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Brief introduction of energy malnutrition in protein
Protein energy malnutrition (PEM) in protein is a malnutrition disease caused by insufficient food supply or disease factors, and its clinical manifestations are mara *** us and kwashiorkor. Weight loss is the result of long-term lack of calories, protein and other nutrients in the diet, or patients have obstacles in digestion, absorption and utilization of food. This type is characterized by energy deficiency and protein deficiency, characterized by progressive emaciation, subcutaneous fat loss, edema and dysfunction of various organs. Malignant malnutrition is characterized by the lack of prominent protein in the diet, and the supply of heat energy is still sufficient, mainly manifested as dystrophic edema. However, most patients are in between. Energy malnutrition in mild and chronic protein is often neglected, which affects children's growth and development, immune function, and is easy to get sick and difficult to recover. Severe energy malnutrition in protein can directly lead to death; Mild and chronic protein energy malnutrition is often neglected, but it has a great influence on children's growth and rehabilitation. Therefore, protein energy malnutrition is an important issue in clinical nutrition.
The heart is a metabolically active organ, which can use many substances as energy sources, such as sugar, lactic acid, pyruvate, fatty acids, phospholipids and amino acids. Nutritional cardiomyopathy refers to a group of diseases that lead to abnormal energy metabolism and pathological changes in cell structure of myocardial cells due to malnutrition or overnutrition, and ultimately lead to cardiac insufficiency. Timely supplementation of insufficient nutrients or removal of excessive nutrients may prevent or reverse the above changes. The common clinical causes of nutritional cardiomyopathy are protein energy malnutrition (PEM), vitamin B 1 deficiency, excessive drinking, selenium deficiency and obesity. At present, it is considered that selenium deficiency is related to Keshan disease, and alcoholic cardiomyopathy caused by excessive drinking is introduced. Obesity coexists with hypertension, hyperlipidemia and insulin resistance, which is one of the risk factors of coronary heart disease and has been listed as "metabolic and invasive cardiomyopathy". This article focuses on the cardiac changes caused by energy malnutrition and vitamin B 1 deficiency in protein.
2 disease name protein energy malnutrition
3 English name protein energy malnutrition
4. Alias of energy malnutrition in protein; Energy malnutrition in protein; Heat malnutrition in protein; Energy malnutrition in protein
5 ICDNo。 : E46 5. 1 Classified Metabolism Department >: Deficiency syndrome
6 ICDNo。 : I 43.2 ~ 6. 1 Classification Cardiology >: Cardiomyopathy
Epidemiology protein's energy malnutrition occurs all over the world, especially in underdeveloped countries. Especially during natural disasters and wars, when food and food supply are insufficient, the incidence rate is higher, which is one of the serious diseases that affect children's health and lead to death. This disease can occur in people of all ages, but it is more common in babies. Secondary malnutrition is mostly induced by diseases. In economically developed countries such as Europe and America, as well as older children and adults, malnutrition is mostly secondary. According to statistics, the incidence of hospitalized patients can reach 28% ~ 80%.
Etiology protein's energy malnutrition can be caused by severe protein deficiency and/or severe energy intake deficiency. The reasons are as follows: ① Insufficient intake: food shortage or imbalance caused by famine, war or economic backwardness. Patients with mental disorder, anorexia nervosa and upper gastrointestinal obstruction can't eat normally like normal people. ② Dyspepsia: stubborn and long-term vomiting, diarrhea and digestive and absorption disorders accompanied by other diseases. ③ The body needs to increase but the supply is insufficient: it is more common in infants, pregnant women and lactating women. In addition, consumptive diseases such as hyperthyroidism, tumor, tuberculosis, diabetes, etc. will increase the consumption of various nutrients in the body, and insufficient supplementation will also lead to energy malnutrition in protein.
