Re: FW: Hospital chain, under scrutiny, reports rare illness

[Guest guest]

This is something that I've been screaming from rooftops for some time

now. I could go on and on about this, but in a nutshell:

Kwashiorkor does not exist (at least not outside of isolated, mainly

pediatric case reports) in developed areas of the world. There is

growing evidence that it is not a simple nutrition problem and

requires a unique set of circumstances for development. When Cecily

first described the condition in the 1930s, we didn't have

the ability to study the acute phase response very well at all. Even

though we know more now about the condition, for some reason educators

in medicine and dietetics continue to teach an incorrect perspective.

WHat has happened here is that the ICD codes, which are used for

billing purposes include a term called " kwashiorkor " . The definition

is incorrect and has been for quite some time. No one seemed to care

and it was rarely used. Not to long ago, CMS began reimbursing

facilities a bit more when certain conditions were met that seemed to

increase the severity of the primary diagnosis and thus drive up costs

of care. Malnutrition was one of them. There are several ICD codes

that refer to nutrition problems; in the current version of ICD, they

fall in the 263.xx codes.

Coders, often with advice from misguided RDs, went hog wild because

you can " easily diagnose malnutrition using albumin levels " . Because

albumin is an acute phase reactant (meaning, when you get sick, it

gets low), far too many folks who were sick but not malnourished were

thus coded for kwashiorkor.

CMS will now and then take a look at facility's trends in coding and

compare them to your population base and similar facilities. I don't

really see how one can justify the incidence of " kwashiorkor " at this

one facility.

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> This is a very interesting article. Aside from the fact that our tax

> $$ are

> now going to our neighbor to the North, what is the accurate

> definition of

> Kwashiorkor IYO? And how is it diagnosed?

>

> Digna

>

> Hospital chain, under scrutiny, reports rare illness |

> Local News |

> PE.com | Southern California News | News for Inland Southern

> California

>

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> tml

>

>

>

[Guest guest]

This is something that I've been screaming from rooftops for some time

now. I could go on and on about this, but in a nutshell:

Kwashiorkor does not exist (at least not outside of isolated, mainly

pediatric case reports) in developed areas of the world. There is

growing evidence that it is not a simple nutrition problem and

requires a unique set of circumstances for development. When Cecily

first described the condition in the 1930s, we didn't have

the ability to study the acute phase response very well at all. Even

though we know more now about the condition, for some reason educators

in medicine and dietetics continue to teach an incorrect perspective.

WHat has happened here is that the ICD codes, which are used for

billing purposes include a term called " kwashiorkor " . The definition

is incorrect and has been for quite some time. No one seemed to care

and it was rarely used. Not to long ago, CMS began reimbursing

facilities a bit more when certain conditions were met that seemed to

increase the severity of the primary diagnosis and thus drive up costs

of care. Malnutrition was one of them. There are several ICD codes

that refer to nutrition problems; in the current version of ICD, they

fall in the 263.xx codes.

Coders, often with advice from misguided RDs, went hog wild because

you can " easily diagnose malnutrition using albumin levels " . Because

albumin is an acute phase reactant (meaning, when you get sick, it

gets low), far too many folks who were sick but not malnourished were

thus coded for kwashiorkor.

CMS will now and then take a look at facility's trends in coding and

compare them to your population base and similar facilities. I don't

really see how one can justify the incidence of " kwashiorkor " at this

one facility.

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> This is a very interesting article. Aside from the fact that our tax

> $$ are

> now going to our neighbor to the North, what is the accurate

> definition of

> Kwashiorkor IYO? And how is it diagnosed?

>

> Digna

>

> Hospital chain, under scrutiny, reports rare illness |

> Local News |

> PE.com | Southern California News | News for Inland Southern

> California

>

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> tml

>

>

>

[Guest guest]

,

With all due respect, one should not use Today's Dietitian as the

place to learn the latest science. The information published there is

not peer reviewed, nor is it systematic. It's what we call a

" journalistic review " . That's not a bad thing, I've written for them

myself, it's just that you should know the difference.

I know you like magnesium as the perpetrator for a number of health

conditions, based on your recent posts here. However, kwashiorkor is

not protein and electrolyte imbalance, at least not at the root cause.

In fact, in some research, when you give folks with (real) kwashiorkor

protein and electrolytes without considering co-morbid conditions, you

often end up increasing mortality, which we really don't want to do.

What's going on here is much more complex; it's a mix of facilities

trying to pull as much medicare money their way and RDs not stepping

up with evidence to show what is and what is not truly a nutrition

problem.

I'd urge you to search PubMed for some of the more recent papers on

kwashiorkor. Golden from the UK had published some that are

very readable. There are others in the tropical medicine journals that

also talk about some other purported etiologies for kwashiorkor.

Regards,

pam

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Marasmus is starvation, kwashiorkor is protein starvation and

> electrolyte

> imbalance. A Today's Dietitian article a few months age directed me

> to B1 for

> refeeding anorexia - it worked - I was so disoriented, and my heart

> was fluttery

> and weird. The magazine had flipped open to that page and it was a

> life saver.

> When you are that underfed, there really is no appetite - zinc

> deficiency

> worsens appetite I believe. The magnesium deficiency adds to the

> edema problem

> that the lack of albumin causes. Loss of muscle tone, alopecia, and

> dermatologic

> symptoms would all relate to protein deficiency. Getting rehydrated

> was

> necessary before I could swallow much food. When one or two bites

> feels like

> sawdust it is easy to give up eating and not figure out how to start

> again.

> Rehydration requires magnesium as well as sodium and potassium. Many

> major

> electrolyte brands don't even have magnesium - it was regulated out

> sometime in

> the 20's - 30's.

>

> I think that that doctor and hospital system is recognizing the

> problem I've

> been working on - we can't heal and regenerate tissue if we don't

> have the

> nutrients. As for increased Medicare billing I hope the hospital/

> doctor is

> figuring out how to use that money to actually nourish the starving

> seniors and

> isn't just bonusing it out to executives.

>

> Kwashiorkor was more prevalent in starving children countries -

> edamatous belly

> - but I just saw that in my father-in-law. I couldn't find a formula

> that didn't

> have the high calcium level that throws off absorption. Our enteral

> feedings

> are not based on ratios that the chronically ill can absorb. The

> feeding made

> him worse, 40 pounds edamatous. So painfully swollen with water and

> skin

> integrity you could poke a fingernail through (it seemed). He is

> getting better

> finally.

>

> Providing " Health Shakes " and supplemental formulas that are high in

> calcium

> isn't helping. The problem is not that there is no protein in the

> diet or even

> in the body - the problem is keeping the protein in the cells and

> blood vessels

> where it can do some good. Magnesium is what is needed to prevent

> the leaky

> membranes and in the chronically ill calcium is being preferentially

> absorbed.

>

> I want to make sweet potato ginger smoothies boosted with garbanzo

> bean puree

> for everybody.

>

>

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

>

> Protein-Calorie Malnutrition: Overview and Treatment

> Protein-calorie malnutritionresults in 2 similar but distinct

> diseases, marasmus and kwashiorkor.

>

> Marasmus is defined simply as chronic deprivation of energy needed

> to maintain body weight. Its extreme form is characterized by severe

> weight loss and cachexia.1 Marasmus is further characterized by

> subnormal body temperature, decreased pulse and metabolic rate, loss

> of skin turgor, constipation, and starvation diarrhea, consisting of

> frequent, small, mucus-containing stools.2

> Kwashiorkor is a somewhat more complex disease. It is characterized

> by edema, low capillary-filtration rate, hypoalbuminemia, and

> dermatitis.

>

> Derived from an African term meaning " the disease that occurs when

> the next baby is born " , kwashiorkor was initially thought to result

> from a diet high in calories (mainly carbohydrates, such as maize),

> yet deficient in protein. However, infection, aflatoxin poisoning,

> and oxidative stress may also play causative roles.1,3 Edema, a

> defining

> characteristic of kwashiorkor, resolves with treatment, despite

> continuing hypoalbuminemia, suggesting that the edema is due to

> leaky cell membranes, low capillary filtration rates, high

> concentrations of free iron, and free radicals that increase capillary

> permeability.4 Kwashiorkor is further distinguished from marasmus by

> the following findings:

> * Massive edema of the hands and feet.

> * Profound irritability.

> * Anorexia.

> * Dermatologic symptoms (desquamative rash, hypopigmentation).

> * Alopecia or hair discoloration.

> * Fatty liver.

> * Loss of muscle tone.

> * Anemia and low blood concentrations of albumin, glucose, potassium,

> and magnesium.5,6

> Kwashiorkor may also involve severe, life-threatening hypophosphatemia

> (<1.0 mg/dL), which has been found to triple the mortality rate when

> compared with children who have normal phosphorus levels.7

> Treatment

> Individuals treated for protein-energy malnutrition are at risk for

> refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> systems. Guidelines have been developed to help prevent these

> complications

> and to establish a transition to normalcy. Treatment consists of 2

> phases: stabilization and rehabilitation.

>

> The initial (stabilization) phase proceeds from days 1 through 7. It

> consists of treatment and prevention of hypoglycemia, hypothermia,

> dehydration, and infection; correction of electrolyte imbalance and

> micronutrient deficiencies; and a cautious feeding regimen.

>

> http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

>

> Protein-calorie malnutrition: Excerpt from Professional Guide to

> Diseases

> (Eighth Edition)

> " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> are common in

> underdeveloped countries and in areas in which dietary amino acid

> content is

> insufficient to satisfy growth requirements. Kwashiorkor typically

> occurs at

> about age 1, after infants are weaned from breast milk to a protein-

> deficient

> diet of starchy gruels or sugar water, but it can develop at any

> time during

> the formative years. Marasmus affects infants ages 6 to 18 months as

> a result

> of breast-feeding failure, or a debilitating condition such as chronic

> diarrhea.

>

> In industrialized countries, PCM may occur secondary to chronic

> metabolic

> disease that decreases protein and calorie intake or absorption, or

> trauma that

> increases protein and calorie requirements. In the United States,

> PCM is

> estimated to occur to some extent in 50% of elderly people in

> nursing homes.

> Those who aren’t allowed anything by mouth for an extended period

> are at high

> risk of developing PCM. Conditions that increase protein-calorie

> requirements

> include severe burns and injuries, systemic infections, and cancer

> (accounts

> for the largest group of hospitalized patients with PCM). Conditions

> that cause

> defective utilization of nutrients include malabsorption syndrome,

> short-bowel syndrome, and Crohn’s disease.

>

> Read more at

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

>

> Signs and symptoms

> Children with chronic PCM are small for their chronological age and

> tend to be

> physically inactive, mentally apathetic, and susceptible to frequent

> infections. Anorexia and diarrhea are common.

>

> In acute PCM, children are small, gaunt, and emaciated, with no

> adipose tissue.

> Skin is dry and “baggy,†and hair is sparse and dull brown or

> reddish-yellow.

> Temperature is low; pulse rate and respirations are slowed. Such

> children are

> weak, irritable, and usually hungry, although they may have

> anorexia, with

> nausea and vomiting.

>

> Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> height, but

> adipose tissue diminishes as fat metabolizes to meet energy demands.

> Edema

> often masks severe muscle wasting; dry, peeling skin and

> hepatomegaly are

> common. Patients with secondary PCM show signs similar to marasmus,

> primarily

> loss of adipose tissue and lean body mass, lethargy, and edema. Severe

> secondary PCM may cause loss of immunocompetence.

>

> Diagnosis

> CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> anthropometry

> confirm PCM. If the patient doesn’t suffer from fluid retention,

> weight change

> over time is the best index of nutritional status.

>

> The following factors support the diagnosis:

> ①height and weight less than 80% of standard for the patient’s

> age and sex,

> and below-normal arm circumference and triceps skinfold

>

> â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> â‘ urinary creatinine (24-hour) level used to show lean body mass

> status by

> relating creatinine excretion to height and ideal body weight, to

> yield

> creatinine-height index.

>

> R Vajda, R.D.

> www.GingerJens.com

>

> ________________________________

>

> To: rd-usa ; dhcc@...

> Sent: Sun, February 20, 2011 8:50:58 PM

> Subject: FW: Hospital chain, under scrutiny, reports rare

> illness |

> Local News | PE.com | Southern California News | News for Inland

> Southern

> California

>

> This is a very interesting article. Aside from the fact that our tax

> $$ are

> now going to our neighbor to the North, what is the accurate

> definition of

> Kwashiorkor IYO? And how is it diagnosed?

>

> Digna

>

> Hospital chain, under scrutiny, reports rare illness |

> Local News |

> PE.com | Southern California News | News for Inland Southern

> California

>

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> tml

>

>

[Guest guest]

,

With all due respect, one should not use Today's Dietitian as the

place to learn the latest science. The information published there is

not peer reviewed, nor is it systematic. It's what we call a

" journalistic review " . That's not a bad thing, I've written for them

myself, it's just that you should know the difference.

I know you like magnesium as the perpetrator for a number of health

conditions, based on your recent posts here. However, kwashiorkor is

not protein and electrolyte imbalance, at least not at the root cause.

In fact, in some research, when you give folks with (real) kwashiorkor

protein and electrolytes without considering co-morbid conditions, you

often end up increasing mortality, which we really don't want to do.

What's going on here is much more complex; it's a mix of facilities

trying to pull as much medicare money their way and RDs not stepping

up with evidence to show what is and what is not truly a nutrition

problem.

I'd urge you to search PubMed for some of the more recent papers on

kwashiorkor. Golden from the UK had published some that are

very readable. There are others in the tropical medicine journals that

also talk about some other purported etiologies for kwashiorkor.

Regards,

pam

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Marasmus is starvation, kwashiorkor is protein starvation and

> electrolyte

> imbalance. A Today's Dietitian article a few months age directed me

> to B1 for

> refeeding anorexia - it worked - I was so disoriented, and my heart

> was fluttery

> and weird. The magazine had flipped open to that page and it was a

> life saver.

> When you are that underfed, there really is no appetite - zinc

> deficiency

> worsens appetite I believe. The magnesium deficiency adds to the

> edema problem

> that the lack of albumin causes. Loss of muscle tone, alopecia, and

> dermatologic

> symptoms would all relate to protein deficiency. Getting rehydrated

> was

> necessary before I could swallow much food. When one or two bites

> feels like

> sawdust it is easy to give up eating and not figure out how to start

> again.

> Rehydration requires magnesium as well as sodium and potassium. Many

> major

> electrolyte brands don't even have magnesium - it was regulated out

> sometime in

> the 20's - 30's.

>

> I think that that doctor and hospital system is recognizing the

> problem I've

> been working on - we can't heal and regenerate tissue if we don't

> have the

> nutrients. As for increased Medicare billing I hope the hospital/

> doctor is

> figuring out how to use that money to actually nourish the starving

> seniors and

> isn't just bonusing it out to executives.

>

> Kwashiorkor was more prevalent in starving children countries -

> edamatous belly

> - but I just saw that in my father-in-law. I couldn't find a formula

> that didn't

> have the high calcium level that throws off absorption. Our enteral

> feedings

> are not based on ratios that the chronically ill can absorb. The

> feeding made

> him worse, 40 pounds edamatous. So painfully swollen with water and

> skin

> integrity you could poke a fingernail through (it seemed). He is

> getting better

> finally.

>

> Providing " Health Shakes " and supplemental formulas that are high in

> calcium

> isn't helping. The problem is not that there is no protein in the

> diet or even

> in the body - the problem is keeping the protein in the cells and

> blood vessels

> where it can do some good. Magnesium is what is needed to prevent

> the leaky

> membranes and in the chronically ill calcium is being preferentially

> absorbed.

>

> I want to make sweet potato ginger smoothies boosted with garbanzo

> bean puree

> for everybody.

>

>

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

>

> Protein-Calorie Malnutrition: Overview and Treatment

> Protein-calorie malnutritionresults in 2 similar but distinct

> diseases, marasmus and kwashiorkor.

>

> Marasmus is defined simply as chronic deprivation of energy needed

> to maintain body weight. Its extreme form is characterized by severe

> weight loss and cachexia.1 Marasmus is further characterized by

> subnormal body temperature, decreased pulse and metabolic rate, loss

> of skin turgor, constipation, and starvation diarrhea, consisting of

> frequent, small, mucus-containing stools.2

> Kwashiorkor is a somewhat more complex disease. It is characterized

> by edema, low capillary-filtration rate, hypoalbuminemia, and

> dermatitis.

>

> Derived from an African term meaning " the disease that occurs when

> the next baby is born " , kwashiorkor was initially thought to result

> from a diet high in calories (mainly carbohydrates, such as maize),

> yet deficient in protein. However, infection, aflatoxin poisoning,

> and oxidative stress may also play causative roles.1,3 Edema, a

> defining

> characteristic of kwashiorkor, resolves with treatment, despite

> continuing hypoalbuminemia, suggesting that the edema is due to

> leaky cell membranes, low capillary filtration rates, high

> concentrations of free iron, and free radicals that increase capillary

> permeability.4 Kwashiorkor is further distinguished from marasmus by

> the following findings:

> * Massive edema of the hands and feet.

> * Profound irritability.

> * Anorexia.

> * Dermatologic symptoms (desquamative rash, hypopigmentation).

> * Alopecia or hair discoloration.

> * Fatty liver.

> * Loss of muscle tone.

> * Anemia and low blood concentrations of albumin, glucose, potassium,

> and magnesium.5,6

> Kwashiorkor may also involve severe, life-threatening hypophosphatemia

> (<1.0 mg/dL), which has been found to triple the mortality rate when

> compared with children who have normal phosphorus levels.7

> Treatment

> Individuals treated for protein-energy malnutrition are at risk for

> refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> systems. Guidelines have been developed to help prevent these

> complications

> and to establish a transition to normalcy. Treatment consists of 2

> phases: stabilization and rehabilitation.

>

> The initial (stabilization) phase proceeds from days 1 through 7. It

> consists of treatment and prevention of hypoglycemia, hypothermia,

> dehydration, and infection; correction of electrolyte imbalance and

> micronutrient deficiencies; and a cautious feeding regimen.

>

> http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

>

> Protein-calorie malnutrition: Excerpt from Professional Guide to

> Diseases

> (Eighth Edition)

> " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> are common in

> underdeveloped countries and in areas in which dietary amino acid

> content is

> insufficient to satisfy growth requirements. Kwashiorkor typically

> occurs at

> about age 1, after infants are weaned from breast milk to a protein-

> deficient

> diet of starchy gruels or sugar water, but it can develop at any

> time during

> the formative years. Marasmus affects infants ages 6 to 18 months as

> a result

> of breast-feeding failure, or a debilitating condition such as chronic

> diarrhea.

>

> In industrialized countries, PCM may occur secondary to chronic

> metabolic

> disease that decreases protein and calorie intake or absorption, or

> trauma that

> increases protein and calorie requirements. In the United States,

> PCM is

> estimated to occur to some extent in 50% of elderly people in

> nursing homes.

> Those who aren’t allowed anything by mouth for an extended period

> are at high

> risk of developing PCM. Conditions that increase protein-calorie

> requirements

> include severe burns and injuries, systemic infections, and cancer

> (accounts

> for the largest group of hospitalized patients with PCM). Conditions

> that cause

> defective utilization of nutrients include malabsorption syndrome,

> short-bowel syndrome, and Crohn’s disease.

>

> Read more at

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

>

> Signs and symptoms

> Children with chronic PCM are small for their chronological age and

> tend to be

> physically inactive, mentally apathetic, and susceptible to frequent

> infections. Anorexia and diarrhea are common.

>

> In acute PCM, children are small, gaunt, and emaciated, with no

> adipose tissue.

