Protein energy malnutrition

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Kwashiorkor
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Kwashiorkor is a type of malnutrition with controversial causes, but it is commonly believed to be caused by insufficient protein intake. It usually affects children aged 1–4 years, although it also occurs in older children and adults. Jamaican pediatrician Cicely D. Williams introduced the name into international scientific circles in her 1935 Lancet article. When a child is nursing, it receives certain amino acids vital to growth from its mother's milk. When the child is weaned, if the diet that replaces the milk is high in starches and carbohydrates, and deficient in protein (as is common in parts of the world where the bulk of the diet consists of starchy vegetables, or where famine has struck), the child may develop kwashiorkor.

Derivation of kwashiorkor

The name is derived from one of the languages of coastal Ghana and means "one who is physically displaced" reflecting the development of the condition in the older child who has been weaned from the breast.

Symptoms of kwashiorkor

Symptoms of kwashiorkor include a swollen abdomen known as a pot belly, as well as reddish discoloration of the hair and depigmented skin. The swollen abdomen is generally attributed to two causes: First, the observation of ascites due to increased capillary permeability from the increased production of cysteinyl leukotrienes (LTC4 and LTE4) as a result of generalized intracellular deficiency of glutathione. It is also thought to be attributed to the effect of malnutrition on reducing plasma proteins (discussed below), resulting in a reduced oncotic pressure and therefore increased osmotic flux through the capillary wall. A second cause may be due to a grossly enlarged liver due to fatty liver. This fatty change occurs because of the lack of apolipoproteins which transport lipids from the liver to tissues throughout the body. Victims of kwashiorkor fail to produce antibodies following vaccination against diseases including diphtheria and typhoid.[2] Generally, the disease can be treated by adding food energy and protein to the diet; however, mortality can be as high as 60% and it can have a long-term impact on a child's physical growth and, in severe cases, affect mental development.

Possible causes of kwashiorkor

Many of the children in this photograph from a Nigerian orphanage in the late 1960's show symptoms of malnutrition, with four in particular illustrating the gray-blond hair symptomatic of kwashiorkor.

There are various explanations for the development of kwashiorkor, and the topic remains controversial. It is now accepted that protein deficiency, in combination with energy and micronutrient deficiency, is certainly important but may not be the key factor. The condition is likely to be due to deficiency of one of several type one nutrients (e.g. iron, folic acid, iodine, selenium, vitamin C), particularly those involved with anti-oxidant protection. Important anti-oxidants in the body that are reduced in children with kwashiorkor include glutathione, albumin, vitamin E and polyunsaturated fatty acids. Therefore, if a child with reduced type one nutrients or anti-oxidants is exposed to stress (e.g. an infection or toxin) he/she is more liable to develop kwashiorkor.

Ignorance of nutrition can be a cause. Dr. Latham, director of the Program in International Nutrition at Cornell University cited a case where parents who fed their child cassava failed to recognize malnutrition because of the edema caused by the syndrome and insisted the child was well-nourished despite the lack of dietary protein.

One important factor in the development of kwashiorkor is aflatoxin poisoning. Aflatoxins are produced by molds and ingested with moldy foods. They are toxified by the cytochrome P450 system in the liver, the resulting epoxides damage liver DNA. Since many serum proteins, in particular albumin, are produced in the liver, the symptoms of kwashiorkor are easily explained. It is noteworthy that kwashiorkor occurs mostly in warm humid climates that encourage mold growth, in dry climate marasmus is the more frequent disease associated with malnutrition. This has important consequences for treatment of the patients: Protein should be supplied only for anabolic purposes, the catabolic needs should be satisfied with carbohydrate and fat. Protein catabolism involves the urea cycle, which is located in the liver and can easily overwhelm the capacity of an already damaged organ. The resulting liver failure can be fatal.

Other malnutrition syndromes include marasmus and cachexia, although the latter is often caused by underlying illnesses.

• Malnutrition in Third World Countries

References

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