9 Pathogenesis The occurrence of energy malnutrition in protein is a complex pathophysiological process. When protein and energy in food are insufficient, the body begins to reduce the demand of tissues and organs for nutrients through physiological adjustment, which can enable the body to survive in an environment with low nutritional level. However, when protein and energy are continuously lacking, the physiological function is unbalanced and the adaptive mechanism fails, which may lead to death. Energy malnutrition in protein will lead to the lack of other nutrients, such as vitamin B 1, vitamin B6, folic acid, iron and magnesium. Often accompanied by hypokalemia, hypomagnesemia and hypophosphatemia. These factors may aggravate malnutrition and organ damage.
Patients with energy malnutrition in protein have no symptoms of heart failure because of mental fatigue, slow exercise, low metabolic rate and relatively light heart load. Hepatomegaly, pleural effusion and peripheral sunken edema are mostly caused by malnutrition, so people have not fully understood the heart changes caused by energy malnutrition in protein for a long time. It was not until 1958 Gomez reported that Quashie olko's heart enlarged, cardiac output decreased, and caused refractory heart failure that people realized this disease again. Smythe reported in 1962 that the heart weight of patients with malignant malnutrition is obviously lighter than that of normal people. 197 1 year, Pisa performed autopsies on 93 children with energy malnutrition in protein. It was confirmed that 56 cases of heart damage were serious enough to cause symptoms of heart failure. Pulmonary congestion and hepatic lobular congestion confirmed that the patient had heart failure before his death. It shows that energy malnutrition in protein will lead to nutritional cardiomyopathy and fatal heart failure.
9. 1 protein metabolism When protein and energy supply are insufficient, the content of protein in plasma decreases, and the synthesis and decomposition of protein slow down.
Albumin: the content of body bank decreases, mainly in the extravascular part, and the rate of decomposition and synthesis decreases. When serum albumin drops to 30g/L, other substances in the body, such as lipoprotein, alanine and valine, change obviously.
Globulin: There is no obvious change in plasma concentration and distribution in vivo, but plasma ferritin is obviously decreased.
Protein transformation rate in vivo: Although the protein deficiency of tissues and organs in vivo is different, the synthesis and decomposition rates have changed; Generally, after 5-6 weeks of protein deficiency, the conversion rate drops by 30%. In animal experiments, 23% of amino acids are converted into urea and excreted. However, when protein was insufficient, only 3.4% of amino acids were converted into urea, and nitrogen excretion decreased.
9.2 In protein energy malnutrition with severe amino acid metabolism, the concentration of amino acids in plasma can be reduced to 65,438+0/2, especially branched-chain amino acids and threonine. Valine in patients with edema can be reduced to 30μmol/L (250μmol/L in normal children), and plasma alanine concentration is increased in the early stage of edema, which may be caused by increased gluconeogenesis or decreased urea production. In the later stage, alanine was used as the substance to form glucose, and the concentration in plasma decreased. In advanced protein's energy malnutrition, the ratio of phenylalanine to tyrosine also decreased.
9.3 When protein's energy malnutrition occurs in carbohydrate metabolism, the blood sugar is generally reduced, and the wasting type is more obvious than the edema type, and the gluconeogenesis of glycogen is enhanced. Studies have proved that 8% of the glucose in malnourished children comes from protein decomposition products, and the recovery period can be increased to 16%.
9.4 Lipid metabolism protein's energy malnutrition is often complicated with fatty liver. The contents of triglyceride, cholesterol and β lipoprotein in emaciated blood are normal or slightly increased. The contents of triglyceride, cholesterol and β lipoprotein in edema blood are normal or slightly lower.
9.5 protein energy malnutrition of body fluids and minerals, whether emaciation type or edema type, has fluid retention and edema. The expansion of extravascular body fluid space is the main reason for the increase of body fluid, and the degree of edema is related to hypoalbuminemia The mechanism of edema is shown in figure 1. In protein, the content of total potassium and magnesium decreased, while the content of sodium increased.
