kg/m2) consecutively attending the outpatient unit between January 1994 and December 1997. Hospitalization and mortality rates were evaluated up to Jan 1999 with a minimum follow-up of 18 months. There were 23 admissions to the Clinical Nutrition ward for 19 patients (i.e. 12.9%) mostly due to severe protein energy malnutrition, and 2 deaths, only 1 strictly related to anorexia (mortality rate 0.7%). Integrated outpatient medical-psychiatric treatment for major eating disorders is an effective and inexpensive procedure that reduces mortality and admissions due to medical complications in the medium term.