> Skin is dry and “baggy,†and hair is sparse and dull brown or

> reddish-yellow.

> Temperature is low; pulse rate and respirations are slowed. Such

> children are

> weak, irritable, and usually hungry, although they may have

> anorexia, with

> nausea and vomiting.

>

> Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> height, but

> adipose tissue diminishes as fat metabolizes to meet energy demands.

> Edema

> often masks severe muscle wasting; dry, peeling skin and

> hepatomegaly are

> common. Patients with secondary PCM show signs similar to marasmus,

> primarily

> loss of adipose tissue and lean body mass, lethargy, and edema. Severe

> secondary PCM may cause loss of immunocompetence.

>

> Diagnosis

> CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> anthropometry

> confirm PCM. If the patient doesn’t suffer from fluid retention,

> weight change

> over time is the best index of nutritional status.

>

> The following factors support the diagnosis:

> ①height and weight less than 80% of standard for the patient’s

> age and sex,

> and below-normal arm circumference and triceps skinfold

>

> â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> â‘ urinary creatinine (24-hour) level used to show lean body mass

> status by

> relating creatinine excretion to height and ideal body weight, to

> yield

> creatinine-height index.

>

> R Vajda, R.D.

> www.GingerJens.com

>

> ________________________________

>

> To: rd-usa ; dhcc@...

> Sent: Sun, February 20, 2011 8:50:58 PM

> Subject: FW: Hospital chain, under scrutiny, reports rare

> illness |

> Local News | PE.com | Southern California News | News for Inland

> Southern

> California

>

> This is a very interesting article. Aside from the fact that our tax

> $$ are

> now going to our neighbor to the North, what is the accurate

> definition of

> Kwashiorkor IYO? And how is it diagnosed?

>

> Digna

>

> Hospital chain, under scrutiny, reports rare illness |

> Local News |

> PE.com | Southern California News | News for Inland Southern

> California

>

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> tml

>

>

[Guest guest]

,

With all due respect, one should not use Today's Dietitian as the

place to learn the latest science. The information published there is

not peer reviewed, nor is it systematic. It's what we call a

" journalistic review " . That's not a bad thing, I've written for them

myself, it's just that you should know the difference.

I know you like magnesium as the perpetrator for a number of health

conditions, based on your recent posts here. However, kwashiorkor is

not protein and electrolyte imbalance, at least not at the root cause.

In fact, in some research, when you give folks with (real) kwashiorkor

protein and electrolytes without considering co-morbid conditions, you

often end up increasing mortality, which we really don't want to do.

What's going on here is much more complex; it's a mix of facilities

trying to pull as much medicare money their way and RDs not stepping

up with evidence to show what is and what is not truly a nutrition

problem.

I'd urge you to search PubMed for some of the more recent papers on

kwashiorkor. Golden from the UK had published some that are

very readable. There are others in the tropical medicine journals that

also talk about some other purported etiologies for kwashiorkor.

Regards,

pam

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Marasmus is starvation, kwashiorkor is protein starvation and

> electrolyte

> imbalance. A Today's Dietitian article a few months age directed me

> to B1 for

> refeeding anorexia - it worked - I was so disoriented, and my heart

> was fluttery

> and weird. The magazine had flipped open to that page and it was a

> life saver.

> When you are that underfed, there really is no appetite - zinc

> deficiency

> worsens appetite I believe. The magnesium deficiency adds to the

> edema problem

> that the lack of albumin causes. Loss of muscle tone, alopecia, and

> dermatologic

> symptoms would all relate to protein deficiency. Getting rehydrated

> was

> necessary before I could swallow much food. When one or two bites

> feels like

> sawdust it is easy to give up eating and not figure out how to start

> again.

> Rehydration requires magnesium as well as sodium and potassium. Many

> major

> electrolyte brands don't even have magnesium - it was regulated out

> sometime in

> the 20's - 30's.

>

> I think that that doctor and hospital system is recognizing the

> problem I've

> been working on - we can't heal and regenerate tissue if we don't

> have the

> nutrients. As for increased Medicare billing I hope the hospital/

> doctor is

> figuring out how to use that money to actually nourish the starving

> seniors and

> isn't just bonusing it out to executives.

>

> Kwashiorkor was more prevalent in starving children countries -

> edamatous belly

> - but I just saw that in my father-in-law. I couldn't find a formula

> that didn't

> have the high calcium level that throws off absorption. Our enteral

> feedings

> are not based on ratios that the chronically ill can absorb. The

> feeding made

> him worse, 40 pounds edamatous. So painfully swollen with water and

> skin

> integrity you could poke a fingernail through (it seemed). He is

> getting better

> finally.

>

> Providing " Health Shakes " and supplemental formulas that are high in

> calcium

> isn't helping. The problem is not that there is no protein in the

> diet or even

> in the body - the problem is keeping the protein in the cells and

> blood vessels

> where it can do some good. Magnesium is what is needed to prevent

> the leaky

> membranes and in the chronically ill calcium is being preferentially

> absorbed.

>

> I want to make sweet potato ginger smoothies boosted with garbanzo

> bean puree

> for everybody.

>

>

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

>

> Protein-Calorie Malnutrition: Overview and Treatment

> Protein-calorie malnutritionresults in 2 similar but distinct

> diseases, marasmus and kwashiorkor.

>

> Marasmus is defined simply as chronic deprivation of energy needed

> to maintain body weight. Its extreme form is characterized by severe

> weight loss and cachexia.1 Marasmus is further characterized by

> subnormal body temperature, decreased pulse and metabolic rate, loss

> of skin turgor, constipation, and starvation diarrhea, consisting of

> frequent, small, mucus-containing stools.2

> Kwashiorkor is a somewhat more complex disease. It is characterized

> by edema, low capillary-filtration rate, hypoalbuminemia, and

> dermatitis.

>

> Derived from an African term meaning " the disease that occurs when

> the next baby is born " , kwashiorkor was initially thought to result

> from a diet high in calories (mainly carbohydrates, such as maize),

> yet deficient in protein. However, infection, aflatoxin poisoning,

> and oxidative stress may also play causative roles.1,3 Edema, a

> defining

> characteristic of kwashiorkor, resolves with treatment, despite

> continuing hypoalbuminemia, suggesting that the edema is due to

> leaky cell membranes, low capillary filtration rates, high

> concentrations of free iron, and free radicals that increase capillary

> permeability.4 Kwashiorkor is further distinguished from marasmus by

> the following findings:

> * Massive edema of the hands and feet.

> * Profound irritability.

> * Anorexia.

> * Dermatologic symptoms (desquamative rash, hypopigmentation).

> * Alopecia or hair discoloration.

> * Fatty liver.

> * Loss of muscle tone.

> * Anemia and low blood concentrations of albumin, glucose, potassium,

> and magnesium.5,6

> Kwashiorkor may also involve severe, life-threatening hypophosphatemia

> (<1.0 mg/dL), which has been found to triple the mortality rate when

> compared with children who have normal phosphorus levels.7

> Treatment

> Individuals treated for protein-energy malnutrition are at risk for

> refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> systems. Guidelines have been developed to help prevent these

> complications

> and to establish a transition to normalcy. Treatment consists of 2

> phases: stabilization and rehabilitation.

>

> The initial (stabilization) phase proceeds from days 1 through 7. It

> consists of treatment and prevention of hypoglycemia, hypothermia,

> dehydration, and infection; correction of electrolyte imbalance and

> micronutrient deficiencies; and a cautious feeding regimen.

>

> http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

>

> Protein-calorie malnutrition: Excerpt from Professional Guide to

> Diseases

> (Eighth Edition)

> " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> are common in

> underdeveloped countries and in areas in which dietary amino acid

> content is

> insufficient to satisfy growth requirements. Kwashiorkor typically

> occurs at

> about age 1, after infants are weaned from breast milk to a protein-

> deficient

> diet of starchy gruels or sugar water, but it can develop at any

> time during

> the formative years. Marasmus affects infants ages 6 to 18 months as

> a result

> of breast-feeding failure, or a debilitating condition such as chronic

> diarrhea.

>

> In industrialized countries, PCM may occur secondary to chronic

> metabolic

> disease that decreases protein and calorie intake or absorption, or

> trauma that

> increases protein and calorie requirements. In the United States,

> PCM is

> estimated to occur to some extent in 50% of elderly people in

> nursing homes.

> Those who aren’t allowed anything by mouth for an extended period

> are at high

> risk of developing PCM. Conditions that increase protein-calorie

> requirements

> include severe burns and injuries, systemic infections, and cancer

> (accounts

> for the largest group of hospitalized patients with PCM). Conditions

> that cause

> defective utilization of nutrients include malabsorption syndrome,

> short-bowel syndrome, and Crohn’s disease.

>

> Read more at

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

>

> Signs and symptoms

> Children with chronic PCM are small for their chronological age and

> tend to be

> physically inactive, mentally apathetic, and susceptible to frequent

> infections. Anorexia and diarrhea are common.

>

> In acute PCM, children are small, gaunt, and emaciated, with no

> adipose tissue.

> Skin is dry and “baggy,†and hair is sparse and dull brown or

> reddish-yellow.

> Temperature is low; pulse rate and respirations are slowed. Such

> children are

> weak, irritable, and usually hungry, although they may have

> anorexia, with

> nausea and vomiting.

>

> Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> height, but

> adipose tissue diminishes as fat metabolizes to meet energy demands.

> Edema

> often masks severe muscle wasting; dry, peeling skin and

> hepatomegaly are

> common. Patients with secondary PCM show signs similar to marasmus,

> primarily

> loss of adipose tissue and lean body mass, lethargy, and edema. Severe

> secondary PCM may cause loss of immunocompetence.

>

> Diagnosis

> CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> anthropometry

> confirm PCM. If the patient doesn’t suffer from fluid retention,

> weight change

> over time is the best index of nutritional status.

>

> The following factors support the diagnosis:

> ①height and weight less than 80% of standard for the patient’s

> age and sex,

> and below-normal arm circumference and triceps skinfold

>

> â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> â‘ urinary creatinine (24-hour) level used to show lean body mass

> status by

> relating creatinine excretion to height and ideal body weight, to

> yield

> creatinine-height index.

>

> R Vajda, R.D.

> www.GingerJens.com

>

> ________________________________

>

> To: rd-usa ; dhcc@...

> Sent: Sun, February 20, 2011 8:50:58 PM

> Subject: FW: Hospital chain, under scrutiny, reports rare

> illness |

> Local News | PE.com | Southern California News | News for Inland

> Southern

> California

>

> This is a very interesting article. Aside from the fact that our tax

> $$ are

> now going to our neighbor to the North, what is the accurate

> definition of

> Kwashiorkor IYO? And how is it diagnosed?

>

> Digna

>

> Hospital chain, under scrutiny, reports rare illness |

> Local News |

> PE.com | Southern California News | News for Inland Southern

> California

>

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> tml

>

>

[Guest guest]

Pam, The research is backwards and not pure science. Like you stated,

it is money or politics at play here. Malnutrition is a slow occuring

process in which once it gets to a certain point, it starts the slow

cycle of illness leading to chronic illness and organ failure. You are

right, when illness due to this malnutrition occurs, refeeding could

be dangerous and even deadly. As with everything in life, timing is

everything. It is really the denial of malnutrition, malabsorption and

hypermetabolism that is the problem!

Sent from my iPhone

> ,

>

> With all due respect, one should not use Today's Dietitian as the

> place to learn the latest science. The information published there is

> not peer reviewed, nor is it systematic. It's what we call a

> " journalistic review " . That's not a bad thing, I've written for them

> myself, it's just that you should know the difference.

>

> I know you like magnesium as the perpetrator for a number of health

> conditions, based on your recent posts here. However, kwashiorkor is

> not protein and electrolyte imbalance, at least not at the root cause.

> In fact, in some research, when you give folks with (real) kwashiorkor

> protein and electrolytes without considering co-morbid conditions, you

> often end up increasing mortality, which we really don't want to do.

>

> What's going on here is much more complex; it's a mix of facilities

> trying to pull as much medicare money their way and RDs not stepping

> up with evidence to show what is and what is not truly a nutrition

> problem.

>

> I'd urge you to search PubMed for some of the more recent papers on

> kwashiorkor. Golden from the UK had published some that are

> very readable. There are others in the tropical medicine journals that

> also talk about some other purported etiologies for kwashiorkor.

>

> Regards,

> pam

>

> Pam Charney, PhD, RD

>

> Pamela Charney and Associates, LLC

> consultants in nutrition informatics

> Transforming Nutrition Care With Informatics

>

> pcharney@...

> http://www.linkedin.com/in/pamcharney

>

>

>

> > Marasmus is starvation, kwashiorkor is protein starvation and

> > electrolyte

> > imbalance. A Today's Dietitian article a few months age directed me

> > to B1 for

> > refeeding anorexia - it worked - I was so disoriented, and my heart

> > was fluttery

> > and weird. The magazine had flipped open to that page and it was a

> > life saver.

> > When you are that underfed, there really is no appetite - zinc

> > deficiency

> > worsens appetite I believe. The magnesium deficiency adds to the

> > edema problem

> > that the lack of albumin causes. Loss of muscle tone, alopecia, and

> > dermatologic

> > symptoms would all relate to protein deficiency. Getting rehydrated

> > was

> > necessary before I could swallow much food. When one or two bites

> > feels like

> > sawdust it is easy to give up eating and not figure out how to start

> > again.

> > Rehydration requires magnesium as well as sodium and potassium. Many

> > major

> > electrolyte brands don't even have magnesium - it was regulated out

> > sometime in

> > the 20's - 30's.

> >

> > I think that that doctor and hospital system is recognizing the

> > problem I've

> > been working on - we can't heal and regenerate tissue if we don't

> > have the

> > nutrients. As for increased Medicare billing I hope the hospital/

> > doctor is

> > figuring out how to use that money to actually nourish the starving

> > seniors and

> > isn't just bonusing it out to executives.

> >

> > Kwashiorkor was more prevalent in starving children countries -

> > edamatous belly

> > - but I just saw that in my father-in-law. I couldn't find a formula

> > that didn't

> > have the high calcium level that throws off absorption. Our enteral

> > feedings

> > are not based on ratios that the chronically ill can absorb. The

> > feeding made

> > him worse, 40 pounds edamatous. So painfully swollen with water and

> > skin

> > integrity you could poke a fingernail through (it seemed). He is

> > getting better

> > finally.

> >

> > Providing " Health Shakes " and supplemental formulas that are high in

> > calcium

> > isn't helping. The problem is not that there is no protein in the

> > diet or even

> > in the body - the problem is keeping the protein in the cells and

> > blood vessels

> > where it can do some good. Magnesium is what is needed to prevent

> > the leaky

> > membranes and in the chronically ill calcium is being preferentially

> > absorbed.

> >

> > I want to make sweet potato ginger smoothies boosted with garbanzo

> > bean puree

> > for everybody.

> >

> >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> >

> > Protein-Calorie Malnutrition: Overview and Treatment

> > Protein-calorie malnutritionresults in 2 similar but distinct

> > diseases, marasmus and kwashiorkor.

> >

> > Marasmus is defined simply as chronic deprivation of energy needed

> > to maintain body weight. Its extreme form is characterized by severe

> > weight loss and cachexia.1 Marasmus is further characterized by

> > subnormal body temperature, decreased pulse and metabolic rate, loss

> > of skin turgor, constipation, and starvation diarrhea, consisting of

> > frequent, small, mucus-containing stools.2

> > Kwashiorkor is a somewhat more complex disease. It is characterized

> > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > dermatitis.

> >

> > Derived from an African term meaning " the disease that occurs when

> > the next baby is born " , kwashiorkor was initially thought to result

> > from a diet high in calories (mainly carbohydrates, such as maize),

> > yet deficient in protein. However, infection, aflatoxin poisoning,

> > and oxidative stress may also play causative roles.1,3 Edema, a

> > defining

> > characteristic of kwashiorkor, resolves with treatment, despite

> > continuing hypoalbuminemia, suggesting that the edema is due to

> > leaky cell membranes, low capillary filtration rates, high

> > concentrations of free iron, and free radicals that increase

> capillary

> > permeability.4 Kwashiorkor is further distinguished from marasmus by

> > the following findings:

> > * Massive edema of the hands and feet.

> > * Profound irritability.

> > * Anorexia.

> > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > * Alopecia or hair discoloration.

> > * Fatty liver.

> > * Loss of muscle tone.

> > * Anemia and low blood concentrations of albumin, glucose,

> potassium,

> > and magnesium.5,6

> > Kwashiorkor may also involve severe, life-threatening

> hypophosphatemia

> > (<1.0 mg/dL), which has been found to triple the mortality rate when

> > compared with children who have normal phosphorus levels.7

> > Treatment

> > Individuals treated for protein-energy malnutrition are at risk for

> > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> > gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> > systems. Guidelines have been developed to help prevent these

> > complications

> > and to establish a transition to normalcy. Treatment consists of 2

> > phases: stabilization and rehabilitation.

> >

> > The initial (stabilization) phase proceeds from days 1 through 7. It

> > consists of treatment and prevention of hypoglycemia, hypothermia,

> > dehydration, and infection; correction of electrolyte imbalance and

> > micronutrient deficiencies; and a cautious feeding regimen.

> >

> > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> >

> > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > Diseases

> > (Eighth Edition)

> > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > are common in

> > underdeveloped countries and in areas in which dietary amino acid

> > content is

> > insufficient to satisfy growth requirements. Kwashiorkor typically

> > occurs at

> > about age 1, after infants are weaned from breast milk to a protein-

> > deficient

> > diet of starchy gruels or sugar water, but it can develop at any

> > time during

> > the formative years. Marasmus affects infants ages 6 to 18 months as

> > a result

> > of breast-feeding failure, or a debilitating condition such as

> chronic

> > diarrhea.

> >

> > In industrialized countries, PCM may occur secondary to chronic

> > metabolic

> > disease that decreases protein and calorie intake or absorption, or

> > trauma that

> > increases protein and calorie requirements. In the United States,

> > PCM is

> > estimated to occur to some extent in 50% of elderly people in

> > nursing homes.

> > Those who aren’t allowed anything by mouth for an extended period

> > are at high

> > risk of developing PCM. Conditions that increase protein-calorie

> > requirements

> > include severe burns and injuries, systemic infections, and cancer

> > (accounts

> > for the largest group of hospitalized patients with PCM). Conditions

> > that cause

> > defective utilization of nutrients include malabsorption syndrome,

> > short-bowel syndrome, and Crohn’s disease.

> >

> > Read more at

> >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> >

> > Signs and symptoms

> > Children with chronic PCM are small for their chronological age and

> > tend to be

> > physically inactive, mentally apathetic, and susceptible to frequent

> > infections. Anorexia and diarrhea are common.

> >

> > In acute PCM, children are small, gaunt, and emaciated, with no

> > adipose tissue.

> > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > reddish-yellow.

> > Temperature is low; pulse rate and respirations are slowed. Such

> > children are

> > weak, irritable, and usually hungry, although they may have

> > anorexia, with

> > nausea and vomiting.

> >

> > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > height, but

> > adipose tissue diminishes as fat metabolizes to meet energy demands.

> > Edema

> > often masks severe muscle wasting; dry, peeling skin and

> > hepatomegaly are

> > common. Patients with secondary PCM show signs similar to marasmus,

> > primarily

> > loss of adipose tissue and lean body mass, lethargy, and edema.

> Severe

> > secondary PCM may cause loss of immunocompetence.

> >

> > Diagnosis

> > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > anthropometry

> > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > weight change

> > over time is the best index of nutritional status.