9.6 Classification of energy malnutrition in protein protein energy malnutrition is divided into the following three types: ① severe protein deficiency, and calories are mainly supplied by carbohydrates; ② Serious lack of energy (mara *** us), also known as emaciation and weakness; ③ Mixed type (Quashie Okumara * * * America). "kwashiorkor" is a transliteration of Ghanaian in Africa, which means "red child". This is because the hair and skin of sick children are often red. Due to the serious lack of protein and essential amino acids in food, the hair turns from black to gray or red, and the skin is rough. Malignant malnutrition is also called malnutrition syndrome.
10 pathology 10. 1 macroscopic observation, the heart has shrunk or slightly enlarged, and the wall of the cardiac cavity is thin; Pericardial fat disappeared and pericardial effusion was seen.
10.2 light microscope showed that myocardial cells were atrophied, the texture of myocardial fibers was blurred, and the nucleus of myocardial cells was degenerated and necrotic. Myocardial interstitial edema; The conduction system has degenerated.
10.3 electron microscope showed that the arrangement of myocardial fibers was disordered and the gap between muscle fibers was enlarged; Broken or missing myofilament. Chromosomes are clustered together. Mitochondrial morphology is changeable, containing dense particles, the mitochondrial crest is elongated and the mitochondrial membrane is destroyed.
10.4 pathological changes such as myocardial atrophy, edema, myofilament breakage and myocardial fibrosis lead to impaired myocardial contraction and relaxation function and decreased cardiac output. However, due to the weight loss of patients, low metabolism often goes hand in hand with the decline of cardiac function; Unless a large number of blood transfusions, infections or excessive nutritional supplements cause serious electrolyte disorder and water and sodium retention, the clinical symptoms of heart failure often do not appear.
1 1 Clinical manifestations of energy malnutrition in protein The clinical manifestations of energy malnutrition in protein are different due to individual differences, severity, onset time and other factors. Clinical symptoms include weight loss, subcutaneous fat reduction and disappearance, and various organs and systems of the whole body have different degrees of dysfunction. Clinically, it is generally divided into three types: mara *** us, kwashiorkor and mara * * * ickwashiorkor. According to the degree of nutritional deficiency, it is divided into mild, moderate and severe; According to the pathogenesis, it can be divided into three types: acute, subacute and chronic.
1 1. 1 wasting type is caused by serious lack of energy. It is characterized by emaciation, subcutaneous fat loss, dry and loose skin, loss of elasticity and luster, and severe emaciation is skin and bones. Hair is yellow and sparse, easy to fall off, and the cheeks are sunken in the shape of monkey cheeks. The patient is weak, listless, with slow pulse, low blood pressure and body temperature, atrophy of internal organs and easy access to lymph nodes. The child is obviously thin, irritable and afraid of cold. In severe cases, they are accompanied by diarrhea and vomiting, which can lead to dehydration, acidosis and electrolyte disorder, which is often the cause of death.
1 1.2 edema type is caused by severe protein deficiency, and it shows systemic edema. Edema first appeared in the lower limbs and instep, and gradually spread to the whole body. The patient is weak, listless and has poor appetite, often accompanied by diarrhea, hepatosplenomegaly and ascites. Severe edema can be complicated with bronchopneumonia, pulmonary edema, septicemia, gastrointestinal infection and electrolyte disorder, which is often the cause of death.
Most patients with 1 1.3 mixed type have the above two types of clinical manifestations due to the lack of both protein and energy.
12 Complications of energy malnutrition in protein 12. 1 Water-electrolyte disorder Patients with this disease often have hypoproteinemia, and the total amount of body fluids increases, making extracellular fluid hypotonic. When vomiting and diarrhea occur, it is easy to cause hypotonic dehydration and serious electrolyte disorder, resulting in hypokalemia, hyponatremia, hypocalcemia and hypocalcemia, causing corresponding symptoms. It has also been reported that the mortality rate has increased due to low blood phosphorus.
