Malnutrition, Starvation and Refeeding Syndrome

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Malnutrition, Starvation and Refeeding Syndrome

• Khursheed Jeejeebhoy

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Starvation and Semi-starvation

• State of Negative Protein-Energy Balance
• Absence of nutrient intake
• Intake below requirements

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Metabolic Adaptation to Starvation
Post Absorptive state --- Overnight fast after a
meal
Fast lasting 12-24 Hours
Fast lasting gt 3days
Prolonged Starvation
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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

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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

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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

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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

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Clinical effects of Fasting Weight loss
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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

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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

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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.

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PEM Nitrogen adaptation Martin and Robison 1922
Neg N balance
Pos. N balance
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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

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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

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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

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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

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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

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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

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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

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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

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REFEEDING EDEMA CARDIAC FAILURE
36 year old Anorexia fed by NG 3200 kcal/d
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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
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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

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Relationship of Protein and Energy to Nitrogen
retention
Energy intake kcal/d
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Refeeding SyndromeJournal of Internal Medicine
2005 257 461468

• Case controlled study in Geriatric ward
• 325 had hypophosphatemia
• 326 normal plasma phosphorus levels

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Refeeding SyndromeJournal of Internal Medicine
2005 257 461468
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Refeeding SyndromeJournal of Internal Medicine
2005 257 461468
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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

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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.