> >

> > The following factors support the diagnosis:

> > ①height and weight less than 80% of standard for the patient’s

> > age and sex,

> > and below-normal arm circumference and triceps skinfold

> >

> > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > status by

> > relating creatinine excretion to height and ideal body weight, to

> > yield

> > creatinine-height index.

> >

> > R Vajda, R.D.

> > www.GingerJens.com

> >

> > ________________________________

> >

> > To: rd-usa ; dhcc@...

> > Sent: Sun, February 20, 2011 8:50:58 PM

> > Subject: FW: Hospital chain, under scrutiny, reports rare

> > illness |

> > Local News | PE.com | Southern California News | News for Inland

> > Southern

> > California

> >

> > This is a very interesting article. Aside from the fact that our tax

> > $$ are

> > now going to our neighbor to the North, what is the accurate

> > definition of

> > Kwashiorkor IYO? And how is it diagnosed?

> >

> > Digna

> >

> > Hospital chain, under scrutiny, reports rare illness |

> > Local News |

> > PE.com | Southern California News | News for Inland Southern

> > California

> >

> > http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > tml

> >

> >

[Guest guest]

Pam, The research is backwards and not pure science. Like you stated,

it is money or politics at play here. Malnutrition is a slow occuring

process in which once it gets to a certain point, it starts the slow

cycle of illness leading to chronic illness and organ failure. You are

right, when illness due to this malnutrition occurs, refeeding could

be dangerous and even deadly. As with everything in life, timing is

everything. It is really the denial of malnutrition, malabsorption and

hypermetabolism that is the problem!

Sent from my iPhone

> ,

>

> With all due respect, one should not use Today's Dietitian as the

> place to learn the latest science. The information published there is

> not peer reviewed, nor is it systematic. It's what we call a

> " journalistic review " . That's not a bad thing, I've written for them

> myself, it's just that you should know the difference.

>

> I know you like magnesium as the perpetrator for a number of health

> conditions, based on your recent posts here. However, kwashiorkor is

> not protein and electrolyte imbalance, at least not at the root cause.

> In fact, in some research, when you give folks with (real) kwashiorkor

> protein and electrolytes without considering co-morbid conditions, you

> often end up increasing mortality, which we really don't want to do.

>

> What's going on here is much more complex; it's a mix of facilities

> trying to pull as much medicare money their way and RDs not stepping

> up with evidence to show what is and what is not truly a nutrition

> problem.

>

> I'd urge you to search PubMed for some of the more recent papers on

> kwashiorkor. Golden from the UK had published some that are

> very readable. There are others in the tropical medicine journals that

> also talk about some other purported etiologies for kwashiorkor.

>

> Regards,

> pam

>

> Pam Charney, PhD, RD

>

> Pamela Charney and Associates, LLC

> consultants in nutrition informatics

> Transforming Nutrition Care With Informatics

>

> pcharney@...

> http://www.linkedin.com/in/pamcharney

>

>

>

> > Marasmus is starvation, kwashiorkor is protein starvation and

> > electrolyte

> > imbalance. A Today's Dietitian article a few months age directed me

> > to B1 for

> > refeeding anorexia - it worked - I was so disoriented, and my heart

> > was fluttery

> > and weird. The magazine had flipped open to that page and it was a

> > life saver.

> > When you are that underfed, there really is no appetite - zinc

> > deficiency

> > worsens appetite I believe. The magnesium deficiency adds to the

> > edema problem

> > that the lack of albumin causes. Loss of muscle tone, alopecia, and

> > dermatologic

> > symptoms would all relate to protein deficiency. Getting rehydrated

> > was

> > necessary before I could swallow much food. When one or two bites

> > feels like

> > sawdust it is easy to give up eating and not figure out how to start

> > again.

> > Rehydration requires magnesium as well as sodium and potassium. Many

> > major

> > electrolyte brands don't even have magnesium - it was regulated out

> > sometime in

> > the 20's - 30's.

> >

> > I think that that doctor and hospital system is recognizing the

> > problem I've

> > been working on - we can't heal and regenerate tissue if we don't

> > have the

> > nutrients. As for increased Medicare billing I hope the hospital/

> > doctor is

> > figuring out how to use that money to actually nourish the starving

> > seniors and

> > isn't just bonusing it out to executives.

> >

> > Kwashiorkor was more prevalent in starving children countries -

> > edamatous belly

> > - but I just saw that in my father-in-law. I couldn't find a formula

> > that didn't

> > have the high calcium level that throws off absorption. Our enteral

> > feedings

> > are not based on ratios that the chronically ill can absorb. The

> > feeding made

> > him worse, 40 pounds edamatous. So painfully swollen with water and

> > skin

> > integrity you could poke a fingernail through (it seemed). He is

> > getting better

> > finally.

> >

> > Providing " Health Shakes " and supplemental formulas that are high in

> > calcium

> > isn't helping. The problem is not that there is no protein in the

> > diet or even

> > in the body - the problem is keeping the protein in the cells and

> > blood vessels

> > where it can do some good. Magnesium is what is needed to prevent

> > the leaky

> > membranes and in the chronically ill calcium is being preferentially

> > absorbed.

> >

> > I want to make sweet potato ginger smoothies boosted with garbanzo

> > bean puree

> > for everybody.

> >

> >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> >

> > Protein-Calorie Malnutrition: Overview and Treatment

> > Protein-calorie malnutritionresults in 2 similar but distinct

> > diseases, marasmus and kwashiorkor.

> >

> > Marasmus is defined simply as chronic deprivation of energy needed

> > to maintain body weight. Its extreme form is characterized by severe

> > weight loss and cachexia.1 Marasmus is further characterized by

> > subnormal body temperature, decreased pulse and metabolic rate, loss

> > of skin turgor, constipation, and starvation diarrhea, consisting of

> > frequent, small, mucus-containing stools.2

> > Kwashiorkor is a somewhat more complex disease. It is characterized

> > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > dermatitis.

> >

> > Derived from an African term meaning " the disease that occurs when

> > the next baby is born " , kwashiorkor was initially thought to result

> > from a diet high in calories (mainly carbohydrates, such as maize),

> > yet deficient in protein. However, infection, aflatoxin poisoning,

> > and oxidative stress may also play causative roles.1,3 Edema, a

> > defining

> > characteristic of kwashiorkor, resolves with treatment, despite

> > continuing hypoalbuminemia, suggesting that the edema is due to

> > leaky cell membranes, low capillary filtration rates, high

> > concentrations of free iron, and free radicals that increase

> capillary

> > permeability.4 Kwashiorkor is further distinguished from marasmus by

> > the following findings:

> > * Massive edema of the hands and feet.

> > * Profound irritability.

> > * Anorexia.

> > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > * Alopecia or hair discoloration.

> > * Fatty liver.

> > * Loss of muscle tone.

> > * Anemia and low blood concentrations of albumin, glucose,

> potassium,

> > and magnesium.5,6

> > Kwashiorkor may also involve severe, life-threatening

> hypophosphatemia

> > (<1.0 mg/dL), which has been found to triple the mortality rate when

> > compared with children who have normal phosphorus levels.7

> > Treatment

> > Individuals treated for protein-energy malnutrition are at risk for

> > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> > gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> > systems. Guidelines have been developed to help prevent these

> > complications

> > and to establish a transition to normalcy. Treatment consists of 2

> > phases: stabilization and rehabilitation.

> >

> > The initial (stabilization) phase proceeds from days 1 through 7. It

> > consists of treatment and prevention of hypoglycemia, hypothermia,

> > dehydration, and infection; correction of electrolyte imbalance and

> > micronutrient deficiencies; and a cautious feeding regimen.

> >

> > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> >

> > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > Diseases

> > (Eighth Edition)

> > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > are common in

> > underdeveloped countries and in areas in which dietary amino acid

> > content is

> > insufficient to satisfy growth requirements. Kwashiorkor typically

> > occurs at

> > about age 1, after infants are weaned from breast milk to a protein-

> > deficient

> > diet of starchy gruels or sugar water, but it can develop at any

> > time during

> > the formative years. Marasmus affects infants ages 6 to 18 months as

> > a result

> > of breast-feeding failure, or a debilitating condition such as

> chronic

> > diarrhea.

> >

> > In industrialized countries, PCM may occur secondary to chronic

> > metabolic

> > disease that decreases protein and calorie intake or absorption, or

> > trauma that

> > increases protein and calorie requirements. In the United States,

> > PCM is

> > estimated to occur to some extent in 50% of elderly people in

> > nursing homes.

> > Those who aren’t allowed anything by mouth for an extended period

> > are at high

> > risk of developing PCM. Conditions that increase protein-calorie

> > requirements

> > include severe burns and injuries, systemic infections, and cancer

> > (accounts

> > for the largest group of hospitalized patients with PCM). Conditions

> > that cause

> > defective utilization of nutrients include malabsorption syndrome,

> > short-bowel syndrome, and Crohn’s disease.

> >

> > Read more at

> >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> >

> > Signs and symptoms

> > Children with chronic PCM are small for their chronological age and

> > tend to be

> > physically inactive, mentally apathetic, and susceptible to frequent

> > infections. Anorexia and diarrhea are common.

> >

> > In acute PCM, children are small, gaunt, and emaciated, with no

> > adipose tissue.

> > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > reddish-yellow.

> > Temperature is low; pulse rate and respirations are slowed. Such

> > children are

> > weak, irritable, and usually hungry, although they may have

> > anorexia, with

> > nausea and vomiting.

> >

> > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > height, but

> > adipose tissue diminishes as fat metabolizes to meet energy demands.

> > Edema

> > often masks severe muscle wasting; dry, peeling skin and

> > hepatomegaly are

> > common. Patients with secondary PCM show signs similar to marasmus,

> > primarily

> > loss of adipose tissue and lean body mass, lethargy, and edema.

> Severe

> > secondary PCM may cause loss of immunocompetence.

> >

> > Diagnosis

> > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > anthropometry

> > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > weight change

> > over time is the best index of nutritional status.

> >

> > The following factors support the diagnosis:

> > ①height and weight less than 80% of standard for the patient’s

> > age and sex,

> > and below-normal arm circumference and triceps skinfold

> >

> > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > status by

> > relating creatinine excretion to height and ideal body weight, to

> > yield

> > creatinine-height index.

> >

> > R Vajda, R.D.

> > www.GingerJens.com

> >

> > ________________________________

> >

> > To: rd-usa ; dhcc@...

> > Sent: Sun, February 20, 2011 8:50:58 PM

> > Subject: FW: Hospital chain, under scrutiny, reports rare

> > illness |

> > Local News | PE.com | Southern California News | News for Inland

> > Southern

> > California

> >

> > This is a very interesting article. Aside from the fact that our tax

> > $$ are

> > now going to our neighbor to the North, what is the accurate

> > definition of

> > Kwashiorkor IYO? And how is it diagnosed?

> >

> > Digna

> >

> > Hospital chain, under scrutiny, reports rare illness |

> > Local News |

> > PE.com | Southern California News | News for Inland Southern

> > California

> >

> > http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > tml

> >

> >

[Guest guest]

Pam, The research is backwards and not pure science. Like you stated,

it is money or politics at play here. Malnutrition is a slow occuring

process in which once it gets to a certain point, it starts the slow

cycle of illness leading to chronic illness and organ failure. You are

right, when illness due to this malnutrition occurs, refeeding could

be dangerous and even deadly. As with everything in life, timing is

everything. It is really the denial of malnutrition, malabsorption and

hypermetabolism that is the problem!

Sent from my iPhone

> ,

>

> With all due respect, one should not use Today's Dietitian as the

> place to learn the latest science. The information published there is

> not peer reviewed, nor is it systematic. It's what we call a

> " journalistic review " . That's not a bad thing, I've written for them

> myself, it's just that you should know the difference.

>

> I know you like magnesium as the perpetrator for a number of health

> conditions, based on your recent posts here. However, kwashiorkor is

> not protein and electrolyte imbalance, at least not at the root cause.

> In fact, in some research, when you give folks with (real) kwashiorkor

> protein and electrolytes without considering co-morbid conditions, you

> often end up increasing mortality, which we really don't want to do.

>

> What's going on here is much more complex; it's a mix of facilities

> trying to pull as much medicare money their way and RDs not stepping

> up with evidence to show what is and what is not truly a nutrition

> problem.

>

> I'd urge you to search PubMed for some of the more recent papers on

> kwashiorkor. Golden from the UK had published some that are

> very readable. There are others in the tropical medicine journals that

> also talk about some other purported etiologies for kwashiorkor.

>

> Regards,

> pam

>

> Pam Charney, PhD, RD

>

> Pamela Charney and Associates, LLC

> consultants in nutrition informatics

> Transforming Nutrition Care With Informatics

>

> pcharney@...

> http://www.linkedin.com/in/pamcharney

>

>

>

> > Marasmus is starvation, kwashiorkor is protein starvation and

> > electrolyte

> > imbalance. A Today's Dietitian article a few months age directed me

> > to B1 for

> > refeeding anorexia - it worked - I was so disoriented, and my heart

> > was fluttery

> > and weird. The magazine had flipped open to that page and it was a

> > life saver.

> > When you are that underfed, there really is no appetite - zinc

> > deficiency

> > worsens appetite I believe. The magnesium deficiency adds to the

> > edema problem

> > that the lack of albumin causes. Loss of muscle tone, alopecia, and

> > dermatologic

> > symptoms would all relate to protein deficiency. Getting rehydrated

> > was

> > necessary before I could swallow much food. When one or two bites

> > feels like

> > sawdust it is easy to give up eating and not figure out how to start

> > again.

> > Rehydration requires magnesium as well as sodium and potassium. Many

> > major

> > electrolyte brands don't even have magnesium - it was regulated out

> > sometime in

> > the 20's - 30's.

> >

> > I think that that doctor and hospital system is recognizing the

> > problem I've

> > been working on - we can't heal and regenerate tissue if we don't

> > have the

> > nutrients. As for increased Medicare billing I hope the hospital/

> > doctor is

> > figuring out how to use that money to actually nourish the starving

> > seniors and

> > isn't just bonusing it out to executives.

> >

> > Kwashiorkor was more prevalent in starving children countries -

> > edamatous belly

> > - but I just saw that in my father-in-law. I couldn't find a formula

> > that didn't

> > have the high calcium level that throws off absorption. Our enteral

> > feedings

> > are not based on ratios that the chronically ill can absorb. The

> > feeding made

> > him worse, 40 pounds edamatous. So painfully swollen with water and

> > skin

> > integrity you could poke a fingernail through (it seemed). He is

> > getting better

> > finally.

> >

> > Providing " Health Shakes " and supplemental formulas that are high in

> > calcium

> > isn't helping. The problem is not that there is no protein in the

> > diet or even

> > in the body - the problem is keeping the protein in the cells and

> > blood vessels

> > where it can do some good. Magnesium is what is needed to prevent

> > the leaky

> > membranes and in the chronically ill calcium is being preferentially

> > absorbed.

> >

> > I want to make sweet potato ginger smoothies boosted with garbanzo

> > bean puree

> > for everybody.

> >

> >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> >

> > Protein-Calorie Malnutrition: Overview and Treatment

> > Protein-calorie malnutritionresults in 2 similar but distinct

> > diseases, marasmus and kwashiorkor.

> >

> > Marasmus is defined simply as chronic deprivation of energy needed

> > to maintain body weight. Its extreme form is characterized by severe

> > weight loss and cachexia.1 Marasmus is further characterized by

> > subnormal body temperature, decreased pulse and metabolic rate, loss

> > of skin turgor, constipation, and starvation diarrhea, consisting of

> > frequent, small, mucus-containing stools.2

> > Kwashiorkor is a somewhat more complex disease. It is characterized

> > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > dermatitis.

> >

> > Derived from an African term meaning " the disease that occurs when

> > the next baby is born " , kwashiorkor was initially thought to result

> > from a diet high in calories (mainly carbohydrates, such as maize),

> > yet deficient in protein. However, infection, aflatoxin poisoning,

> > and oxidative stress may also play causative roles.1,3 Edema, a

> > defining

> > characteristic of kwashiorkor, resolves with treatment, despite

> > continuing hypoalbuminemia, suggesting that the edema is due to

> > leaky cell membranes, low capillary filtration rates, high

> > concentrations of free iron, and free radicals that increase

> capillary

> > permeability.4 Kwashiorkor is further distinguished from marasmus by

> > the following findings:

> > * Massive edema of the hands and feet.

> > * Profound irritability.

> > * Anorexia.

> > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > * Alopecia or hair discoloration.

> > * Fatty liver.

> > * Loss of muscle tone.

> > * Anemia and low blood concentrations of albumin, glucose,

> potassium,

> > and magnesium.5,6

> > Kwashiorkor may also involve severe, life-threatening

> hypophosphatemia

> > (<1.0 mg/dL), which has been found to triple the mortality rate when

> > compared with children who have normal phosphorus levels.7

> > Treatment

> > Individuals treated for protein-energy malnutrition are at risk for

> > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> > gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> > systems. Guidelines have been developed to help prevent these

> > complications

> > and to establish a transition to normalcy. Treatment consists of 2

> > phases: stabilization and rehabilitation.

> >

> > The initial (stabilization) phase proceeds from days 1 through 7. It

> > consists of treatment and prevention of hypoglycemia, hypothermia,

> > dehydration, and infection; correction of electrolyte imbalance and

> > micronutrient deficiencies; and a cautious feeding regimen.

> >

> > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> >

> > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > Diseases

> > (Eighth Edition)

> > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > are common in

> > underdeveloped countries and in areas in which dietary amino acid

> > content is

> > insufficient to satisfy growth requirements. Kwashiorkor typically

> > occurs at

> > about age 1, after infants are weaned from breast milk to a protein-

> > deficient

> > diet of starchy gruels or sugar water, but it can develop at any

> > time during

> > the formative years. Marasmus affects infants ages 6 to 18 months as

> > a result

> > of breast-feeding failure, or a debilitating condition such as

> chronic

> > diarrhea.

> >

> > In industrialized countries, PCM may occur secondary to chronic

> > metabolic

> > disease that decreases protein and calorie intake or absorption, or

> > trauma that

> > increases protein and calorie requirements. In the United States,

> > PCM is

> > estimated to occur to some extent in 50% of elderly people in

> > nursing homes.

> > Those who aren’t allowed anything by mouth for an extended period

> > are at high

> > risk of developing PCM. Conditions that increase protein-calorie

> > requirements

> > include severe burns and injuries, systemic infections, and cancer

> > (accounts

> > for the largest group of hospitalized patients with PCM). Conditions

> > that cause

> > defective utilization of nutrients include malabsorption syndrome,

> > short-bowel syndrome, and Crohn’s disease.

> >

> > Read more at

> >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> >

> > Signs and symptoms

> > Children with chronic PCM are small for their chronological age and

> > tend to be

> > physically inactive, mentally apathetic, and susceptible to frequent

> > infections. Anorexia and diarrhea are common.

> >

> > In acute PCM, children are small, gaunt, and emaciated, with no

> > adipose tissue.

> > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > reddish-yellow.

> > Temperature is low; pulse rate and respirations are slowed. Such

> > children are

> > weak, irritable, and usually hungry, although they may have

> > anorexia, with

> > nausea and vomiting.

> >

> > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > height, but

> > adipose tissue diminishes as fat metabolizes to meet energy demands.

> > Edema

> > often masks severe muscle wasting; dry, peeling skin and

> > hepatomegaly are

> > common. Patients with secondary PCM show signs similar to marasmus,

> > primarily

> > loss of adipose tissue and lean body mass, lethargy, and edema.

> Severe

> > secondary PCM may cause loss of immunocompetence.

> >

> > Diagnosis

> > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > anthropometry

> > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > weight change

> > over time is the best index of nutritional status.

