Kwashiokor is a form of protein-energy malnutrition that we generally associate with children in war-torn countries in Africa. Financial and social wealth generally protects our population, especially children, from protein deprivation. The low incidence of Kwashiokor delays its diagnosis in special groups that are at risk of developing it. Chase HP, in a review of kwashiorkor, suggests that children with severe protein restriction due to nutritional ignorance, perceived milk intolerance, or fads may develop Kwashiokar. Chronic malabsorptive conditions such as cystic fibrosis are also a high-risk group. Hospitalized patients with decreased nutritional intake or severe nutritional loss are also prone to protein-energy malnutrition.
Symptoms include delayed height and tissue development, poor muscle development and lack of tone, edema, swollen belly, legs and face, anorexia, and diarrhoea. The person stops interacting with the environment. Pathologic and biochemical changes include fatty infiltration of the liver, reduced serum levels of triglycerides, phospholipids, and cholesterol, reduced amylase, lyase, and trypsin. Serum protein and albumin fractions are markedly reduced. Hemoglobin levels are especially reduced. This could be a serious complication leading to blindness and death. (Chetali Agrawal, 2000).
Dietary management of kwashiorkor focuses primarily on providing a high-protein diet. Five grams of protein/kg body weight/day should be given for existing weight. Calories derived from protein should be 10% of the total calculated calories per day if the primary source is animal protein. If the main or only source is grains and legumes, the percentage of calories derived from protein may be 13-14% of total calories because the net utilization of protein from grains and legumes is about 60%, while in milk or eggs, it is around 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 serum albumin regeneration. This can be overcome by giving 3 parts vegetable protein to one part animal protein like skimmed milk (Srilakshmi)
Dietary supplements containing proteins such as whey and casein may be beneficial for 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 supplying nutrients. The clot can 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, rich source of protein that continues to feed muscle (which is essential for kwashiorkor) long after the whey protein has passed through the digestive system. In fact, studies with this underrated form of casein protein isolate (Proc Natl. Acad Sci USA 1997) have shown that it maintains a constant elevation of amino acids 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 overall net protein balance in comparison. Glutamine is the predominant amino acid in casein, which plays an important role in brain metabolism. Proline, aspartic, leucine, lysine and valine are also present. Casein is a good source of essential amino acids.
Serum proteins are composed of a-lacbumin and ß-lactoglobulin (which defend against infection), albumin, immunoglobulins, enzymes and proteases, peptones. ß-Lactoglobulin represents about 50% of the total whey protein. They also contain small amounts of lactoferrin (iron, a protein that has a protective effect) and serum transferin (Srilakshmi, 1996).
Whey proteins provide the highest BCAA (Branched Chain Amino Acid) value. This is highly valued for muscle building, an essential requirement in kwashiorkor, and recovery. Whey proteins are the highest quality proteins, as they contain the best combination of amino acids compared to proteins from dairy, soy, vegetables, and even meat. Whey proteins also support immune functions by increasing glutathione levels, thus exhibiting antioxidant properties. Whey proteins contain many similar ingredients found in breast milk. Other whey protein benefits include the fact that it is easily absorbed, which helps increase lean muscle mass and aids in fat loss.
It is necessary to maintain electrolyte balance in patients with Protein-Energy Malnutrition. Vitamin and mineral supplements should be administered in accordance with the doctor’s advice. If vitamin A deficiency is present, a single oral dose of 50,000 International Units (IU) of fat-soluble vitamin A should be given immediately, followed by 5,000 units daily. Deficiency symptoms will clear up in about two weeks. Anemia is most often found in people suffering from protein-energy malnutrition. For the treatment of anemia, ferrous ammonium citrate (0.8 g) should be administered daily as a syrup divided into three doses for a period of one month. 100 mcg of folic acid should be administered daily (Srilakshmi).
Treatment strategy involves provision of adequate protein, provision of casein and whey protein supplementation, provision of vitamin and mineral supplementation, resolution of life-threatening conditions, restoration of nutritional status without disruption of homeostasis , ensuring nutritional rehabilitation. Criteria for improvement involve disappearance of mental apathy and edema, increased serum albumin level, and increased weight gain.
