Undernutrition
Tory Davis, PA-C
Malnutrition

Undernutrition and overnutrition

Undernutrition can result from
inadequate ingestion of nutrients,
malabsorption, impaired metabolism,
loss of nutrients due to diarrhea, or
increased nutritional requirements (as
in cancer or infection).
Stages of
Undernutrition
Each takes time to develop
 First, nutrient levels in blood and
tissues change
 Second, intracellular changes in
biochemical functions and structure
 Finally, signs and symptoms

Risk Factors
Ages and stages
 Social circumstances: poverty
 Medical conditions

Infancy and Childhood

High demands for:
– Vit E
– Energy
– Essential nutrients
 Nutrients
req’d for nl body fxn that we can’t
produce – must be obtained by diet

Vegan mother breastfeeding  B12
deficiency
Adolescence
Anorexia
 Rapid growth

Pregnancy
Fe deficiency anemia
 Folate deficiency anemia
 Pica – seen more in pregnancy – want
to eat things that aren’t normally
considered food – sometimes to
replace nutrional deficit

Old Age
Sarcopenia (progressive loss of lean
body mass) begins at 40!
  physical activity
 food intake

– Anorexia
cytokine levels
 androgen levels
 Basic metabolic rate

Disorders/Procedures
DM – can’t absorb
 GI Tract disorders

– Malabsorptions, IBD,Bowel resection
– Impaired absorption of fats. Fat-sol
vitamins, B12, Ca, Fe

Liver d/o
– Impair metabolism of vit A, B12, protein
Disorders/Procedures

Renal disorders
– Deficiencies of protein, vit D, Fe

Increased metabolic demands
– Infection, trauma, fevers, burns
Diets

Vegetarian
– B12 in vegans
– Fe defic in ovo-lacto
– Protein

Fad diets
– Protein, vit, minerals
– Ask Liberace
Diet

Meds/drugs/supplements
– Alter appetite
– Alter absorption and metabolism

Etoh/Drugs
– Neglect of nutritional needs
– Etoh deficiencies of Mg, Zinc, thiamine
 Thus
the “banana bag (mg, zinc thiamine +
others).” Why? – see note below
Diagnosis of
Undernutrition



Hx: dietary intake, weight change, above
risk factors
SHx: money for food? Able to prepare
meals? Think elders!
PE: BMI, look for signs of deficiencies OR
conditions that could predispose to
undernutition.
– Like what? Jaundice, spoon nails, wasted, pale
(sign of anemia), hair loss or thinning, etc

MNA- Mini Nutritional Assessment
Testing- Labs

Serum albumin as indirect measure
– May indicate protein deficiency

Other testing– Vitamin/mineral levels as specific tests
PEM
Protein Energy Malnutrition
 Energy deficit secondary to chronic
deficiency of all macronutrients
 Graded mild to severe, based on
percentage of expected wt
 Primary- inadequate intake
 Secondary from drug or d/o that
interferes with nutrient use

PEM

Developing countries:
– Children who can’t consume enough
protein and calories
 Lack

of access
Developed countries:
– Institutionalized elderly
– Abuse (child or elder)
– Pts with decreased appetite or impaired
digestion/absorption/metabolism
Vitamins

Organic compound required as
nutrient in tiny amounts but can’t be
synthesized by the organism and must
be obtained via diet.

See posted vitamin chart for sources,
functions, effects of deficiencies
Vitamin Deficiencies in
developed countries
Poverty
 Food faddism
 Drugs (ie drug/vit interactions)
 Alcoholism
 Parenteral nutrition (prolonged or with
inadequate supplementation)

S/S Nutritional
Deficiency: General
Wasting
 Cachexia


Energy deficiency
Skin

Rash
– many vits (usually def), zinc, fatty acids

Rash in sun-exposed areas
– Niacin (pellagra)

Easy bruising
– Vit C or K
Hair/nails

Thinning or loss of hair
– Protein

Premature whitening of hair
– Selenium

Spooning of nails
– Iron
Eyes
Impaired night vision and
 Corneal keratomalacia

– Vit A
Mouth

Cheilosis (angular cheilitis) and
glossitis
– Riboflavin, niacin, pyridoxine, iron

Bleeding gums
– Vitamin C, riboflavin
Extremities

Edema
– Protein def

Why?
Neuro

Stocking/glove paresthesias and
numbness
– Thiamin

Tetany
– Ca, Mg

Cognitive and sensory deficits
– Thiamin, niacin, B12
MSSK

Wasting
– Protein

Bony deformities
– Vit D, Ca

Bone tenderness
– Vit D

Joint pain/swelling
– Vit C
GI

Diarrhea
– Protein, niacin, folic acid, B12

Diarrhea with dysgeusia
– Zinc

Dysphagia/odynophagia (PlummerVinson syndrome)
– Iron
Endo

Thyromegaly
– Iodine