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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 African countries. Economic and social prosperity generally protects our population, especially children, from protein deprivation. The low incidence of Kwashiokor delays its diagnosis in the special groups 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 phenomenology may develop kwashiorkor. Chronic malabsorptive conditions such as cystic fibrosis are also a high-risk group. Hospitalized patients with reduced nutritional intake or severe nutritional loss are also prone to protein-energy malnutrition.

Symptoms include stunting and tissue growth, poor muscle growth and lack of tone, oedema, abdomen, swollen legs and face, anorexia and diarrhoea. The person stops interacting with the environment. Pathologic and biochemical changes include fatty infiltration of the liver, decreased serum triglyceride, phospholipid, and cholesterol levels, decreased amylase, lyase, and trypsin. Serum proteins and albumin fractions are significantly reduced. Hemoglobin levels are particularly low. This could be a serious complication leading to blindness and death. (Chetali Agrawal, 2000).

Nutritional management for kwashiorkor focuses primarily on providing a high protein diet. Five grams of protein/kg of body weight/day should be given for current weight. Calories from protein should be 10% of 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 from protein may be 13 to 14% of total calories, because the net protein utilization of grains and legumes is about 60%, while in milk or eggs, is around 90%. Although plant proteins are as good as milk proteins in reversing the acute onset of kwashiorkor, they are inferior in their ability to promote regeneration of serum albumin. This can be overcome by giving 3 parts vegetable protein to one part animal protein such as skimmed milk (Srilakshmi)

Dietary supplements containing proteins such as whey and casein may be beneficial in malnourished individuals. 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 effective at delivering nutrients. The clot is able to provide a sustained slow release of amino acids into the bloodstream, sometimes lasting for several hours (Boirie et al., 1997).

Micellar casein is an extremely slow-digesting and rich source of protein that continues to fuel the muscles (which is essential for kwashiorkor) long after the whey protein has passed through the digestive system. In fact, studies with this degraded form of casein protein isolate (Proc Natl. Acad Sci USA 1997) have shown that it maintains a steady increase in 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 dominant amino acid of casein, which plays an important role in brain metabolism. There are also proline, aspartate, leucine, lysine and valine. Casein is a good source of essential amino acids.

Whey proteins consist of α-lactalbumin and β-lactoglobulin (which protect against infection), albumin, immunoglobulins, enzymes and protease, peptones. β-Lactoglobulin accounts for approximately 50% of total whey protein. They also contain small amounts of lactoferrin (an iron containing protein with a protective effect) and serum transferrin (Srilakshmi, 1996).

Whey proteins provide the highest value of BCAA (branched chain amino acid). This is especially valued for building muscle – a key requirement in kwashiorkor – and recovery. Whey proteins are the highest quality protein as they contain the best combination of amino acids compared to proteins in dairy products, soy, vegetables and even meat. Whey proteins also support immune functions by increasing glutathione levels, thus exhibiting antioxidant properties. Whey proteins contain many similar components found in breast milk. Other benefits of whey proteins include the fact that they are easily absorbed, which helps increase lean muscle mass and aids in fat loss.

It is essential to maintain electrolyte balance in patients with protein energy malnutrition. Vitamin and mineral supplements should be given according to the doctor’s advice. If vitamin A deficiency is present, a single oral dose of 50,000 International Units (IUs) of fat-soluble vitamin A should be given immediately, followed by 5,000 units daily. Deficiency symptoms will resolve in about two weeks. Anemia is more common in people suffering from protein energy malnutrition. For the treatment of anemia, ferric 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).

The treatment strategy includes providing adequate proteins, providing casein and whey protein supplements, providing vitamin and mineral supplements, resolving life-threatening conditions, restoring nutritional status without disrupting homeostasis by ensuring nutritional rehabilitation. Criteria for improvement include resolution of mental apathy and edema, increase in serum albumin levels, and increase in weight gain.

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