> >

> > The following factors support the diagnosis:

> > ①height and weight less than 80% of standard for the patient’s

> > age and sex,

> > and below-normal arm circumference and triceps skinfold

> >

> > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > status by

> > relating creatinine excretion to height and ideal body weight, to

> > yield

> > creatinine-height index.

> >

> > R Vajda, R.D.

> > www.GingerJens.com

> >

> > ________________________________

> >

> > To: rd-usa ; dhcc@...

> > Sent: Sun, February 20, 2011 8:50:58 PM

> > Subject: FW: Hospital chain, under scrutiny, reports rare

> > illness |

> > Local News | PE.com | Southern California News | News for Inland

> > Southern

> > California

> >

> > This is a very interesting article. Aside from the fact that our tax

> > $$ are

> > now going to our neighbor to the North, what is the accurate

> > definition of

> > Kwashiorkor IYO? And how is it diagnosed?

> >

> > Digna

> >

> > Hospital chain, under scrutiny, reports rare illness |

> > Local News |

> > PE.com | Southern California News | News for Inland Southern

> > California

> >

> > http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > tml

> >

> >

[Guest guest]

,

The research is not backwards, although I'm not sure what you mean by

that. Research is what is it. I'm in complete agreement with you

regarding the connection between nutrition and chronic illness,

however, kwashiorkor is not malnutrition as we have been taught in the

past.

When I talk about increased mortality with refeeding folks with

kwashiorkor, I am not talking about the " refeeding syndrome " (that is

really an iatrogenic complication, not a condition) that most of us

might have seen in hospitals. That " refeeding syndrome " is an acute

hypophosphatemia, hypokalemia, and not quite as severe hypomagnesemia

along with pulmonary and cardiac complications seen when one provides

carbohydrates in excess of capacity for cellular uptake and utilization.

Malnutrition does not equal malabsorption, nor does it equal

hypermetabolism. All are separate but can interact when present

concurrently. I think it behooves us to approach this from a science-

based perspective. The National Library of Medicine (NLM) offers the

free search engine, PubMed that can be used to search for literature

that has been peer-reviewed.

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Pam, The research is backwards and not pure science. Like you stated,

> it is money or politics at play here. Malnutrition is a slow occuring

> process in which once it gets to a certain point, it starts the slow

> cycle of illness leading to chronic illness and organ failure. You are

> right, when illness due to this malnutrition occurs, refeeding could

> be dangerous and even deadly. As with everything in life, timing is

> everything. It is really the denial of malnutrition, malabsorption and

> hypermetabolism that is the problem!

>

> Sent from my iPhone

>

>

>

> > ,

> >

> > With all due respect, one should not use Today's Dietitian as the

> > place to learn the latest science. The information published there

> is

> > not peer reviewed, nor is it systematic. It's what we call a

> > " journalistic review " . That's not a bad thing, I've written for them

> > myself, it's just that you should know the difference.

> >

> > I know you like magnesium as the perpetrator for a number of health

> > conditions, based on your recent posts here. However, kwashiorkor is

> > not protein and electrolyte imbalance, at least not at the root

> cause.

> > In fact, in some research, when you give folks with (real)

> kwashiorkor

> > protein and electrolytes without considering co-morbid conditions,

> you

> > often end up increasing mortality, which we really don't want to do.

> >

> > What's going on here is much more complex; it's a mix of facilities

> > trying to pull as much medicare money their way and RDs not stepping

> > up with evidence to show what is and what is not truly a nutrition

> > problem.

> >

> > I'd urge you to search PubMed for some of the more recent papers on

> > kwashiorkor. Golden from the UK had published some that are

> > very readable. There are others in the tropical medicine journals

> that

> > also talk about some other purported etiologies for kwashiorkor.

> >

> > Regards,

> > pam

> >

> > Pam Charney, PhD, RD

> >

> > Pamela Charney and Associates, LLC

> > consultants in nutrition informatics

> > Transforming Nutrition Care With Informatics

> >

> > pcharney@...

> > http://www.linkedin.com/in/pamcharney

> >

> >

> >

> > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > electrolyte

> > > imbalance. A Today's Dietitian article a few months age directed

> me

> > > to B1 for

> > > refeeding anorexia - it worked - I was so disoriented, and my

> heart

> > > was fluttery

> > > and weird. The magazine had flipped open to that page and it was a

> > > life saver.

> > > When you are that underfed, there really is no appetite - zinc

> > > deficiency

> > > worsens appetite I believe. The magnesium deficiency adds to the

> > > edema problem

> > > that the lack of albumin causes. Loss of muscle tone, alopecia,

> and

> > > dermatologic

> > > symptoms would all relate to protein deficiency. Getting

> rehydrated

> > > was

> > > necessary before I could swallow much food. When one or two bites

> > > feels like

> > > sawdust it is easy to give up eating and not figure out how to

> start

> > > again.

> > > Rehydration requires magnesium as well as sodium and potassium.

> Many

> > > major

> > > electrolyte brands don't even have magnesium - it was regulated

> out

> > > sometime in

> > > the 20's - 30's.

> > >

> > > I think that that doctor and hospital system is recognizing the

> > > problem I've

> > > been working on - we can't heal and regenerate tissue if we don't

> > > have the

> > > nutrients. As for increased Medicare billing I hope the hospital/

> > > doctor is

> > > figuring out how to use that money to actually nourish the

> starving

> > > seniors and

> > > isn't just bonusing it out to executives.

> > >

> > > Kwashiorkor was more prevalent in starving children countries -

> > > edamatous belly

> > > - but I just saw that in my father-in-law. I couldn't find a

> formula

> > > that didn't

> > > have the high calcium level that throws off absorption. Our

> enteral

> > > feedings

> > > are not based on ratios that the chronically ill can absorb. The

> > > feeding made

> > > him worse, 40 pounds edamatous. So painfully swollen with water

> and

> > > skin

> > > integrity you could poke a fingernail through (it seemed). He is

> > > getting better

> > > finally.

> > >

> > > Providing " Health Shakes " and supplemental formulas that are

> high in

> > > calcium

> > > isn't helping. The problem is not that there is no protein in the

> > > diet or even

> > > in the body - the problem is keeping the protein in the cells and

> > > blood vessels

> > > where it can do some good. Magnesium is what is needed to prevent

> > > the leaky

> > > membranes and in the chronically ill calcium is being

> preferentially

> > > absorbed.

> > >

> > > I want to make sweet potato ginger smoothies boosted with garbanzo

> > > bean puree

> > > for everybody.

> > >

> > >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> > >

> > > Protein-Calorie Malnutrition: Overview and Treatment

> > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > diseases, marasmus and kwashiorkor.

> > >

> > > Marasmus is defined simply as chronic deprivation of energy needed

> > > to maintain body weight. Its extreme form is characterized by

> severe

> > > weight loss and cachexia.1 Marasmus is further characterized by

> > > subnormal body temperature, decreased pulse and metabolic rate,

> loss

> > > of skin turgor, constipation, and starvation diarrhea,

> consisting of

> > > frequent, small, mucus-containing stools.2

> > > Kwashiorkor is a somewhat more complex disease. It is

> characterized

> > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > dermatitis.

> > >

> > > Derived from an African term meaning " the disease that occurs when

> > > the next baby is born " , kwashiorkor was initially thought to

> result

> > > from a diet high in calories (mainly carbohydrates, such as

> maize),

> > > yet deficient in protein. However, infection, aflatoxin poisoning,

> > > and oxidative stress may also play causative roles.1,3 Edema, a

> > > defining

> > > characteristic of kwashiorkor, resolves with treatment, despite

> > > continuing hypoalbuminemia, suggesting that the edema is due to

> > > leaky cell membranes, low capillary filtration rates, high

> > > concentrations of free iron, and free radicals that increase

> > capillary

> > > permeability.4 Kwashiorkor is further distinguished from

> marasmus by

> > > the following findings:

> > > * Massive edema of the hands and feet.

> > > * Profound irritability.

> > > * Anorexia.

> > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > * Alopecia or hair discoloration.

> > > * Fatty liver.

> > > * Loss of muscle tone.

> > > * Anemia and low blood concentrations of albumin, glucose,

> > potassium,

> > > and magnesium.5,6

> > > Kwashiorkor may also involve severe, life-threatening

> > hypophosphatemia

> > > (<1.0 mg/dL), which has been found to triple the mortality rate

> when

> > > compared with children who have normal phosphorus levels.7

> > > Treatment

> > > Individuals treated for protein-energy malnutrition are at risk

> for

> > > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > > hypomagnesemia may lead to disturbances in the cardiac,

> neurologic,

> > > gastrointestinal, respiratory, hematologic, skeletal, and

> endocrine

> > > systems. Guidelines have been developed to help prevent these

> > > complications

> > > and to establish a transition to normalcy. Treatment consists of 2

> > > phases: stabilization and rehabilitation.

> > >

> > > The initial (stabilization) phase proceeds from days 1 through

> 7. It

> > > consists of treatment and prevention of hypoglycemia, hypothermia,

> > > dehydration, and infection; correction of electrolyte imbalance

> and

> > > micronutrient deficiencies; and a cautious feeding regimen.

> > >

> > > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > >

> > > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > > Diseases

> > > (Eighth Edition)

> > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > > are common in

> > > underdeveloped countries and in areas in which dietary amino acid

> > > content is

> > > insufficient to satisfy growth requirements. Kwashiorkor typically

> > > occurs at

> > > about age 1, after infants are weaned from breast milk to a

> protein-

> > > deficient

> > > diet of starchy gruels or sugar water, but it can develop at any

> > > time during

> > > the formative years. Marasmus affects infants ages 6 to 18

> months as

> > > a result

> > > of breast-feeding failure, or a debilitating condition such as

> > chronic

> > > diarrhea.

> > >

> > > In industrialized countries, PCM may occur secondary to chronic

> > > metabolic

> > > disease that decreases protein and calorie intake or absorption,

> or

> > > trauma that

> > > increases protein and calorie requirements. In the United States,

> > > PCM is

> > > estimated to occur to some extent in 50% of elderly people in

> > > nursing homes.

> > > Those who aren’t allowed anything by mouth for an extended

> period

> > > are at high

> > > risk of developing PCM. Conditions that increase protein-calorie

> > > requirements

> > > include severe burns and injuries, systemic infections, and cancer

> > > (accounts

> > > for the largest group of hospitalized patients with PCM).

> Conditions

> > > that cause

> > > defective utilization of nutrients include malabsorption syndrome,

> > > short-bowel syndrome, and Crohn’s disease.

> > >

> > > Read more at

> > >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > >

> > > Signs and symptoms

> > > Children with chronic PCM are small for their chronological age

> and

> > > tend to be

> > > physically inactive, mentally apathetic, and susceptible to

> frequent

> > > infections. Anorexia and diarrhea are common.

> > >

> > > In acute PCM, children are small, gaunt, and emaciated, with no

> > > adipose tissue.

> > > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > > reddish-yellow.

> > > Temperature is low; pulse rate and respirations are slowed. Such

> > > children are

> > > weak, irritable, and usually hungry, although they may have

> > > anorexia, with

> > > nausea and vomiting.

> > >

> > > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > > height, but

> > > adipose tissue diminishes as fat metabolizes to meet energy

> demands.

> > > Edema

> > > often masks severe muscle wasting; dry, peeling skin and

> > > hepatomegaly are

> > > common. Patients with secondary PCM show signs similar to

> marasmus,

> > > primarily

> > > loss of adipose tissue and lean body mass, lethargy, and edema.

> > Severe

> > > secondary PCM may cause loss of immunocompetence.

> > >

> > > Diagnosis

> > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > anthropometry

> > > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > > weight change

> > > over time is the best index of nutritional status.

> > >

> > > The following factors support the diagnosis:

> > > â‘ height and weight less than 80% of standard for the

> patient’s

> > > age and sex,

> > > and below-normal arm circumference and triceps skinfold

> > >

> > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/

> dl)

> > > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > > status by

> > > relating creatinine excretion to height and ideal body weight, to

> > > yield

> > > creatinine-height index.

> > >

> > > R Vajda, R.D.

> > > www.GingerJens.com

> > >

> > > ________________________________

> > >

> > > To: rd-usa ; dhcc@...

> > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > Subject: FW: Hospital chain, under scrutiny, reports rare

> > > illness |

> > > Local News | PE.com | Southern California News | News for Inland

> > > Southern

> > > California

> > >

> > > This is a very interesting article. Aside from the fact that our

> tax

> > > $$ are

> > > now going to our neighbor to the North, what is the accurate

> > > definition of

> > > Kwashiorkor IYO? And how is it diagnosed?

> > >

> > > Digna

> > >

> > > Hospital chain, under scrutiny, reports rare illness |

> > > Local News |

> > > PE.com | Southern California News | News for Inland Southern

> > > California

> > >

> > >

http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > tml

> > >

> > >

[Guest guest]

,

The research is not backwards, although I'm not sure what you mean by

that. Research is what is it. I'm in complete agreement with you

regarding the connection between nutrition and chronic illness,

however, kwashiorkor is not malnutrition as we have been taught in the

past.

When I talk about increased mortality with refeeding folks with

kwashiorkor, I am not talking about the " refeeding syndrome " (that is

really an iatrogenic complication, not a condition) that most of us

might have seen in hospitals. That " refeeding syndrome " is an acute

hypophosphatemia, hypokalemia, and not quite as severe hypomagnesemia

along with pulmonary and cardiac complications seen when one provides

carbohydrates in excess of capacity for cellular uptake and utilization.

Malnutrition does not equal malabsorption, nor does it equal

hypermetabolism. All are separate but can interact when present

concurrently. I think it behooves us to approach this from a science-

based perspective. The National Library of Medicine (NLM) offers the

free search engine, PubMed that can be used to search for literature

that has been peer-reviewed.

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Pam, The research is backwards and not pure science. Like you stated,

> it is money or politics at play here. Malnutrition is a slow occuring

> process in which once it gets to a certain point, it starts the slow

> cycle of illness leading to chronic illness and organ failure. You are

> right, when illness due to this malnutrition occurs, refeeding could

> be dangerous and even deadly. As with everything in life, timing is

> everything. It is really the denial of malnutrition, malabsorption and

> hypermetabolism that is the problem!

>

> Sent from my iPhone

>

>

>

> > ,

> >

> > With all due respect, one should not use Today's Dietitian as the

> > place to learn the latest science. The information published there

> is

> > not peer reviewed, nor is it systematic. It's what we call a

> > " journalistic review " . That's not a bad thing, I've written for them

> > myself, it's just that you should know the difference.

> >

> > I know you like magnesium as the perpetrator for a number of health

> > conditions, based on your recent posts here. However, kwashiorkor is

> > not protein and electrolyte imbalance, at least not at the root

> cause.

> > In fact, in some research, when you give folks with (real)

> kwashiorkor

> > protein and electrolytes without considering co-morbid conditions,

> you

> > often end up increasing mortality, which we really don't want to do.

> >

> > What's going on here is much more complex; it's a mix of facilities

> > trying to pull as much medicare money their way and RDs not stepping

> > up with evidence to show what is and what is not truly a nutrition

> > problem.

> >

> > I'd urge you to search PubMed for some of the more recent papers on

> > kwashiorkor. Golden from the UK had published some that are

> > very readable. There are others in the tropical medicine journals

> that

> > also talk about some other purported etiologies for kwashiorkor.

> >

> > Regards,

> > pam

> >

> > Pam Charney, PhD, RD

> >

> > Pamela Charney and Associates, LLC

> > consultants in nutrition informatics

> > Transforming Nutrition Care With Informatics

> >

> > pcharney@...

> > http://www.linkedin.com/in/pamcharney

> >

> >

> >

> > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > electrolyte

> > > imbalance. A Today's Dietitian article a few months age directed

> me

> > > to B1 for

> > > refeeding anorexia - it worked - I was so disoriented, and my

> heart

> > > was fluttery

> > > and weird. The magazine had flipped open to that page and it was a

> > > life saver.

> > > When you are that underfed, there really is no appetite - zinc

> > > deficiency

> > > worsens appetite I believe. The magnesium deficiency adds to the

> > > edema problem

> > > that the lack of albumin causes. Loss of muscle tone, alopecia,

> and

> > > dermatologic

> > > symptoms would all relate to protein deficiency. Getting

> rehydrated

> > > was

> > > necessary before I could swallow much food. When one or two bites

> > > feels like

> > > sawdust it is easy to give up eating and not figure out how to

> start

> > > again.

> > > Rehydration requires magnesium as well as sodium and potassium.

> Many

> > > major

> > > electrolyte brands don't even have magnesium - it was regulated

> out

> > > sometime in

> > > the 20's - 30's.

> > >

> > > I think that that doctor and hospital system is recognizing the

> > > problem I've

> > > been working on - we can't heal and regenerate tissue if we don't

> > > have the

> > > nutrients. As for increased Medicare billing I hope the hospital/

> > > doctor is

> > > figuring out how to use that money to actually nourish the

> starving

> > > seniors and

> > > isn't just bonusing it out to executives.

> > >

> > > Kwashiorkor was more prevalent in starving children countries -

> > > edamatous belly

> > > - but I just saw that in my father-in-law. I couldn't find a

> formula

> > > that didn't

> > > have the high calcium level that throws off absorption. Our

> enteral

> > > feedings

> > > are not based on ratios that the chronically ill can absorb. The

> > > feeding made

> > > him worse, 40 pounds edamatous. So painfully swollen with water

> and

> > > skin

> > > integrity you could poke a fingernail through (it seemed). He is

> > > getting better

> > > finally.

> > >

> > > Providing " Health Shakes " and supplemental formulas that are

> high in

> > > calcium

> > > isn't helping. The problem is not that there is no protein in the

> > > diet or even

> > > in the body - the problem is keeping the protein in the cells and

> > > blood vessels

> > > where it can do some good. Magnesium is what is needed to prevent

> > > the leaky

> > > membranes and in the chronically ill calcium is being

> preferentially

> > > absorbed.

> > >

> > > I want to make sweet potato ginger smoothies boosted with garbanzo

> > > bean puree

> > > for everybody.

> > >

> > >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> > >

> > > Protein-Calorie Malnutrition: Overview and Treatment

> > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > diseases, marasmus and kwashiorkor.

> > >

> > > Marasmus is defined simply as chronic deprivation of energy needed

> > > to maintain body weight. Its extreme form is characterized by

> severe

> > > weight loss and cachexia.1 Marasmus is further characterized by

> > > subnormal body temperature, decreased pulse and metabolic rate,

> loss

> > > of skin turgor, constipation, and starvation diarrhea,

> consisting of

> > > frequent, small, mucus-containing stools.2

> > > Kwashiorkor is a somewhat more complex disease. It is

> characterized

> > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > dermatitis.

> > >

> > > Derived from an African term meaning " the disease that occurs when

> > > the next baby is born " , kwashiorkor was initially thought to

> result

> > > from a diet high in calories (mainly carbohydrates, such as

> maize),

> > > yet deficient in protein. However, infection, aflatoxin poisoning,

> > > and oxidative stress may also play causative roles.1,3 Edema, a

> > > defining

> > > characteristic of kwashiorkor, resolves with treatment, despite

> > > continuing hypoalbuminemia, suggesting that the edema is due to

> > > leaky cell membranes, low capillary filtration rates, high

> > > concentrations of free iron, and free radicals that increase

> > capillary

> > > permeability.4 Kwashiorkor is further distinguished from

> marasmus by

> > > the following findings:

> > > * Massive edema of the hands and feet.

> > > * Profound irritability.

> > > * Anorexia.

> > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > * Alopecia or hair discoloration.

