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 affluence 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. Hospitalized patients with decreased nutritional intake or severe nutritional loss are also prone to protein-energy malnutrition.

The symptoms include retardation in stature and tissue development, poor development of muscle and lack of tone, edema, potbelly, swollen legs and face, anorexia and diarrhea. The person stops interacting with the surroundings. The pathologic and biochemical changes include fatty infiltration of the liver, reduced serum levels of triglycerides, phospholipids, and cholesterol, reduced amylase, lyase and trypsin. Serum proteins 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 for kwashiorkor concentrates mainly on providing a diet that is high in protein. Five grams of proteins/kg of 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 the only source is from cereals and pulses, then the percentage of calories derived from protein can be 13 to 14% of the total calories because of the net protein utilization of cereals and pulses is around 60% whereas in milk or eggs, it is around 90%. Though 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 like skim milk (Srilakshmi)

Dietary supplements containing proteins like whey and casein can 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 nutrient supply. The clot is able to provide a sustained slow release of amino acids into the blood stream, sometimes lasting for several hours (Boirie et al., 1997)

Micellar casein is an extremely slow digesting and rich protein source that continues to feed 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 demonstrated it to sustain steady amino acid elevation for an incredible seven hours. It was shown to offer a strong anti-catabolic effect not noticed with fast digesting whey protein, and actually fostered 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.

Whey 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 total whey protein. They also contain small amounts of lactoferrin (iron, containing protein having protecting effect) and serum transferin (Srilakshmi, 1996).

Whey 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. Whey proteins are the highest quality of proteins as they contain the best combination of amino acids as compared to proteins in dairy products, soy, vegetable, and even meat. Whey proteins also support the immune functions by increasing glutathione levels, thereby exhibiting antioxidants properties. Whey proteins contain many similar ingredients found in a mother’s milk. Other benefits of whey proteins include the fact that they are easily absorbed, which help in increasing lean muscle mass and helps fat loss.

It is necessary to maintain electrolyte balance in patients with Protein Energy Malnutrition. Vitamin and mineral supplementation must be given according to the physician’s advice. If vitamin A deficiency is present, oral administration of a single dose of 50,000 International Units (I.U.s) 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 frequently encountered in people suffering from protein energy malnutrition. For the treatment of anemia, ferrous ammonium citrate (0.8g) should be given daily in the form of syrup in three divided doses for a period of one month. 100 mcg of Folic acid should be given daily (Srilakshmi).

Treatment strategy involves provision of adequate protein, provision of casein and whey protein supplementation, provision of vitamin and mineral supplementation, resolving life threatening conditions, restoring nutritional status without disruption of homeostasis ensuring nutritional rehabilitation. Criteria for improvement involves disappearance of mental apathy and edema, rise in serum albumin level and an increase in weight gain.