12.2 is often accompanied by other nutritional deficiencies, especially vitamin A deficiency, which can cause corneal dryness, softening and even perforation. It is often accompanied by angular stomatitis caused by vitamin B deficiency. Due to slow growth and development, rickets is rare and often accompanied by nutritional anemia.
12.3 low systemic immune function is easy to be complicated with various acute and chronic infections and infectious diseases, especially intestinal and respiratory infections, infectious diseases and parasitic diseases such as measles and tuberculosis, and fungal infections in digestive tract or whole body are not uncommon. Once an infection occurs, it usually persists. Gram-negative bacilli enteritis, septicemia or urinary tract infection are often difficult to cure.
13 laboratory examination showed that the normal value of plasma albumin was > 35g/L, 30 ~ 34g/L in low nutritional status and 25 ~ 25g/L in low nutritional status. When the plasma albumin protein is lower than 25g/L, the body has obviously changed.
The half-life of 13.2 serum transferrin is 8 ~ 10 day, which is shorter than albumin (about 20 days), so the evaluation of nutritional status is more sensitive than albumin. Normal value is 1.7 ~ 2.5g/L, moderate malnutrition is 1.0 ~ 1.5g/L, and severe malnutrition is less than1.0g/L. ..
The half-life of 13.3 prealbumin in the body is only 2 days, which is more sensitive to the evaluation of nutritional status, and the normal value is 280 ~ 350 mg/L, which is obviously decreased when energy malnutrition occurs in protein.
13.4 determination of serum amino acids in the early stage of nutritional deficiency, the ratio of non-essential amino acids to essential amino acids in serum is more sensitive than plasma protein and albumin, and the normal value is 2 ~ 3.
Serum amino acid ratio glycine serine glutamate taurine/leucine isoleucine valine methionine.
Its ratio > 3 has diagnostic reference value.
13.5 ratio of urea to creatinine When eating a low-protein diet, the excretion of urea in urine decreases, so the ratio decreases.
13.6 urinary hydroxyproline excretion is related to the growth rate, and the urinary excretion of malnourished children is reduced. The amount of hydroxyproline and creatinine in urine can be determined, and the hydroxyproline index can be obtained.
Hydroxyproline index hydroxyproline (μmol/ml)/ creatinine [μ mol/(ml kg)].
This index is relatively constant within 3 years old, and it is between 2.0 and 5.0 for preschool children. < 2 means slow growth.
14 assisted ECG examination, sinus tachycardia relieved QRS wave low voltage, STT was abnormal, and obvious U wave was visible.
Two-dimensional echocardiography showed contraction of the heart, enlargement of a few cardiac chambers and decrease of cardiac output.
Chest X-ray examination: the heart shrinks, a few patients have slightly enlarged hearts, and the chest wall and spine are osteoporosis.
15 diagnosis According to the patient's history of severe protein's and/or energy malnutrition, specific skin and hair changes, emaciation and weakness, slow pulse, hypotension, hypothermia, low weight, presence or absence of edema and other clinical manifestations, nutritional cardiomyopathy should be highly suspected. However, such patients often have no symptoms of heart failure such as jugular vein dilatation and hepatomegaly. Electrocardiogram and two-dimensional echocardiography have no specificity and are not helpful for diagnosis. Endocardial myocardial biopsy is helpful to confirm myocardial lesions.
15. 1 medical history according to the diet, understand the history of insufficient food intake and the history of diseases that affect the body's digestion and absorption.
15.2 Clinical manifestations (1) Symptoms: There were no obvious symptoms in the early stage, only poor appetite, and the height and weight of the child were slightly lower than normal. The disease continues to develop, the digestive function may decline, and it is easy to suffer from respiratory infection. Severe malnutrition is characterized by emaciation in appearance, refusal to eat, apathy and slow response, often accompanied by multivitamin deficiency and various complications such as keratitis, keratomalacia and purpura. And finally enter a state of generalized edema and inhibition.