> > > * Fatty liver.

> > > * Loss of muscle tone.

> > > * Anemia and low blood concentrations of albumin, glucose,

> > potassium,

> > > and magnesium.5,6

> > > Kwashiorkor may also involve severe, life-threatening

> > hypophosphatemia

> > > (<1.0 mg/dL), which has been found to triple the mortality rate

> when

> > > compared with children who have normal phosphorus levels.7

> > > Treatment

> > > Individuals treated for protein-energy malnutrition are at risk

> for

> > > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > > hypomagnesemia may lead to disturbances in the cardiac,

> neurologic,

> > > gastrointestinal, respiratory, hematologic, skeletal, and

> endocrine

> > > systems. Guidelines have been developed to help prevent these

> > > complications

> > > and to establish a transition to normalcy. Treatment consists of 2

> > > phases: stabilization and rehabilitation.

> > >

> > > The initial (stabilization) phase proceeds from days 1 through

> 7. It

> > > consists of treatment and prevention of hypoglycemia, hypothermia,

> > > dehydration, and infection; correction of electrolyte imbalance

> and

> > > micronutrient deficiencies; and a cautious feeding regimen.

> > >

> > > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > >

> > > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > > Diseases

> > > (Eighth Edition)

> > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > > are common in

> > > underdeveloped countries and in areas in which dietary amino acid

> > > content is

> > > insufficient to satisfy growth requirements. Kwashiorkor typically

> > > occurs at

> > > about age 1, after infants are weaned from breast milk to a

> protein-

> > > deficient

> > > diet of starchy gruels or sugar water, but it can develop at any

> > > time during

> > > the formative years. Marasmus affects infants ages 6 to 18

> months as

> > > a result

> > > of breast-feeding failure, or a debilitating condition such as

> > chronic

> > > diarrhea.

> > >

> > > In industrialized countries, PCM may occur secondary to chronic

> > > metabolic

> > > disease that decreases protein and calorie intake or absorption,

> or

> > > trauma that

> > > increases protein and calorie requirements. In the United States,

> > > PCM is

> > > estimated to occur to some extent in 50% of elderly people in

> > > nursing homes.

> > > Those who aren’t allowed anything by mouth for an extended

> period

> > > are at high

> > > risk of developing PCM. Conditions that increase protein-calorie

> > > requirements

> > > include severe burns and injuries, systemic infections, and cancer

> > > (accounts

> > > for the largest group of hospitalized patients with PCM).

> Conditions

> > > that cause

> > > defective utilization of nutrients include malabsorption syndrome,

> > > short-bowel syndrome, and Crohn’s disease.

> > >

> > > Read more at

> > >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > >

> > > Signs and symptoms

> > > Children with chronic PCM are small for their chronological age

> and

> > > tend to be

> > > physically inactive, mentally apathetic, and susceptible to

> frequent

> > > infections. Anorexia and diarrhea are common.

> > >

> > > In acute PCM, children are small, gaunt, and emaciated, with no

> > > adipose tissue.

> > > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > > reddish-yellow.

> > > Temperature is low; pulse rate and respirations are slowed. Such

> > > children are

> > > weak, irritable, and usually hungry, although they may have

> > > anorexia, with

> > > nausea and vomiting.

> > >

> > > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > > height, but

> > > adipose tissue diminishes as fat metabolizes to meet energy

> demands.

> > > Edema

> > > often masks severe muscle wasting; dry, peeling skin and

> > > hepatomegaly are

> > > common. Patients with secondary PCM show signs similar to

> marasmus,

> > > primarily

> > > loss of adipose tissue and lean body mass, lethargy, and edema.

> > Severe

> > > secondary PCM may cause loss of immunocompetence.

> > >

> > > Diagnosis

> > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > anthropometry

> > > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > > weight change

> > > over time is the best index of nutritional status.

> > >

> > > The following factors support the diagnosis:

> > > â‘ height and weight less than 80% of standard for the

> patient’s

> > > age and sex,

> > > and below-normal arm circumference and triceps skinfold

> > >

> > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/

> dl)

> > > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > > status by

> > > relating creatinine excretion to height and ideal body weight, to

> > > yield

> > > creatinine-height index.

> > >

> > > R Vajda, R.D.

> > > www.GingerJens.com

> > >

> > > ________________________________

> > >

> > > To: rd-usa ; dhcc@...

> > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > Subject: FW: Hospital chain, under scrutiny, reports rare

> > > illness |

> > > Local News | PE.com | Southern California News | News for Inland

> > > Southern

> > > California

> > >

> > > This is a very interesting article. Aside from the fact that our

> tax

> > > $$ are

> > > now going to our neighbor to the North, what is the accurate

> > > definition of

> > > Kwashiorkor IYO? And how is it diagnosed?

> > >

> > > Digna

> > >

> > > Hospital chain, under scrutiny, reports rare illness |

> > > Local News |

> > > PE.com | Southern California News | News for Inland Southern

> > > California

> > >

> > >

http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > tml

> > >

> > >

[Guest guest]

Thanks for your comments Pam,

I'll continue to look into kwashiokor, but edematous PCM doesn't need to be

tropical or infantile. Dietitians do need to step up with evidence regarding

what is and is not a nutritional problem.

The reason I mentioned the B1 is more to point out that malnutrition is due to a

variety of things (and that day the magazine seemed like a house call by a

friendly dietitian). Refeeding can make things worse - more sick to the stomach.

If giving 'protein and electrolytes' often increases mortality, then I wonder

what balance of electrolytes were given and how. Magnesium isn't even in the

IOM's " water and electrolytes " report. Just potassium and sodium.

I hope the doctor and hosptial chain aren't just billing more and doing the

standard care of practice. Edematous PCM is occurring in our hospitals and

nursing homes. I don't know the billing, coding permutations. $2700 extra

dollars for a Dx does seem ridiculous (50% more than $5300).

Nephrologists seem to know the most about hydration. I had already been doing a

variety of reading on this.

http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstract

Effect

of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting in

End-Stage

Renal Disease, Nazanin Noori1, D. Kopple1,2Article first published online:

13 APR 2010DOI: 10.1111/j.1525-139X.2010.00705.x

http://www.ncbi.nlm.nih.gov/pubmed/19121473 Semin Nephrol. 2009

Jan;29(1):39-49.Causes and prevention of protein-energy wasting in chronic

kidney failure.Dukkipati R, Kopple JD.

Division of Nephrology and Hypertension, Los Angeles Biomedical Research

Institute at Harbor-UCLA Medical Center, Torrance, CA 90509, USA.

http://www.ncbi.nlm.nih.gov/pubmed/19121477

Semin Nephrol. 2009 Jan;29(1):75-84.Nutrition support for the chronically wasted

or acutely catabolic chronic kidney disease patient.Ikizler TA.Department of

Medicine, Division of Nephrology, Vanderbilt University School of Medicine,

Nashville, TN 37232-2372, USA. alp.ikizler@...

http://www.ncbi.nlm.nih.gov/pubmed/16129200

Am J Kidney Dis. 2005 Sep;46(3):387-405.Multinutrient oral supplements and tube

feeding in maintenance dialysis: a systematic review and meta-analysis.Stratton

RJ, Bircher G, Fouque D, Stenvinkel P, de Mutsert R, Engfer M, Elia M.Institute

of Human Nutrition, University of Southampton, UK. r.j.stratton@...

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed

New Insights into the Role of Anabolic Interventions in Dialysis Patients with

Protein Energy Wasting

Jie Dong and T. Alp Ikizler1 Curr Opin Nephrol Hypertens. Curr Opin Nephrol

Hypertens. 2009 November; 18(6): 469–475.doi: 10.1097/MNH.0b013e328331489d.

" Economic Implications of Nutritional interventions

It is also important to assess the impact of nutritional supplements not only

in terms of changes in nutritional parameters, but to extrapolate these

observations to potential improvements in hospitalization, mortality, and

cost-effectiveness. In a recent study, Lacson et al showed that a hypothetical

increase in serum albumin concentration in the order of 2 g/L in 50% of the

United States dialysis population would be associated with projections of

approximately 1400 lives saved, approximately 6000 hospitalizations averted,

and approximately $36 million in Medicare cost savings resulting from a

reduction of approximately 20,000 hospital days over one year[68]. This is a

reasonable estimation since 2 g/L increase in serum albumin is the average

improvement reported in most nutritional intervention studies. "

***The above paper is suggesting that giving them growth hormones and other

anabolic steroids along with protein will help them to stop catabolizing. They

have had success with the strategy, but wouldn't magnesium plus protein be

cheaper than hormones and protein. One chart that I reviewed was for an anemic

woman who is getting erthropoetin hormone injections and CBC blood draws

biweekly to monthly. Her hemoglobin goes up temporarily and then falls again and

they repeat the expense and needle sticks. If she was nourished, then her bone

marrow might want to make blood cells spontaneously instead of by force. The

irony is that her body is being forced to produce a few extra blood cells and

then we take them out with a blood draw - net result - wasted money and further

depletion of her poor body stores.

The seniors and other catabolic patients aren't going to heal quickly if we

can't get their bodies to retain nutrients in their cells.

So lesson for me to take home if I want magnesium to get a fair hearing

eventually - get all odd references out of my bibliography and mainly use the

Pubmed type - Correct Pam?

http://asheducationbook.hematologylibrary.org/cgi/content/full/2010/1/271 Marrow

Responses to Aging and Inflammation,Anemia in Elderly Patients: An Emerging

Problem for the 21st Century, J. Vanasse1,2 and Berliner2 " It is

estimated that more than 3 million Americans aged 65 yearsand older are anemic.

Of the anemic patients, one-third wereidentified to have nutritional deficiency,

one-third were diagnosedon the basis of iron studies to have anemia of

inflammation,and one-third were diagnosed with " unexplained " anemia.3A

wideethnic disparity was also noted, with non-Hispanic blacks havinga rate of

anemia that was three times that of non-Hispanic whites;a finding that is

consistent with the results seen in otherstudies.4,5 " " Anemia and inflammation

are strongly associated with, and maycontribute to, the development of

" frailty, " a poorly definedsyndrome of the elderly population associated with

weight loss,impaired mobility, generalized weakness, and poor balance.24Some

studies have suggested that elevated proinflammatory markersare associated with

development of frailty.24 Furthermore, anemiais associated with an increase in

nearly all markers of frailtyin elderly populations, suggesting that there may

be a linkbetween the pathogenesis of the two syndromes.25 "

" Anemia of inflammation (AI) has historically been termed the " anemia of chronic

disease " and is most commonly seen in associationwith infection, rheumatologic

disorders, malignancy, and otherchronic illnesses. On a biochemical level, it is

classicallycharacterized by low serum iron and low iron binding capacityin the

setting of an elevated serum ferritin. Although the etiologyof classical AI has

been attributed to decreased red cell survival,disordered iron-limited

erythropoiesis, and progressive EPOresistance of erythroid progenitors, the

relative role and interplayof these three mechanisms in the development of

anemia remainunknown, as are the potential common pathways that may linkthem. "

" In phases 1 and2 of NHANES III, we examined the association between anemiaand

vitamin D levels in men and women older than age 60 years(n = 5100) and found

that vitamin D deficiency was associatedwith anemia independent of age, sex,

race/ethnicity, with theodds for anemia being increased approximately 60% in the

presenceof vitamin D deficiency (odds ratio [OR] 1.6; 95% CI [1.37;1.95];P <

..05). Using phase 2 data, we next examined the prevalenceof vitamin D deficiency

in anemia subtypes in men and womenolder than age 60 years (n = 2657) and found

that, among thosewith anemia, vitamin D deficiency was most prevalent among

thosewith AI. The risk of AI was significantly increased in vitaminD-deficient

versus nondeficient participants (OR 1.85; 95% CI[1.64;2.07]; P < .05). These

are the first population-basedstudies demonstrating an association between

vitamin D deficiencyand anemia, particularly AI, in an older adult cohort (T.

Perlsteinand G. Vanasse, manuscript submitted, 2010) and provide

compellingevidence that vitamin D deficiency may be a previously

unrecognizedcontributor to the development of anemia in relatively healthyolder

individuals and is particularly prevalent among thosewith AI. The potential

efficacy of vitamin D in amelioratinginflammatory anemia in elderly patients and

the physiologicmechanisms by which vitamin D may abrogate anemia remain tobe

studied. " (AI = anemia of inflammation)

**trust me - vitamin D not effective at reducing anemia - seen a number of

charts - 1000 IU to 4000 IU started a year ago - all still anemic if not worse.

R Vajda, R.D.

www.GingerJens.com

________________________________

To: rd-usa

Sent: Mon, February 21, 2011 11:35:08 AM

Subject: Re: FW: Hospital chain, under scrutiny, reports rare illness

,

With all due respect, one should not use Today's Dietitian as the

place to learn the latest science. The information published there is

not peer reviewed, nor is it systematic. It's what we call a

" journalistic review " . That's not a bad thing, I've written for them

myself, it's just that you should know the difference.

I know you like magnesium as the perpetrator for a number of health

conditions, based on your recent posts here. However, kwashiorkor is

not protein and electrolyte imbalance, at least not at the root cause.

In fact, in some research, when you give folks with (real) kwashiorkor

protein and electrolytes without considering co-morbid conditions, you

often end up increasing mortality, which we really don't want to do.

What's going on here is much more complex; it's a mix of facilities

trying to pull as much medicare money their way and RDs not stepping

up with evidence to show what is and what is not truly a nutrition

problem.

I'd urge you to search PubMed for some of the more recent papers on

kwashiorkor. Golden from the UK had published some that are

very readable. There are others in the tropical medicine journals that

also talk about some other purported etiologies for kwashiorkor.

Regards,

pam

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Marasmus is starvation, kwashiorkor is protein starvation and

> electrolyte

> imbalance. A Today's Dietitian article a few months age directed me

> to B1 for

> refeeding anorexia - it worked - I was so disoriented, and my heart

> was fluttery

> and weird. The magazine had flipped open to that page and it was a

> life saver.

> When you are that underfed, there really is no appetite - zinc

> deficiency

> worsens appetite I believe. The magnesium deficiency adds to the

> edema problem

> that the lack of albumin causes. Loss of muscle tone, alopecia, and

> dermatologic

> symptoms would all relate to protein deficiency. Getting rehydrated

> was

> necessary before I could swallow much food. When one or two bites

> feels like

> sawdust it is easy to give up eating and not figure out how to start

> again.

> Rehydration requires magnesium as well as sodium and potassium. Many

> major

> electrolyte brands don't even have magnesium - it was regulated out

> sometime in

> the 20's - 30's.

>

> I think that that doctor and hospital system is recognizing the

> problem I've

> been working on - we can't heal and regenerate tissue if we don't

> have the

> nutrients. As for increased Medicare billing I hope the hospital/

> doctor is

> figuring out how to use that money to actually nourish the starving

> seniors and

> isn't just bonusing it out to executives.

>

> Kwashiorkor was more prevalent in starving children countries -

> edamatous belly

> - but I just saw that in my father-in-law. I couldn't find a formula

> that didn't

> have the high calcium level that throws off absorption. Our enteral

> feedings

> are not based on ratios that the chronically ill can absorb. The

> feeding made

> him worse, 40 pounds edamatous. So painfully swollen with water and

> skin

> integrity you could poke a fingernail through (it seemed). He is

> getting better

> finally.

>

> Providing " Health Shakes " and supplemental formulas that are high in

> calcium

> isn't helping. The problem is not that there is no protein in the

> diet or even

> in the body - the problem is keeping the protein in the cells and

> blood vessels

> where it can do some good. Magnesium is what is needed to prevent

> the leaky

> membranes and in the chronically ill calcium is being preferentially

> absorbed.

>

> I want to make sweet potato ginger smoothies boosted with garbanzo

> bean puree

> for everybody.

>

>http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_maln\

utrition.html

>l

>

> Protein-Calorie Malnutrition: Overview and Treatment

> Protein-calorie malnutritionresults in 2 similar but distinct

> diseases, marasmus and kwashiorkor.

>

> Marasmus is defined simply as chronic deprivation of energy needed

> to maintain body weight. Its extreme form is characterized by severe

> weight loss and cachexia.1 Marasmus is further characterized by

> subnormal body temperature, decreased pulse and metabolic rate, loss

> of skin turgor, constipation, and starvation diarrhea, consisting of

> frequent, small, mucus-containing stools.2

> Kwashiorkor is a somewhat more complex disease. It is characterized

> by edema, low capillary-filtration rate, hypoalbuminemia, and

> dermatitis.

>

> Derived from an African term meaning " the disease that occurs when

> the next baby is born " , kwashiorkor was initially thought to result

> from a diet high in calories (mainly carbohydrates, such as maize),

> yet deficient in protein. However, infection, aflatoxin poisoning,

> and oxidative stress may also play causative roles.1,3 Edema, a

> defining

> characteristic of kwashiorkor, resolves with treatment, despite

> continuing hypoalbuminemia, suggesting that the edema is due to

> leaky cell membranes, low capillary filtration rates, high

> concentrations of free iron, and free radicals that increase capillary

> permeability.4 Kwashiorkor is further distinguished from marasmus by

> the following findings:

> * Massive edema of the hands and feet.

> * Profound irritability.

> * Anorexia.

> * Dermatologic symptoms (desquamative rash, hypopigmentation).

> * Alopecia or hair discoloration.

> * Fatty liver.

> * Loss of muscle tone.

> * Anemia and low blood concentrations of albumin, glucose, potassium,

> and magnesium.5,6

> Kwashiorkor may also involve severe, life-threatening hypophosphatemia

> (<1.0 mg/dL), which has been found to triple the mortality rate when

> compared with children who have normal phosphorus levels.7

> Treatment

> Individuals treated for protein-energy malnutrition are at risk for

> refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> systems. Guidelines have been developed to help prevent these

> complications

> and to establish a transition to normalcy. Treatment consists of 2

> phases: stabilization and rehabilitation.

>

> The initial (stabilization) phase proceeds from days 1 through 7. It

> consists of treatment and prevention of hypoglycemia, hypothermia,

> dehydration, and infection; correction of electrolyte imbalance and

> micronutrient deficiencies; and a cautious feeding regimen.

>

> http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

>

> Protein-calorie malnutrition: Excerpt from Professional Guide to

> Diseases

> (Eighth Edition)

> " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> are common in

> underdeveloped countries and in areas in which dietary amino acid

> content is

> insufficient to satisfy growth requirements. Kwashiorkor typically

> occurs at

> about age 1, after infants are weaned from breast milk to a protein-

> deficient

> diet of starchy gruels or sugar water, but it can develop at any

> time during

> the formative years. Marasmus affects infants ages 6 to 18 months as

> a result

> of breast-feeding failure, or a debilitating condition such as chronic

> diarrhea.

>

> In industrialized countries, PCM may occur secondary to chronic

> metabolic

> disease that decreases protein and calorie intake or absorption, or

> trauma that

> increases protein and calorie requirements. In the United States,

> PCM is

> estimated to occur to some extent in 50% of elderly people in

> nursing homes.

> Those who aren’t allowed anything by mouth for an extended period

> are at high

> risk of developing PCM. Conditions that increase protein-calorie

> requirements

> include severe burns and injuries, systemic infections, and cancer

> (accounts

> for the largest group of hospitalized patients with PCM). Conditions

> that cause

> defective utilization of nutrients include malabsorption syndrome,

> short-bowel syndrome, and Crohn’s disease.

>

> Read more at

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

>

> Signs and symptoms

> Children with chronic PCM are small for their chronological age and

> tend to be

> physically inactive, mentally apathetic, and susceptible to frequent

> infections. Anorexia and diarrhea are common.

