Chapter 072. Malnutrition and Nutritional Assessment (Part 1) Harrison's Internal Medicine > Chapter 72. Malnutrition and Nutritional Assessment Malnutrition and Nutritional Assessment: Introduction Malnutrition can arise from primary or secondary causes, with the former resulting from inadequate or poor-quality food intake and the latter from diseases that alter food intake or nutrient requirements, metabolism, or absorption. Primary malnutrition occurs mainly in developing countries and under conditions of war or famine. Secondary malnutrition, the main form encountered in industrialized countries, was largely unrecognized until the early 1970s, when it became appreciated that persons with adequate food supplies can become malnourished as a result of acute or chronic diseases that alter nutrient intake or metabolism. Various studies have shown that protein-energy malnutrition (PEM) affects one- third to one-half of patients on general medical and surgical wards in teaching hospitals. The consistent finding that nutritional status influences patient prognosis underscores the importance of preventing, detecting, and treating malnutrition. Protein-Energy Malnutrition The two major types of PEM are marasmus and kwashiorkor. These conditions are compared in Table 72-1. Marasmus and kwashiorkor can occur singly or in combination, as marasmic kwashiorkor. Kwashiorkor can occur rapidly, whereas marasmus is the end result of a gradual wasting process that passes through stages of underweight, then mild, moderate, and severe cachexia. Table 72-1 Comparison of Marasmus and Kwashiorkor Marasmus Kwashiorkor a Clinical setting Energy intake Protein intake during stress state Marasmus Kwashiorkor a Time course to develop Months or years Weeks Clinical features Starved appearance Well-nourished appearance Weight <80% standard for height Easy hair pluckability b Triceps skinfold <3 mm Edema Mid- arm muscle circumference <15 cm Laboratory Creatinine-height Serum albumin <2.8 Marasmus Kwashiorkor a findings index <60% standard g/dL Total iron-bindi ng capacity <200 µg/dL Lymphocytes <1500/µL Anergy Clinical course Reasonably preserved responsiveness to short-term stress Infections Poor wound healing, decubitus ulcers, skin breakdown Marasmus Kwashiorkor a Mortality Low unless related to underlying disease High Diagnostic criteria Triceps skinfold <3 mm Serum albumin <2.8 g/dL Mid- arm muscle circumference <15 cm At least one of the following: Poor wound healing, decubitus ulcers, or skin breakdown Easy hair pluckability b Marasmus Kwashiorkor a Edema a The findings used to diagnose kwashiorkor must be unexplained by other causes. b Tested by firmly pulling a lock of hair from the top (not the sides or back), grasping with the thumb and forefinger. An average of three or more hairs removed easily and painlessly is considered abnormal hair pluckability. . Chapter 072. Malnutrition and Nutritional Assessment (Part 1) Harrison's Internal Medicine > Chapter 72. Malnutrition and Nutritional Assessment Malnutrition and Nutritional Assessment: . detecting, and treating malnutrition. Protein-Energy Malnutrition The two major types of PEM are marasmus and kwashiorkor. These conditions are compared in Table 72-1. Marasmus and kwashiorkor. that protein-energy malnutrition (PEM) affects one- third to one-half of patients on general medical and surgical wards in teaching hospitals. The consistent finding that nutritional status influences