(2) Signs:
① Weight: protein energy malnutrition will affect children's growth and weight loss. Gomez et al. proposed that the body weight with primary malnutrition was 75% ~ 90% of the standard body weight, the body weight with secondary malnutrition was 60% ~ 75% of the standard body weight, and the body weight with tertiary malnutrition was less than 60%, which had diagnostic significance.
② Height: In childhood, the height rose linearly, and the rise of energy malnutrition in protein continued to slow down. Generally compared with the average height in this area, it is lower or lower, so it has diagnostic value. The height of middle and lower finger is x 2s ~ X2s, and the height of lower finger is below X2s. But pay attention to comprehensive analysis, because protein's energy malnutrition can also occur with normal height; Conversely, short people are not all malnourished.
Weight/height ratio:
A. assessment criteria applicable to preschool children:
Obesity > 22.0; Excellent 22 ~19; Normal19 ~15; Thin15 ~13; Malnutrition13 ~10; Tuberculosis < 10.
B. evaluation criteria for post-school age:
Obesity >156; Obesity156 ~140; Medium140 ~109; Thin109 ~ 92; Excessive emaciation < 92.
③ The thickness of triceps sebum: the standard value is 12.5mm for males and 16.5mm for females. During the evaluation, it is converted into a percentage equivalent to the normal standard (table 1).
④ Limb girth length: measurement of muscle girth length in the middle of upper arm.
Length of upper arm muscle circumference (cm) Upper arm circumference (cm)
The normal standard value is 25.3cm for men and 23.2cm for women. The evaluation method is also to calculate the percentage (%) equivalent to the normal standard value: normal value > 90%, mild malnutrition 80% ~ 90%, moderate malnutrition 60% ~ 80%, severe malnutrition < 60%.
16 The differential diagnosis of edema caused by protein deficiency in children should be differentiated from heart, renal edema, tuberculous peritonitis, ascites due to liver cirrhosis and allergic edema.
Treatment of energy malnutrition in protein 17 The treatment principle of this disease is to supplement nutrition and correct the imbalance of water and electrolyte. Nutritional therapy should be carried out slowly, and the protein should be gradually increased from 0.8g/kg per day to 1.5 ~ 2.0g/kg per day, in which 1/3 should be animal protein. If the patient can eat, encourage oral administration, eat less and more meals, and eat digestible semi-liquid. Sodium content should be controlled. If the patient can't take it orally, nutritional therapy should be given through gastric tube or vein. Anemia should be given a small amount of blood transfusion. At the same time, protein assimilator was supplemented, such as 25 mg of norolone phenylpropionate, intramuscular injection, 1 ~ 2 times, once a week. This medicine has a slight sodium retention effect, so it should not be used too early.
Patients with energy deficiency in protein often die not from hunger, but from water-electrolyte disorder, so it is extremely important to correct the water-electrolyte disorder in time. It is difficult to judge the water loss by conventional methods, so it is necessary to carefully observe whether there is dry mouth, low blood pressure, chills in limbs and decreased urine output. Liquid supplement should ensure that patients have enough urine, children should urinate at least 200ml every 24 hours, and adults should urinate at least 500ml.
The treatment of energy malnutrition in protein can be divided into two stages: first aid period and recovery period.
17. 1 emergency (1) nutritional treatment principles:
(1) protein and energy supply should be higher than normal demand. At first, the supply of protein was1g/(kg d) and the energy was 336 ~ 420 kj/(kg d), and then it was gradually increased to 3 ~ 4g/(kg d) and the energy was 504 ~ 672 kj/(kg d).
(2) Fluid replacement, especially during dehydration and high fever, should be supplemented to maintain the normal discharge of urine.