>

> In acute PCM, children are small, gaunt, and emaciated, with no

> adipose tissue.

> Skin is dry and “baggy,†and hair is sparse and dull brown or

> reddish-yellow.

> Temperature is low; pulse rate and respirations are slowed. Such

> children are

> weak, irritable, and usually hungry, although they may have

> anorexia, with

> nausea and vomiting.

>

> Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> height, but

> adipose tissue diminishes as fat metabolizes to meet energy demands.

> Edema

> often masks severe muscle wasting; dry, peeling skin and

> hepatomegaly are

> common. Patients with secondary PCM show signs similar to marasmus,

> primarily

> loss of adipose tissue and lean body mass, lethargy, and edema. Severe

> secondary PCM may cause loss of immunocompetence.

>

> Diagnosis

> CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> anthropometry

> confirm PCM. If the patient doesn’t suffer from fluid retention,

> weight change

> over time is the best index of nutritional status.

>

> The following factors support the diagnosis:

> ①height and weight less than 80% of standard for the patient’s

> age and sex,

> and below-normal arm circumference and triceps skinfold

>

> â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> â‘ urinary creatinine (24-hour) level used to show lean body mass

> status by

> relating creatinine excretion to height and ideal body weight, to

> yield

> creatinine-height index.

>

> R Vajda, R.D.

> www.GingerJens.com

>

> ________________________________

>

> To: rd-usa ; dhcc@...

> Sent: Sun, February 20, 2011 8:50:58 PM

> Subject: FW: Hospital chain, under scrutiny, reports rare

> illness |

> Local News | PE.com | Southern California News | News for Inland

> Southern

> California

>

> This is a very interesting article. Aside from the fact that our tax

> $$ are

> now going to our neighbor to the North, what is the accurate

> definition of

> Kwashiorkor IYO? And how is it diagnosed?

>

> Digna

>

> Hospital chain, under scrutiny, reports rare illness |

> Local News |

> PE.com | Southern California News | News for Inland Southern

> California

>

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> tml

>

>

[Guest guest]

Pam, I agree with what you are saying! PubMed is the best source but

it also had been influenced by money and politics. There has been some

positive changes in the science publishing community and journals

since now most disclose funding. Science is sometimes backwards or

after the fact. The example is HIV. First it did not exist and was

missed Dx as other diseases since 1950s or longer, then it was a

syndrome, then a virus and then labeled HIV/AIDS. Gulf War syndrome is

similar and when there is no money or explanation it stays a syndrome.

These viruses and syndromes cause hypermetabolic conditions and slow

malabsorption leading to malnutrition. Medical nutrition is an art and

a science! Today's science, medicine, definitions and more change all

the time! Your giving an example of it. Big business is in everything

now, including academia! Special interests trumps what is best for the

patient or student. Bottom line is that if Americans are not given the

opportunity to see a RD and a MD for regular check ups and care,

healthcare cost shall rise and rise bankrupting our country. Time

needs to be spent on basic care. My opinion, more than 90% healthcare

starts with medical nutrition! This message is not getting to Americans!

Sent from my iPhone

> ,

>

> The research is not backwards, although I'm not sure what you mean by

> that. Research is what is it. I'm in complete agreement with you

> regarding the connection between nutrition and chronic illness,

> however, kwashiorkor is not malnutrition as we have been taught in the

> past.

>

> When I talk about increased mortality with refeeding folks with

> kwashiorkor, I am not talking about the " refeeding syndrome " (that is

> really an iatrogenic complication, not a condition) that most of us

> might have seen in hospitals. That " refeeding syndrome " is an acute

> hypophosphatemia, hypokalemia, and not quite as severe hypomagnesemia

> along with pulmonary and cardiac complications seen when one provides

> carbohydrates in excess of capacity for cellular uptake and

> utilization.

>

> Malnutrition does not equal malabsorption, nor does it equal

> hypermetabolism. All are separate but can interact when present

> concurrently. I think it behooves us to approach this from a science-

> based perspective. The National Library of Medicine (NLM) offers the

> free search engine, PubMed that can be used to search for literature

> that has been peer-reviewed.

>

> Pam Charney, PhD, RD

>

> Pamela Charney and Associates, LLC

> consultants in nutrition informatics

> Transforming Nutrition Care With Informatics

>

> pcharney@...

> http://www.linkedin.com/in/pamcharney

>

>

>

> > Pam, The research is backwards and not pure science. Like you

> stated,

> > it is money or politics at play here. Malnutrition is a slow

> occuring

> > process in which once it gets to a certain point, it starts the slow

> > cycle of illness leading to chronic illness and organ failure. You

> are

> > right, when illness due to this malnutrition occurs, refeeding could

> > be dangerous and even deadly. As with everything in life, timing is

> > everything. It is really the denial of malnutrition, malabsorption

> and

> > hypermetabolism that is the problem!

> >

> > Sent from my iPhone

> >

> >

> >

> > > ,

> > >

> > > With all due respect, one should not use Today's Dietitian as the

> > > place to learn the latest science. The information published there

> > is

> > > not peer reviewed, nor is it systematic. It's what we call a

> > > " journalistic review " . That's not a bad thing, I've written for

> them

> > > myself, it's just that you should know the difference.

> > >

> > > I know you like magnesium as the perpetrator for a number of

> health

> > > conditions, based on your recent posts here. However,

> kwashiorkor is

> > > not protein and electrolyte imbalance, at least not at the root

> > cause.

> > > In fact, in some research, when you give folks with (real)

> > kwashiorkor

> > > protein and electrolytes without considering co-morbid conditions,

> > you

> > > often end up increasing mortality, which we really don't want to

> do.

> > >

> > > What's going on here is much more complex; it's a mix of

> facilities

> > > trying to pull as much medicare money their way and RDs not

> stepping

> > > up with evidence to show what is and what is not truly a nutrition

> > > problem.

> > >

> > > I'd urge you to search PubMed for some of the more recent papers

> on

> > > kwashiorkor. Golden from the UK had published some that

> are

> > > very readable. There are others in the tropical medicine journals

> > that

> > > also talk about some other purported etiologies for kwashiorkor.

> > >

> > > Regards,

> > > pam

> > >

> > > Pam Charney, PhD, RD

> > >

> > > Pamela Charney and Associates, LLC

> > > consultants in nutrition informatics

> > > Transforming Nutrition Care With Informatics

> > >

> > > pcharney@...

> > > http://www.linkedin.com/in/pamcharney

> > >

> > >

> > >

> > > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > > electrolyte

> > > > imbalance. A Today's Dietitian article a few months age directed

> > me

> > > > to B1 for

> > > > refeeding anorexia - it worked - I was so disoriented, and my

> > heart

> > > > was fluttery

> > > > and weird. The magazine had flipped open to that page and it

> was a

> > > > life saver.

> > > > When you are that underfed, there really is no appetite - zinc

> > > > deficiency

> > > > worsens appetite I believe. The magnesium deficiency adds to the

> > > > edema problem

> > > > that the lack of albumin causes. Loss of muscle tone, alopecia,

> > and

> > > > dermatologic

> > > > symptoms would all relate to protein deficiency. Getting

> > rehydrated

> > > > was

> > > > necessary before I could swallow much food. When one or two

> bites

> > > > feels like

> > > > sawdust it is easy to give up eating and not figure out how to

> > start

> > > > again.

> > > > Rehydration requires magnesium as well as sodium and potassium.

> > Many

> > > > major

> > > > electrolyte brands don't even have magnesium - it was regulated

> > out

> > > > sometime in

> > > > the 20's - 30's.

> > > >

> > > > I think that that doctor and hospital system is recognizing the

> > > > problem I've

> > > > been working on - we can't heal and regenerate tissue if we

> don't

> > > > have the

> > > > nutrients. As for increased Medicare billing I hope the

> hospital/

> > > > doctor is

> > > > figuring out how to use that money to actually nourish the

> > starving

> > > > seniors and

> > > > isn't just bonusing it out to executives.

> > > >

> > > > Kwashiorkor was more prevalent in starving children countries -

> > > > edamatous belly

> > > > - but I just saw that in my father-in-law. I couldn't find a

> > formula

> > > > that didn't

> > > > have the high calcium level that throws off absorption. Our

> > enteral

> > > > feedings

> > > > are not based on ratios that the chronically ill can absorb. The

> > > > feeding made

> > > > him worse, 40 pounds edamatous. So painfully swollen with water

> > and

> > > > skin

> > > > integrity you could poke a fingernail through (it seemed). He is

> > > > getting better

> > > > finally.

> > > >

> > > > Providing " Health Shakes " and supplemental formulas that are

> > high in

> > > > calcium

> > > > isn't helping. The problem is not that there is no protein in

> the

> > > > diet or even

> > > > in the body - the problem is keeping the protein in the cells

> and

> > > > blood vessels

> > > > where it can do some good. Magnesium is what is needed to

> prevent

> > > > the leaky

> > > > membranes and in the chronically ill calcium is being

> > preferentially

> > > > absorbed.

> > > >

> > > > I want to make sweet potato ginger smoothies boosted with

> garbanzo

> > > > bean puree

> > > > for everybody.

> > > >

> > > >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> > > >

> > > > Protein-Calorie Malnutrition: Overview and Treatment

> > > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > > diseases, marasmus and kwashiorkor.

> > > >

> > > > Marasmus is defined simply as chronic deprivation of energy

> needed

> > > > to maintain body weight. Its extreme form is characterized by

> > severe

> > > > weight loss and cachexia.1 Marasmus is further characterized by

> > > > subnormal body temperature, decreased pulse and metabolic rate,

> > loss

> > > > of skin turgor, constipation, and starvation diarrhea,

> > consisting of

> > > > frequent, small, mucus-containing stools.2

> > > > Kwashiorkor is a somewhat more complex disease. It is

> > characterized

> > > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > > dermatitis.

> > > >

> > > > Derived from an African term meaning " the disease that occurs

> when

> > > > the next baby is born " , kwashiorkor was initially thought to

> > result

> > > > from a diet high in calories (mainly carbohydrates, such as

> > maize),

> > > > yet deficient in protein. However, infection, aflatoxin

> poisoning,

> > > > and oxidative stress may also play causative roles.1,3 Edema, a

> > > > defining

> > > > characteristic of kwashiorkor, resolves with treatment, despite

> > > > continuing hypoalbuminemia, suggesting that the edema is due to

> > > > leaky cell membranes, low capillary filtration rates, high

> > > > concentrations of free iron, and free radicals that increase

> > > capillary

> > > > permeability.4 Kwashiorkor is further distinguished from

> > marasmus by

> > > > the following findings:

> > > > * Massive edema of the hands and feet.

> > > > * Profound irritability.

> > > > * Anorexia.

> > > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > > * Alopecia or hair discoloration.

> > > > * Fatty liver.

> > > > * Loss of muscle tone.

> > > > * Anemia and low blood concentrations of albumin, glucose,

> > > potassium,

> > > > and magnesium.5,6

> > > > Kwashiorkor may also involve severe, life-threatening

> > > hypophosphatemia

> > > > (<1.0 mg/dL), which has been found to triple the mortality rate

> > when

> > > > compared with children who have normal phosphorus levels.7

> > > > Treatment

> > > > Individuals treated for protein-energy malnutrition are at risk

> > for

> > > > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > > > hypomagnesemia may lead to disturbances in the cardiac,

> > neurologic,

> > > > gastrointestinal, respiratory, hematologic, skeletal, and

> > endocrine

> > > > systems. Guidelines have been developed to help prevent these

> > > > complications

> > > > and to establish a transition to normalcy. Treatment consists

> of 2

> > > > phases: stabilization and rehabilitation.

> > > >

> > > > The initial (stabilization) phase proceeds from days 1 through

> > 7. It

> > > > consists of treatment and prevention of hypoglycemia,

> hypothermia,

> > > > dehydration, and infection; correction of electrolyte imbalance

> > and

> > > > micronutrient deficiencies; and a cautious feeding regimen.

> > > >

> > > > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > > >

> > > > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > > > Diseases

> > > > (Eighth Edition)

> > > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous

> PCM)

> > > > are common in

> > > > underdeveloped countries and in areas in which dietary amino

> acid

> > > > content is

> > > > insufficient to satisfy growth requirements. Kwashiorkor

> typically

> > > > occurs at

> > > > about age 1, after infants are weaned from breast milk to a

> > protein-

> > > > deficient

> > > > diet of starchy gruels or sugar water, but it can develop at any

> > > > time during

> > > > the formative years. Marasmus affects infants ages 6 to 18

> > months as

> > > > a result

> > > > of breast-feeding failure, or a debilitating condition such as

> > > chronic

> > > > diarrhea.

> > > >

> > > > In industrialized countries, PCM may occur secondary to chronic

> > > > metabolic

> > > > disease that decreases protein and calorie intake or absorption,

> > or

> > > > trauma that

> > > > increases protein and calorie requirements. In the United

> States,

> > > > PCM is

> > > > estimated to occur to some extent in 50% of elderly people in

> > > > nursing homes.

> > > > Those who aren’t allowed anything by mouth for an extended

> > period

> > > > are at high

> > > > risk of developing PCM. Conditions that increase protein-calorie

> > > > requirements

> > > > include severe burns and injuries, systemic infections, and

> cancer

> > > > (accounts

> > > > for the largest group of hospitalized patients with PCM).

> > Conditions

> > > > that cause

> > > > defective utilization of nutrients include malabsorption

> syndrome,

> > > > short-bowel syndrome, and Crohn’s disease.

> > > >

> > > > Read more at

> > > >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > > >

> > > > Signs and symptoms

> > > > Children with chronic PCM are small for their chronological age

> > and

> > > > tend to be

> > > > physically inactive, mentally apathetic, and susceptible to

> > frequent

> > > > infections. Anorexia and diarrhea are common.

> > > >

> > > > In acute PCM, children are small, gaunt, and emaciated, with no

> > > > adipose tissue.

> > > > Skin is dry and “baggy,†and hair is sparse and dull brown

> or

> > > > reddish-yellow.

> > > > Temperature is low; pulse rate and respirations are slowed. Such

> > > > children are

> > > > weak, irritable, and usually hungry, although they may have

> > > > anorexia, with

> > > > nausea and vomiting.

> > > >

> > > > Unlike marasmus, chronic kwashiorkor allows the patient to

> grow in

> > > > height, but

> > > > adipose tissue diminishes as fat metabolizes to meet energy

> > demands.

> > > > Edema

> > > > often masks severe muscle wasting; dry, peeling skin and

> > > > hepatomegaly are

> > > > common. Patients with secondary PCM show signs similar to

> > marasmus,

> > > > primarily

> > > > loss of adipose tissue and lean body mass, lethargy, and edema.

> > > Severe

> > > > secondary PCM may cause loss of immunocompetence.

> > > >

> > > > Diagnosis

> > > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > > anthropometry

> > > > confirm PCM. If the patient doesn’t suffer from fluid retentio

> n,

> > > > weight change

> > > > over time is the best index of nutritional status.

> > > >

> > > > The following factors support the diagnosis:

> > > > â‘ height and weight less than 80% of standard for the

> > patient’s

> > > > age and sex,

> > > > and below-normal arm circumference and triceps skinfold

> > > >

> > > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3

> g/

> > dl)

> > > > â‘ urinary creatinine (24-hour) level used to show lean body ma

> ss

> > > > status by

> > > > relating creatinine excretion to height and ideal body weight,

> to

> > > > yield

> > > > creatinine-height index.

> > > >

> > > > R Vajda, R.D.

> > > > www.GingerJens.com

> > > >

> > > > ________________________________

> > > >

> > > > To: rd-usa ; dhcc@...

> > > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > > Subject: FW: Hospital chain, under scrutiny, reports

> rare

> > > > illness |

> > > > Local News | PE.com | Southern California News | News for Inland

> > > > Southern

> > > > California

> > > >

> > > > This is a very interesting article. Aside from the fact that our

> > tax

> > > > $$ are

> > > > now going to our neighbor to the North, what is the accurate

> > > > definition of

> > > > Kwashiorkor IYO? And how is it diagnosed?

> > > >

> > > > Digna

> > > >

> > > > Hospital chain, under scrutiny, reports rare illness |

> > > > Local News |

> > > > PE.com | Southern California News | News for Inland Southern

> > > > California

> > > >

> > > >

http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > > tml

> > > >

> > > >

[Guest guest]

This hospital chain's reporting controversy may be just the catalyst

for the need for medical nutrition by RDs! Thank you, for

your information!

Sent from my iPhone

On Feb 21, 2011, at 1:33 PM, Vajda

wrote:

> Thanks for your comments Pam,

>

> I'll continue to look into kwashiokor, but edematous PCM doesn't

> need to be

> tropical or infantile. Dietitians do need to step up with evidence

> regarding

> what is and is not a nutritional problem.

>

> The reason I mentioned the B1 is more to point out that malnutrition

> is due to a

> variety of things (and that day the magazine seemed like a house

> call by a

> friendly dietitian). Refeeding can make things worse - more sick to

> the stomach.

>

> If giving 'protein and electrolytes' often increases mortality, then

> I wonder

> what balance of electrolytes were given and how. Magnesium isn't

> even in the

> IOM's " water and electrolytes " report. Just potassium and sodium.

>

> I hope the doctor and hosptial chain aren't just billing more and

> doing the

> standard care of practice. Edematous PCM is occurring in our

> hospitals and

> nursing homes. I don't know the billing, coding permutations. $2700

> extra

> dollars for a Dx does seem ridiculous (50% more than $5300).

>

> Nephrologists seem to know the most about hydration. I had already

> been doing a

> variety of reading on this.

>

> http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstract

> Effect

> of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting i

> n End-Stage

> Renal Disease, Nazanin Noori1, D. Kopple1,2Article first

> published online:

> 13 APR 2010DOI: 10.1111/j.1525-139X.2010.00705.x

>

> http://www.ncbi.nlm.nih.gov/pubmed/19121473 Semin Nephrol. 2009

> Jan;29(1):39-49.Causes and prevention of protein-energy wasting in

> chronic

> kidney failure.Dukkipati R, Kopple JD.

> Division of Nephrology and Hypertension, Los Angeles Biomedical

> Research

> Institute at Harbor-UCLA Medical Center, Torrance, CA 90509, USA.

> http://www.ncbi.nlm.nih.gov/pubmed/19121477

> Semin Nephrol. 2009 Jan;29(1):75-84.Nutrition support for the

> chronically wasted

> or acutely catabolic chronic kidney disease patient.Ikizler

> TA.Department of

> Medicine, Division of Nephrology, Vanderbilt University School of

> Medicine,

> Nashville, TN 37232-2372, USA. alp.ikizler@...

>

> http://www.ncbi.nlm.nih.gov/pubmed/16129200

> Am J Kidney Dis. 2005 Sep;46(3):387-405.Multinutrient oral

> supplements and tube

> feeding in maintenance dialysis: a systematic review and meta-

> analysis.Stratton

> RJ, Bircher G, Fouque D, Stenvinkel P, de Mutsert R, Engfer M, Elia

> M.Institute

> of Human Nutrition, University of Southampton, UK. r.j.stratton@...

>

> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed

>

> New Insights into the Role of Anabolic Interventions in Dialysis

> Patients with

> Protein Energy Wasting

> Jie Dong and T. Alp Ikizler1 Curr Opin Nephrol Hypertens. Curr Opin

> Nephrol

> Hypertens. 2009 November; 18(6): 469–475.doi: 10.1097/MNH.0b013e3283

> 31489d.

