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Kwashiorkor in an Affluent Society
Kwashiokor is a form of protein-energy malnutrition that we generally associate with children from war-torn countries of Africa. The financial and social abundance generally protects our population, especially the children, from protein deprivation. The low incidence of Kwashiokor delays its diagnosis in the special groups that are at risk of developing it. Chase HP, in a review of kwashiorkor, suggests that children on severe protein restriction due to nutritional ignorance, perceived milk intolerance, or food faddism can develop Kwashiokar. Chronic malabsorptive conditions such as cystic fibrosis are also a high-risk group. Hospital patients with reduced food intake or severe food loss are also susceptible to protein-energy malnutrition.
The symptoms include retardation in stature and tissue development, poor muscle development and lack of tone, edema, potbelly, swollen legs and face, anorexia and diarrhea. The person stops interacting with the environment. The pathological and biochemical changes include fatty infiltration of the liver, decreased serum levels of triglycerides, phospholipids and cholesterol, decreased amylase, lyase and trypsin. Serum proteins and albumin fractions are markedly reduced. Hemoglobin levels are particularly reduced. This can be a serious complication leading to blindness and death. (Chetali Agrawal, 2000).
Dietary management for kwashiorkor mainly focuses on providing a diet that is high in protein. Five grams of proteins/kg body weight/day should be given for the existing weight. The calories derived from protein should be 10% of the total calculated calories per day if the main source is animal protein. If the main or only source is from grains and legumes, then the percentage of calories derived from protein can be 13 to 14% of total calories, because the net protein intake from grains and legumes is about 60%, while in milk or eggs, it’s about 90%. Although vegetable proteins are as good as milk proteins in reversing the acute manifestation of kwashiorkor, they are inferior in their ability to promote regeneration of serum albumin. This can be overcome by giving 3 parts of vegetable protein to one part of animal protein such as skim milk (Srilakshmi)
Dietary supplements containing proteins such as whey and casein may be of benefit in malnourished subjects. Casein is a milk protein and has the ability to form a gel or clot in the stomach. The ability to form this clot makes it very efficient in food supply. The clot is able to provide a sustained slow release of amino acids into the bloodstream, sometimes lasting several hours (Boirie et al., 1997)
Micellar casein is an extremely slow digesting and rich protein source that remains in the muscle (which is essential for kwashiorkor) long after whey protein has passed through the digestive system. In fact, studies with this under-rated form of isolated casein protein (Proc Natl. Acad Sci USA 1997) have shown that it maintains a stable amino acid increase for an incredible seven hours. It was shown to offer a strong anti-catabolic effect not seen with fast-digesting whey protein, and actually promoted a much more positive total net protein balance in comparison. Glutamine is the predominant amino acid in casein, which plays an important role in brain metabolism. Proline, asparagine, leucine, lysine and valine are also present. Casein is a good source of essential amino acids.
Milk proteins are made up of a-lacalbumin and ß-lactoglobulin (which defend against infection), albumin, the immunoglobulins, enzymes and protease, peptones. ß-lactoglobulin accounts for about 50% of the total milk protein. They also contain small amounts of lactoferrin (iron, contains protein with protective effect) and serum transferrin (Srilakshmi, 1996).
Milk proteins provide the highest value of BCAA (Branched Chain amino acid). This is highly valued for muscle building – an essential requirement in kwashiorkor – and recovery. Milk proteins are the highest quality of proteins because they contain the best combination of amino acids compared to proteins in dairy products, soy, vegetables and even meat. Whey proteins also support the immune functions by increasing glutathione levels, showing antioxidant properties. Milk proteins contain many similar ingredients found in a mother’s milk. Other benefits of milk proteins include the fact that they are easily absorbed, which help increase lean muscle mass and aid fat loss.
It is necessary to maintain electrolyte balance in patients with Protein Energy Undernutrition. Vitamin and mineral supplementation should be given according to the doctor’s advice. If vitamin A deficiency is present, oral administration of a single dose of 50,000 international units (IUs) of fat-soluble vitamin A should be given immediately, followed by 5000 units daily. The deficiency symptoms will be cured in about two weeks. Anemia is most common in people suffering from protein energy malnutrition. For the treatment of anemia, ferrous ammonium citrate (0.8 g) should be given daily in the form of syrup in three divided doses for a period of one month. 100 mcg Folic acid should be given daily (Srilakshmi).
Treatment strategy includes providing adequate protein, supplementing casein and whey protein, supplementing vitamins and minerals, resolving life-threatening conditions, restoring nutritional status without disturbing homeostasis, ensuring nutritional rehabilitation. Criteria for improvement include disappearance of mental apathy and edema, rise in serum albumin level and an increase in weight gain.
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