③ Inorganic salts should be supplemented with low sodium and sufficient potassium [6 ~ 8 mmol/(kg d)] and magnesium (intramuscular injection of 50% magnesium sulfate 1.2 ~ 24 h 1 ml) to adjust electrolyte and acid-base balance.
Supplementing enough multivitamins, especially the supply of vitamin A and vitamin C.
⑤ Diet should start from a small amount, gradually increase after adaptation, and a small amount of meals is appropriate.
⑥ According to the patient's specific situation, liquid, semi-liquid and soft rice can be used, and it is best to supply them orally, and parenteral nutrition can be taken when necessary.
(2) Control infection: When energy malnutrition occurs in protein, it is easy to be complicated with various infections, so antibiotics should be selected according to different infections.
(3) Anti-heart failure treatment: Edema malnutrition is often accompanied by heart failure, and diuretics, oxygen inhalation, anti-heart failure treatment and other supportive therapies can be used.
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17.2 The recovery period treatment is mainly based on nutritional therapy, giving a reasonable and comprehensive diet to meet the needs of the body in the recovery period, supplemented by Chinese medicine diet therapy, and at the same time, taking appropriate exercise to enhance cardiopulmonary function and immune ability.
18 Prognosis Nutritional cardiomyopathy can often be reversed if patients with energy malnutrition in protein can be diagnosed and treated in time. We must analyze the causes and treat both the symptoms and the root causes in order to get good results. The prognosis depends on age, duration and degree of malnutrition, among which the onset age is the most important. The younger the age, the greater the long-term influence, and the ability of abstract thinking is more likely to be damaged.
Often died of serious complications or respiratory paralysis caused by sudden spontaneous hypoglycemia.
19 it is very important to prevent energy malnutrition in protein and protein. Because this disease mostly occurs in children, strengthening children's health care is the key. It is necessary to vigorously promote new parenting methods, publicize correct feeding methods, and provide nutritional guidance. Specific measures are as follows.
19. 1 Strengthen children's health care. Infants grow and develop very fast, and need more protein and energy than any age group. However, the function of digestive system is not fully developed, which can easily lead to diarrhea and malnutrition. Therefore, it is extremely important to guide infant health care, including parenting methods, nutrition guidance, correct nursing and disease prevention. Vigorously train nurses, improve their professional level and prevent malnutrition.
19.2 feeding instructions strongly advocate breastfeeding, and those with insufficient breast milk should adopt reasonable mixed feeding and supplement milk or soybean milk. Mothers who can't breastfeed or have insufficient milk should feed school-age formula milk, and can't feed starch, condensed milk and malt extract alone. With the increase of age, the addition of complementary food should be timely and correct For older children, we should pay attention to food collocation, avoid bad eating habits such as partial eclipse and picky eaters, ensure balanced nutrition and provide enough protein. See table 1 for daily supply.
19.3 strengthen physical exercise and improve physical fitness. 19.4 prevention of other diseases, prevention of various infectious diseases and planned immunization. Correct congenital malformations, such as congenital heart disease, cleft lip, cleft palate, hypertrophic pyloric stenosis, etc.
19.5 early detection of energy malnutrition in protein should be corrected as soon as possible. In short, for mild diseases, diet adjustment should be given priority to, and high-quality food with digestibility and high nutrition should be given. The protein of animals should be above 1/2 of the total protein, and the primary disease and complications should be treated at the same time. When the condition improves and the weight rises steadily, a certain amount of activity can be arranged appropriately to promote the recovery of muscle strength.
In order to prevent patients from developing PEM, risk factors should be evaluated, especially for the elderly, the infirm and those suffering from digestive, metabolic and consumptive diseases. Nutrition and diet arrangements should be paid attention to, and the nutritional status should be monitored, so as to find the possibility of PEM early and take nutritional intervention measures as soon as possible to avoid the further development of PEM.
Related drugs: phospholipid, folic acid, vitamin A, alcohol, glutamic acid, taurine, methionine, urea, norolone phenylpropionate.
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