> " Economic Implications of Nutritional interventions

> It is also important to assess the impact of nutritional supplements

> not only

> in terms of changes in nutritional parameters, but to extrapolate

> these

> observations to potential improvements in hospitalization,

> mortality, and

> cost-effectiveness. In a recent study, Lacson et al showed that a

> hypothetical

> increase in serum albumin concentration in the order of 2 g/L in 50%

> of the

> United States dialysis population would be associated with

> projections of

> approximately 1400 lives saved, approximately 6000 hospitalizations

> averted,

> and approximately $36 million in Medicare cost savings resulting

> from a

> reduction of approximately 20,000 hospital days over one year[68].

> This is a

> reasonable estimation since 2 g/L increase in serum albumin is the

> average

> improvement reported in most nutritional intervention studies. "

>

> ***The above paper is suggesting that giving them growth hormones

> and other

> anabolic steroids along with protein will help them to stop

> catabolizing. They

> have had success with the strategy, but wouldn't magnesium plus

> protein be

> cheaper than hormones and protein. One chart that I reviewed was for

> an anemic

> woman who is getting erthropoetin hormone injections and CBC blood

> draws

> biweekly to monthly. Her hemoglobin goes up temporarily and then

> falls again and

> they repeat the expense and needle sticks. If she was nourished,

> then her bone

> marrow might want to make blood cells spontaneously instead of by

> force. The

> irony is that her body is being forced to produce a few extra blood

> cells and

> then we take them out with a blood draw - net result - wasted money

> and further

> depletion of her poor body stores.

>

> The seniors and other catabolic patients aren't going to heal

> quickly if we

> can't get their bodies to retain nutrients in their cells.

>

> So lesson for me to take home if I want magnesium to get a fair

> hearing

> eventually - get all odd references out of my bibliography and

> mainly use the

> Pubmed type - Correct Pam?

>

>

>

> http://asheducationbook.hematologylibrary.org/cgi/content/full/2010/1/271

> Marrow

> Responses to Aging and Inflammation,Anemia in Elderly Patients: An

> Emerging

> Problem for the 21st Century, J. Vanasse1,2 and Berliner2

> " It is

> estimated that more than 3 million Americans aged 65 yearsand older

> are anemic.

> Of the anemic patients, one-third wereidentified to have nutritional

> deficiency,

> one-third were diagnosedon the basis of iron studies to have anemia of

> inflammation,and one-third were diagnosed with " unexplained " anemia.3A

> wideethnic disparity was also noted, with non-Hispanic blacks

> havinga rate of

> anemia that was three times that of non-Hispanic whites;a finding

> that is

> consistent with the results seen in otherstudies.4,5 " " Anemia and

> inflammation

> are strongly associated with, and maycontribute to, the development of

> " frailty, " a poorly definedsyndrome of the elderly population

> associated with

> weight loss,impaired mobility, generalized weakness, and poor

> balance.24Some

> studies have suggested that elevated proinflammatory markersare

> associated with

> development of frailty.24 Furthermore, anemiais associated with an

> increase in

> nearly all markers of frailtyin elderly populations, suggesting that

> there may

> be a linkbetween the pathogenesis of the two syndromes.25 "

>

> " Anemia of inflammation (AI) has historically been termed the " anemia

> of chronic

> disease " and is most commonly seen in associationwith infection,

> rheumatologic

> disorders, malignancy, and otherchronic illnesses. On a biochemical

> level, it is

> classicallycharacterized by low serum iron and low iron binding

> capacityin the

> setting of an elevated serum ferritin. Although the etiologyof

> classical AI has

> been attributed to decreased red cell survival,disordered iron-limited

> erythropoiesis, and progressive EPOresistance of erythroid

> progenitors, the

> relative role and interplayof these three mechanisms in the

> development of

> anemia remainunknown, as are the potential common pathways that may

> linkthem. "

>

> " In phases 1 and2 of NHANES III, we examined the association between

> anemiaand

> vitamin D levels in men and women older than age 60 years(n = 5100)

> and found

> that vitamin D deficiency was associatedwith anemia independent of

> age, sex,

> race/ethnicity, with theodds for anemia being increased

> approximately 60% in the

> presenceof vitamin D deficiency (odds ratio [OR] 1.6; 95% CI

> [1.37;1.95];P <

> .05). Using phase 2 data, we next examined the prevalenceof vitamin

> D deficiency

> in anemia subtypes in men and womenolder than age 60 years (n =

> 2657) and found

> that, among thosewith anemia, vitamin D deficiency was most

> prevalent among

> thosewith AI. The risk of AI was significantly increased in vitaminD-

> deficient

> versus nondeficient participants (OR 1.85; 95% CI[1.64;2.07]; P < .

> 05). These

> are the first population-basedstudies demonstrating an association

> between

> vitamin D deficiencyand anemia, particularly AI, in an older adult

> cohort (T.

> Perlsteinand G. Vanasse, manuscript submitted, 2010) and provide

> compellingevidence that vitamin D deficiency may be a previously

> unrecognizedcontributor to the development of anemia in relatively

> healthyolder

> individuals and is particularly prevalent among thosewith AI. The

> potential

> efficacy of vitamin D in amelioratinginflammatory anemia in elderly

> patients and

> the physiologicmechanisms by which vitamin D may abrogate anemia

> remain tobe

> studied. " (AI = anemia of inflammation)

>

> **trust me - vitamin D not effective at reducing anemia - seen a

> number of

> charts - 1000 IU to 4000 IU started a year ago - all still anemic if

> not worse.

>

> R Vajda, R.D.

> www.GingerJens.com

>

> ________________________________

>

> To: rd-usa

> Sent: Mon, February 21, 2011 11:35:08 AM

> Subject: Re: FW: Hospital chain, under scrutiny, reports

> rare illness

>

> ,

>

> With all due respect, one should not use Today's Dietitian as the

> place to learn the latest science. The information published there is

> not peer reviewed, nor is it systematic. It's what we call a

> " journalistic review " . That's not a bad thing, I've written for them

> myself, it's just that you should know the difference.

>

> I know you like magnesium as the perpetrator for a number of health

> conditions, based on your recent posts here. However, kwashiorkor is

> not protein and electrolyte imbalance, at least not at the root cause.

> In fact, in some research, when you give folks with (real) kwashiorkor

> protein and electrolytes without considering co-morbid conditions, you

> often end up increasing mortality, which we really don't want to do.

>

> What's going on here is much more complex; it's a mix of facilities

> trying to pull as much medicare money their way and RDs not stepping

> up with evidence to show what is and what is not truly a nutrition

> problem.

>

> I'd urge you to search PubMed for some of the more recent papers on

> kwashiorkor. Golden from the UK had published some that are

> very readable. There are others in the tropical medicine journals that

> also talk about some other purported etiologies for kwashiorkor.

>

> Regards,

> pam

>

> Pam Charney, PhD, RD

>

> Pamela Charney and Associates, LLC

> consultants in nutrition informatics

> Transforming Nutrition Care With Informatics

>

> pcharney@...

> http://www.linkedin.com/in/pamcharney

>

>

>

> > Marasmus is starvation, kwashiorkor is protein starvation and

> > electrolyte

> > imbalance. A Today's Dietitian article a few months age directed me

> > to B1 for

> > refeeding anorexia - it worked - I was so disoriented, and my heart

> > was fluttery

> > and weird. The magazine had flipped open to that page and it was a

> > life saver.

> > When you are that underfed, there really is no appetite - zinc

> > deficiency

> > worsens appetite I believe. The magnesium deficiency adds to the

> > edema problem

> > that the lack of albumin causes. Loss of muscle tone, alopecia, and

> > dermatologic

> > symptoms would all relate to protein deficiency. Getting rehydrated

> > was

> > necessary before I could swallow much food. When one or two bites

> > feels like

> > sawdust it is easy to give up eating and not figure out how to start

> > again.

> > Rehydration requires magnesium as well as sodium and potassium. Many

> > major

> > electrolyte brands don't even have magnesium - it was regulated out

> > sometime in

> > the 20's - 30's.

> >

> > I think that that doctor and hospital system is recognizing the

> > problem I've

> > been working on - we can't heal and regenerate tissue if we don't

> > have the

> > nutrients. As for increased Medicare billing I hope the hospital/

> > doctor is

> > figuring out how to use that money to actually nourish the starving

> > seniors and

> > isn't just bonusing it out to executives.

> >

> > Kwashiorkor was more prevalent in starving children countries -

> > edamatous belly

> > - but I just saw that in my father-in-law. I couldn't find a formula

> > that didn't

> > have the high calcium level that throws off absorption. Our enteral

> > feedings

> > are not based on ratios that the chronically ill can absorb. The

> > feeding made

> > him worse, 40 pounds edamatous. So painfully swollen with water and

> > skin

> > integrity you could poke a fingernail through (it seemed). He is

> > getting better

> > finally.

> >

> > Providing " Health Shakes " and supplemental formulas that are high in

> > calcium

> > isn't helping. The problem is not that there is no protein in the

> > diet or even

> > in the body - the problem is keeping the protein in the cells and

> > blood vessels

> > where it can do some good. Magnesium is what is needed to prevent

> > the leaky

> > membranes and in the chronically ill calcium is being preferentially

> > absorbed.

> >

> > I want to make sweet potato ginger smoothies boosted with garbanzo

> > bean puree

> > for everybody.

> >

>

>http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_maln\

utrition.html

> >l

> >

> > Protein-Calorie Malnutrition: Overview and Treatment

> > Protein-calorie malnutritionresults in 2 similar but distinct

> > diseases, marasmus and kwashiorkor.

> >

> > Marasmus is defined simply as chronic deprivation of energy needed

> > to maintain body weight. Its extreme form is characterized by severe

> > weight loss and cachexia.1 Marasmus is further characterized by

> > subnormal body temperature, decreased pulse and metabolic rate, loss

> > of skin turgor, constipation, and starvation diarrhea, consisting of

> > frequent, small, mucus-containing stools.2

> > Kwashiorkor is a somewhat more complex disease. It is characterized

> > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > dermatitis.

> >

> > Derived from an African term meaning " the disease that occurs when

> > the next baby is born " , kwashiorkor was initially thought to result

> > from a diet high in calories (mainly carbohydrates, such as maize),

> > yet deficient in protein. However, infection, aflatoxin poisoning,

> > and oxidative stress may also play causative roles.1,3 Edema, a

> > defining

> > characteristic of kwashiorkor, resolves with treatment, despite

> > continuing hypoalbuminemia, suggesting that the edema is due to

> > leaky cell membranes, low capillary filtration rates, high

> > concentrations of free iron, and free radicals that increase

> capillary

> > permeability.4 Kwashiorkor is further distinguished from marasmus by

> > the following findings:

> > * Massive edema of the hands and feet.

> > * Profound irritability.

> > * Anorexia.

> > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > * Alopecia or hair discoloration.

> > * Fatty liver.

> > * Loss of muscle tone.

> > * Anemia and low blood concentrations of albumin, glucose,

> potassium,

> > and magnesium.5,6

> > Kwashiorkor may also involve severe, life-threatening

> hypophosphatemia

> > (<1.0 mg/dL), which has been found to triple the mortality rate when

> > compared with children who have normal phosphorus levels.7

> > Treatment

> > Individuals treated for protein-energy malnutrition are at risk for

> > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> > gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> > systems. Guidelines have been developed to help prevent these

> > complications

> > and to establish a transition to normalcy. Treatment consists of 2

> > phases: stabilization and rehabilitation.

> >

> > The initial (stabilization) phase proceeds from days 1 through 7. It

> > consists of treatment and prevention of hypoglycemia, hypothermia,

> > dehydration, and infection; correction of electrolyte imbalance and

> > micronutrient deficiencies; and a cautious feeding regimen.

> >

> > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> >

> > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > Diseases

> > (Eighth Edition)

> > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > are common in

> > underdeveloped countries and in areas in which dietary amino acid

> > content is

> > insufficient to satisfy growth requirements. Kwashiorkor typically

> > occurs at

> > about age 1, after infants are weaned from breast milk to a protein-

> > deficient

> > diet of starchy gruels or sugar water, but it can develop at any

> > time during

> > the formative years. Marasmus affects infants ages 6 to 18 months as

> > a result

> > of breast-feeding failure, or a debilitating condition such as

> chronic

> > diarrhea.

> >

> > In industrialized countries, PCM may occur secondary to chronic

> > metabolic

> > disease that decreases protein and calorie intake or absorption, or

> > trauma that

> > increases protein and calorie requirements. In the United States,

> > PCM is

> > estimated to occur to some extent in 50% of elderly people in

> > nursing homes.

> > Those who aren’t allowed anything by mouth for an extended period

> > are at high

> > risk of developing PCM. Conditions that increase protein-calorie

> > requirements

> > include severe burns and injuries, systemic infections, and cancer

> > (accounts

> > for the largest group of hospitalized patients with PCM). Conditions

> > that cause

> > defective utilization of nutrients include malabsorption syndrome,

> > short-bowel syndrome, and Crohn’s disease.

> >

> > Read more at

> >

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> >

> > Signs and symptoms

> > Children with chronic PCM are small for their chronological age and

> > tend to be

> > physically inactive, mentally apathetic, and susceptible to frequent

> > infections. Anorexia and diarrhea are common.

> >

> > In acute PCM, children are small, gaunt, and emaciated, with no

> > adipose tissue.

> > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > reddish-yellow.

> > Temperature is low; pulse rate and respirations are slowed. Such

> > children are

> > weak, irritable, and usually hungry, although they may have

> > anorexia, with

> > nausea and vomiting.

> >

> > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > height, but

> > adipose tissue diminishes as fat metabolizes to meet energy demands.

> > Edema

> > often masks severe muscle wasting; dry, peeling skin and

> > hepatomegaly are

> > common. Patients with secondary PCM show signs similar to marasmus,

> > primarily

> > loss of adipose tissue and lean body mass, lethargy, and edema.

> Severe

> > secondary PCM may cause loss of immunocompetence.

> >

> > Diagnosis

> > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > anthropometry

> > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > weight change

> > over time is the best index of nutritional status.

> >

> > The following factors support the diagnosis:

> > ①height and weight less than 80% of standard for the patient’s

> > age and sex,

> > and below-normal arm circumference and triceps skinfold

> >

> > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > status by

> > relating creatinine excretion to height and ideal body weight, to

> > yield

> > creatinine-height index.

> >

> > R Vajda, R.D.

> > www.GingerJens.com

> >

> > ________________________________

> >

> > To: rd-usa ; dhcc@...

> > Sent: Sun, February 20, 2011 8:50:58 PM

> > Subject: FW: Hospital chain, under scrutiny, reports rare

> > illness |

> > Local News | PE.com | Southern California News | News for Inland

> > Southern

> > California

> >

> > This is a very interesting article. Aside from the fact that our tax

> > $$ are

> > now going to our neighbor to the North, what is the accurate

> > definition of

> > Kwashiorkor IYO? And how is it diagnosed?

> >

> > Digna

> >

> > Hospital chain, under scrutiny, reports rare illness |

> > Local News |

> > PE.com | Southern California News | News for Inland Southern

> > California

> >

> > http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > tml

> >

> >

[Guest guest]

Hello again,

I did a little more homework, good sources give better results - cool - and

found out that bugs are good for preventing kwashiorkor. The chitin is a good

source of glucosamine which is missing from the intestinal lining - the research

team is suggesting that there is a missing enzyme or prior infection in the

subpopulation that get kwashiorkor. It was the same diet, same type of kids in

general but all the ones with kwashiorkor have leakier membranes, worse

intestinal lining.

We need a different word than refeeding or PCM - it isn't calorie malnutrition

in the case of the chronically ill. It is malabsorption and lack of retention.

Aldosterone is messed up in the kids with kwashiorkor as well so they retain

salt.

" However, using 2 well-characterized stains specific for

glycan carbohydrates (15) and sulfates (14, 15), we identified a similar

pattern of reduced sulfated GAG expression throughout the small intestinal

mucosa. Children with marasmus and persistent diarrhea

generally showed HSPG expression similar to that of normal European children.

Thus, it is unlikely that nutritional deficiencies causing

wasting and stunting per se induce this loss. Because sulfated GAGs are now

identified as critical in many aspects of physiology (24), their disruption may

play a role in the signs and pathophysiology of kwashiorkor.

HSPG loss promotes albumin leakage and reduced tissue turgor (9, 14–18, 24,

25).

Although urinary protein loss is rare in kwashiorkor (9), PLE has been reported

and may precipitate disease (26, 27). Although we found normal HSPG in marasmic

kwashiorkor, IEL density was high, which indicated a likely recent infection.

We previously showed that reglycosylation capacity limits PLE after HSPG loss

(16–18) and suggests that these previously marasmic children may have suffered

an acute episode of PLE on infection but were then able to

reglycosylate to restore the epithelial barrier.

HSPG deficiency is consistent with known associations of kwashiorkor. Its

frequent onset after displacement from the breast may

relate to both infections and substrate deficiency, because breast milk is rich

in N-acetyl glucosamine (GlcNAc) and sulfur-containing amino acids (28). It is

intriguing that consumption of insects, high in chitin GlcNAc, appears to

protect infants against kwashiorkor, which suggests the

ironic possibility that Western missionaries may have increased the incidence

of kwashiorkor in the early 20th century because of their

campaign against entomophagy (29). "

from:

http://www.ajcn.org/content/89/2/592.long

Reduced production of sulfated glycosaminoglycans occurs in Zambian children

with kwashiorkor but not marasmus

also good -

http://www.icmr.nic.in/ijmr/2009/November/1128.pdf Oedematous malnutrition

We'll need to look up those insect chefs that found or take a glucosamine

supplement. Or a good rich bone marrow soup stock for clear liquid diets. Fresh

kind that will gel when it chills.

" Magnesium Food Group " , beans, nuts, seeds, greens, etc all have the advantage

of providing many nutrients so I'm recommending a boost of B's and C and E and

other antioxidants and zinc and other trace minerals and the super sugars /

fibers. We need eight, some of us convert between the forms better than other

people. We all get plenty of glucose and galactose but we also need mannose,

fucose, xylose, N-acetylglucosamine, N-acetylgalactosamine, and

N-acetylneuraminic acid. Mushrooms are a good source, aloe vera, echinacea,

fenugreek, slippery elm powder, apple, pears . . .

What do horseradish, sweet potatoes and insects have in common? Good building

blocks.

The cynical side of me believes the Medicare system is being scammed but the

idealistic part of me is glad to have any doctor labeling malnutrition by a

malnutriton label insead of " _____, of unknown origin " .

good night, hope no bed bugs are biting.

Vajda, RD.

www.GingerJens.com - glycocalcyx - our jelly lining

________________________________

To: " rd-usa " <rd-usa >

Sent: Mon, February 21, 2011 3:59:51 PM

Subject: Re: FW: Hospital chain, under scrutiny, reports rare illness

This hospital chain's reporting controversy may be just the catalyst

for the need for medical nutrition by RDs! Thank you, for

your information!

Sent from my iPhone

On Feb 21, 2011, at 1:33 PM, Vajda

wrote:

> Thanks for your comments Pam,

>

> I'll continue to look into kwashiokor, but edematous PCM doesn't

> need to be

> tropical or infantile. Dietitians do need to step up with evidence

> regarding

> what is and is not a nutritional problem.

>

> The reason I mentioned the B1 is more to point out that malnutrition

> is due to a

> variety of things (and that day the magazine seemed like a house

> call by a

> friendly dietitian). Refeeding can make things worse - more sick to

> the stomach.

>

> If giving 'protein and electrolytes' often increases mortality, then

> I wonder

> what balance of electrolytes were given and how. Magnesium isn't

> even in the

> IOM's " water and electrolytes " report. Just potassium and sodium.

>

> I hope the doctor and hosptial chain aren't just billing more and

> doing the

> standard care of practice. Edematous PCM is occurring in our

> hospitals and

> nursing homes. I don't know the billing, coding permutations. $2700

> extra

> dollars for a Dx does seem ridiculous (50% more than $5300).

>

> Nephrologists seem to know the most about hydration. I had already

> been doing a

> variety of reading on this.

>

> http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstract

> Effect

> of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting i

> n End-Stage

> Renal Disease, Nazanin Noori1, D. Kopple1,2Article first

> published online:

> 13 APR 2010DOI: 10.1111/j.1525-139X.2010.00705.x

>

> http://www.ncbi.nlm.nih.gov/pubmed/19121473 Semin Nephrol. 2009

> Jan;29(1):39-49.Causes and prevention of protein-energy wasting in

> chronic

> kidney failure.Dukkipati R, Kopple JD.

> Division of Nephrology and Hypertension, Los Angeles Biomedical

> Research

> Institute at Harbor-UCLA Medical Center, Torrance, CA 90509, USA.

> http://www.ncbi.nlm.nih.gov/pubmed/19121477

> Semin Nephrol. 2009 Jan;29(1):75-84.Nutrition support for the

> chronically wasted

> or acutely catabolic chronic kidney disease patient.Ikizler

> TA.Department of

> Medicine, Division of Nephrology, Vanderbilt University School of

> Medicine,

> Nashville, TN 37232-2372, USA. alp.ikizler@...

>

> http://www.ncbi.nlm.nih.gov/pubmed/16129200

> Am J Kidney Dis. 2005 Sep;46(3):387-405.Multinutrient oral

> supplements and tube

> feeding in maintenance dialysis: a systematic review and meta-

> analysis.Stratton

> RJ, Bircher G, Fouque D, Stenvinkel P, de Mutsert R, Engfer M, Elia

> M.Institute

> of Human Nutrition, University of Southampton, UK. r.j.stratton@...

>

> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed

>

> New Insights into the Role of Anabolic Interventions in Dialysis

> Patients with

> Protein Energy Wasting

> Jie Dong and T. Alp Ikizler1 Curr Opin Nephrol Hypertens. Curr Opin

> Nephrol

> Hypertens. 2009 November; 18(6): 469–475.doi: 10.1097/MNH.0b013e3283

> 31489d.

> " Economic Implications of Nutritional interventions

> It is also important to assess the impact of nutritional supplements

> not only

> in terms of changes in nutritional parameters, but to extrapolate

> these

> observations to potential improvements in hospitalization,

> mortality, and

> cost-effectiveness. In a recent study, Lacson et al showed that a

> hypothetical

> increase in serum albumin concentration in the order of 2 g/L in 50%

> of the

> United States dialysis population would be associated with

> projections of

> approximately 1400 lives saved, approximately 6000 hospitalizations

> averted,

> and approximately $36 million in Medicare cost savings resulting

> from a

> reduction of approximately 20,000 hospital days over one year[68].

> This is a

> reasonable estimation since 2 g/L increase in serum albumin is the

> average

> improvement reported in most nutritional intervention studies. "

>

> ***The above paper is suggesting that giving them growth hormones

> and other

> anabolic steroids along with protein will help them to stop

> catabolizing. They

> have had success with the strategy, but wouldn't magnesium plus

> protein be

> cheaper than hormones and protein. One chart that I reviewed was for

> an anemic

> woman who is getting erthropoetin hormone injections and CBC blood

> draws

> biweekly to monthly. Her hemoglobin goes up temporarily and then

> falls again and

> they repeat the expense and needle sticks. If she was nourished,

> then her bone

> marrow might want to make blood cells spontaneously instead of by

> force. The

> irony is that her body is being forced to produce a few extra blood

> cells and

> then we take them out with a blood draw - net result - wasted money

> and further

> depletion of her poor body stores.

>

> The seniors and other catabolic patients aren't going to heal

> quickly if we

> can't get their bodies to retain nutrients in their cells.

>

> So lesson for me to take home if I want magnesium to get a fair

> hearing

> eventually - get all odd references out of my bibliography and

> mainly use the

> Pubmed type - Correct Pam?

>

>

>

> http://asheducationbook.hematologylibrary.org/cgi/content/full/2010/1/271

> Marrow

> Responses to Aging and Inflammation,Anemia in Elderly Patients: An

> Emerging

> Problem for the 21st Century, J. Vanasse1,2 and Berliner2

> " It is

> estimated that more than 3 million Americans aged 65 yearsand older

> are anemic.

> Of the anemic patients, one-third wereidentified to have nutritional

> deficiency,

> one-third were diagnosedon the basis of iron studies to have anemia of

> inflammation,and one-third were diagnosed with " unexplained " anemia.3A

> wideethnic disparity was also noted, with non-Hispanic blacks

> havinga rate of

> anemia that was three times that of non-Hispanic whites;a finding

> that is

> consistent with the results seen in otherstudies.4,5 " " Anemia and

> inflammation

> are strongly associated with, and maycontribute to, the development of

> " frailty, " a poorly definedsyndrome of the elderly population

> associated with

> weight loss,impaired mobility, generalized weakness, and poor

> balance.24Some

> studies have suggested that elevated proinflammatory markersare

> associated with

> development of frailty.24 Furthermore, anemiais associated with an

> increase in

> nearly all markers of frailtyin elderly populations, suggesting that

> there may

> be a linkbetween the pathogenesis of the two syndromes.25 "

>

> " Anemia of inflammation (AI) has historically been termed the " anemia

> of chronic

> disease " and is most commonly seen in associationwith infection,

> rheumatologic

> disorders, malignancy, and otherchronic illnesses. On a biochemical

> level, it is

> classicallycharacterized by low serum iron and low iron binding

> capacityin the

> setting of an elevated serum ferritin. Although the etiologyof

> classical AI has

> been attributed to decreased red cell survival,disordered iron-limited

> erythropoiesis, and progressive EPOresistance of erythroid

> progenitors, the

> relative role and interplayof these three mechanisms in the

> development of

> anemia remainunknown, as are the potential common pathways that may

> linkthem. "

>

> " In phases 1 and2 of NHANES III, we examined the association between

> anemiaand

> vitamin D levels in men and women older than age 60 years(n = 5100)

> and found

> that vitamin D deficiency was associatedwith anemia independent of

> age, sex,

> race/ethnicity, with theodds for anemia being increased

> approximately 60% in the

> presenceof vitamin D deficiency (odds ratio [OR] 1.6; 95% CI

> [1.37;1.95];P <

> .05). Using phase 2 data, we next examined the prevalenceof vitamin

> D deficiency

> in anemia subtypes in men and womenolder than age 60 years (n =

> 2657) and found

> that, among thosewith anemia, vitamin D deficiency was most

> prevalent among

> thosewith AI. The risk of AI was significantly increased in vitaminD-

> deficient

> versus nondeficient participants (OR 1.85; 95% CI[1.64;2.07]; P < .

> 05). These

> are the first population-basedstudies demonstrating an association

> between

> vitamin D deficiencyand anemia, particularly AI, in an older adult

> cohort (T.

> Perlsteinand G. Vanasse, manuscript submitted, 2010) and provide

> compellingevidence that vitamin D deficiency may be a previously

> unrecognizedcontributor to the development of anemia in relatively

> healthyolder

> individuals and is particularly prevalent among thosewith AI. The

> potential

> efficacy of vitamin D in amelioratinginflammatory anemia in elderly

> patients and

> the physiologicmechanisms by which vitamin D may abrogate anemia

> remain tobe

> studied. " (AI = anemia of inflammation)

>

> **trust me - vitamin D not effective at reducing anemia - seen a

> number of

> charts - 1000 IU to 4000 IU started a year ago - all still anemic if

> not worse.

>

> R Vajda, R.D.

> www.GingerJens.com

>

> ________________________________

>

> To: rd-usa

> Sent: Mon, February 21, 2011 11:35:08 AM

> Subject: Re: FW: Hospital chain, under scrutiny, reports

> rare illness

>

> ,

>

> With all due respect, one should not use Today's Dietitian as the

> place to learn the latest science. The information published there is

> not peer reviewed, nor is it systematic. It's what we call a

> " journalistic review " . That's not a bad thing, I've written for them

> myself, it's just that you should know the difference.

>

> I know you like magnesium as the perpetrator for a number of health

> conditions, based on your recent posts here. However, kwashiorkor is

> not protein and electrolyte imbalance, at least not at the root cause.

> In fact, in some research, when you give folks with (real) kwashiorkor

> protein and electrolytes without considering co-morbid conditions, you

> often end up increasing mortality, which we really don't want to do.

>

> What's going on here is much more complex; it's a mix of facilities

> trying to pull as much medicare money their way and RDs not stepping

> up with evidence to show what is and what is not truly a nutrition

> problem.

>

> I'd urge you to search PubMed for some of the more recent papers on

> kwashiorkor. Golden from the UK had published some that are

> very readable. There are others in the tropical medicine journals that

> also talk about some other purported etiologies for kwashiorkor.

>

> Regards,

> pam

>

> Pam Charney, PhD, RD

>

> Pamela Charney and Associates, LLC

> consultants in nutrition informatics

> Transforming Nutrition Care With Informatics

>

> pcharney@...

> http://www.linkedin.com/in/pamcharney

>

>

>

> > Marasmus is starvation, kwashiorkor is protein starvation and

> > electrolyte

> > imbalance. A Today's Dietitian article a few months age directed me

> > to B1 for

> > refeeding anorexia - it worked - I was so disoriented, and my heart

> > was fluttery

> > and weird. The magazine had flipped open to that page and it was a

> > life saver.

> > When you are that underfed, there really is no appetite - zinc

> > deficiency

> > worsens appetite I believe. The magnesium deficiency adds to the

> > edema problem

> > that the lack of albumin causes. Loss of muscle tone, alopecia, and

> > dermatologic

> > symptoms would all relate to protein deficiency. Getting rehydrated

> > was

> > necessary before I could swallow much food. When one or two bites

> > feels like

> > sawdust it is easy to give up eating and not figure out how to start

> > again.

> > Rehydration requires magnesium as well as sodium and potassium. Many

> > major

> > electrolyte brands don't even have magnesium - it was regulated out

> > sometime in

> > the 20's - 30's.

> >

> > I think that that doctor and hospital system is recognizing the

> > problem I've

> > been working on - we can't heal and regenerate tissue if we don't

> > have the

> > nutrients. As for increased Medicare billing I hope the hospital/

> > doctor is

> > figuring out how to use that money to actually nourish the starving

> > seniors and

> > isn't just bonusing it out to executives.

> >

> > Kwashiorkor was more prevalent in starving children countries -

> > edamatous belly

> > - but I just saw that in my father-in-law. I couldn't find a formula

> > that didn't

> > have the high calcium level that throws off absorption. Our enteral

> > feedings

> > are not based on ratios that the chronically ill can absorb. The

> > feeding made

> > him worse, 40 pounds edamatous. So painfully swollen with water and

> > skin

> > integrity you could poke a fingernail through (it seemed). He is

> > getting better

> > finally.

> >

> > Providing " Health Shakes " and supplemental formulas that are high in

> > calcium

> > isn't helping. The problem is not that there is no protein in the

> > diet or even

> > in the body - the problem is keeping the protein in the cells and

> > blood vessels

> > where it can do some good. Magnesium is what is needed to prevent

> > the leaky

> > membranes and in the chronically ill calcium is being preferentially

> > absorbed.

> >

> > I want to make sweet potato ginger smoothies boosted with garbanzo

> > bean puree

> > for everybody.

> >

>>http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_mal\

nutrition.html

>l

> >l

> >

> > Protein-Calorie Malnutrition: Overview and Treatment

> > Protein-calorie malnutritionresults in 2 similar but distinct

> > diseases, marasmus and kwashiorkor.

> >

> > Marasmus is defined simply as chronic deprivation of energy needed

> > to maintain body weight. Its extreme form is characterized by severe

> > weight loss and cachexia.1 Marasmus is further characterized by

> > subnormal body temperature, decreased pulse and metabolic rate, loss

> > of skin turgor, constipation, and starvation diarrhea, consisting of

> > frequent, small, mucus-containing stools.2

> > Kwashiorkor is a somewhat more complex disease. It is characterized

> > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > dermatitis.

> >

> > Derived from an African term meaning " the disease that occurs when

> > the next baby is born " , kwashiorkor was initially thought to result

> > from a diet high in calories (mainly carbohydrates, such as maize),

> > yet deficient in protein. However, infection, aflatoxin poisoning,

> > and oxidative stress may also play causative roles.1,3 Edema, a

> > defining

> > characteristic of kwashiorkor, resolves with treatment, despite

> > continuing hypoalbuminemia, suggesting that the edema is due to

> > leaky cell membranes, low capillary filtration rates, high

> > concentrations of free iron, and free radicals that increase

> capillary

> > permeability.4 Kwashiorkor is further distinguished from marasmus by

> > the following findings:

> > * Massive edema of the hands and feet.

> > * Profound irritability.

> > * Anorexia.

> > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > * Alopecia or hair discoloration.

> > * Fatty liver.

> > * Loss of muscle tone.

> > * Anemia and low blood concentrations of albumin, glucose,

> potassium,

> > and magnesium.5,6

> > Kwashiorkor may also involve severe, life-threatening

> hypophosphatemia

> > (<1.0 mg/dL), which has been found to triple the mortality rate when

> > compared with children who have normal phosphorus levels.7

> > Treatment

> > Individuals treated for protein-energy malnutrition are at risk for

> > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> > gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> > systems. Guidelines have been developed to help prevent these

> > complications

> > and to establish a transition to normalcy. Treatment consists of 2

> > phases: stabilization and rehabilitation.

> >

> > The initial (stabilization) phase proceeds from days 1 through 7. It

> > consists of treatment and prevention of hypoglycemia, hypothermia,

> > dehydration, and infection; correction of electrolyte imbalance and

> > micronutrient deficiencies; and a cautious feeding regimen.

> >

> > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> >

> > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > Diseases

> > (Eighth Edition)

> > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > are common in

> > underdeveloped countries and in areas in which dietary amino acid

> > content is

> > insufficient to satisfy growth requirements. Kwashiorkor typically

> > occurs at

> > about age 1, after infants are weaned from breast milk to a protein-

> > deficient

> > diet of starchy gruels or sugar water, but it can develop at any

> > time during

> > the formative years. Marasmus affects infants ages 6 to 18 months as

> > a result

> > of breast-feeding failure, or a debilitating condition such as

> chronic

> > diarrhea.

> >

> > In industrialized countries, PCM may occur secondary to chronic

> > metabolic

> > disease that decreases protein and calorie intake or absorption, or

> > trauma that

> > increases protein and calorie requirements. In the United States,

> > PCM is

> > estimated to occur to some extent in 50% of elderly people in

> > nursing homes.

> > Those who aren’t allowed anything by mouth for an extended period

> > are at high

> > risk of developing PCM. Conditions that increase protein-calorie

> > requirements

> > include severe burns and injuries, systemic infections, and cancer

> > (accounts

> > for the largest group of hospitalized patients with PCM). Conditions

> > that cause

> > defective utilization of nutrients include malabsorption syndrome,

> > short-bowel syndrome, and Crohn’s disease.

> >

> > Read more at

> >

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> >

> > Signs and symptoms

> > Children with chronic PCM are small for their chronological age and

> > tend to be

> > physically inactive, mentally apathetic, and susceptible to frequent

> > infections. Anorexia and diarrhea are common.

> >

> > In acute PCM, children are small, gaunt, and emaciated, with no

> > adipose tissue.

> > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > reddish-yellow.

> > Temperature is low; pulse rate and respirations are slowed. Such

> > children are

> > weak, irritable, and usually hungry, although they may have

> > anorexia, with

> > nausea and vomiting.

> >

> > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > height, but

> > adipose tissue diminishes as fat metabolizes to meet energy demands.

> > Edema

> > often masks severe muscle wasting; dry, peeling skin and

> > hepatomegaly are

> > common. Patients with secondary PCM show signs similar to marasmus,

> > primarily

> > loss of adipose tissue and lean body mass, lethargy, and edema.

> Severe

> > secondary PCM may cause loss of immunocompetence.

> >

> > Diagnosis

> > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > anthropometry

> > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > weight change

> > over time is the best index of nutritional status.

> >

> > The following factors support the diagnosis:

> > ①height and weight less than 80% of standard for the patient’s

> > age and sex,

> > and below-normal arm circumference and triceps skinfold

> >

> > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > status by

> > relating creatinine excretion to height and ideal body weight, to

> > yield

> > creatinine-height index.

> >

> > R Vajda, R.D.

> > www.GingerJens.com

> >

> > ________________________________

> >

> > To: rd-usa ; dhcc@...

> > Sent: Sun, February 20, 2011 8:50:58 PM

> > Subject: FW: Hospital chain, under scrutiny, reports rare

> > illness |

> > Local News | PE.com | Southern California News | News for Inland

> > Southern

> > California

> >

> > This is a very interesting article. Aside from the fact that our tax

> > $$ are

> > now going to our neighbor to the North, what is the accurate

> > definition of

> > Kwashiorkor IYO? And how is it diagnosed?

> >

> > Digna

> >

> > Hospital chain, under scrutiny, reports rare illness |

> > Local News |

> > PE.com | Southern California News | News for Inland Southern

> > California

> >

> > http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > tml

> >

> >

[Guest guest]

Thanks, ! Like I said before, most illness goes back to the

fact that nutrients are not being absorbed or utilized which slowly

weakens the body causing the person's condition to get worse. I do

believe that medical nutrition is one of the most important screening

and treatment options that should occur in most patients.

Sent from my iPhone

On Feb 21, 2011, at 8:59 PM, Vajda

wrote:

> Hello again,

>

> I did a little more homework, good sources give better results -

> cool - and

> found out that bugs are good for preventing kwashiorkor. The chitin

> is a good

> source of glucosamine which is missing from the intestinal lining -

> the research

> team is suggesting that there is a missing enzyme or prior infection

> in the

> subpopulation that get kwashiorkor. It was the same diet, same type

> of kids in

> general but all the ones with kwashiorkor have leakier membranes,

> worse

> intestinal lining.

>

> We need a different word than refeeding or PCM - it isn't calorie

> malnutrition

> in the case of the chronically ill. It is malabsorption and lack of

> retention.

> Aldosterone is messed up in the kids with kwashiorkor as well so

> they retain

> salt.

>

> " However, using 2 well-characterized stains specific for

> glycan carbohydrates (15) and sulfates (14, 15), we identified a

> similar

> pattern of reduced sulfated GAG expression throughout the small

> intestinal

> mucosa. Children with marasmus and persistent diarrhea

> generally showed HSPG expression similar to that of normal European

> children.

> Thus, it is unlikely that nutritional deficiencies causing

> wasting and stunting per se induce this loss. Because sulfated GAGs

> are now

> identified as critical in many aspects of physiology (24), their

> disruption may

> play a role in the signs and pathophysiology of kwashiorkor.

>

> HSPG loss promotes albumin leakage and reduced tissue turgor (9, 14–

> 18, 24, 25).

> Although urinary protein loss is rare in kwashiorkor (9), PLE has

> been reported

> and may precipitate disease (26, 27). Although we found normal HSPG

> in marasmic

> kwashiorkor, IEL density was high, which indicated a likely recent

> infection.

> We previously showed that reglycosylation capacity limits PLE after

> HSPG loss

> (16–18) and suggests that these previously marasmic children may hav

> e suffered

> an acute episode of PLE on infection but were then able to

> reglycosylate to restore the epithelial barrier.

>

> HSPG deficiency is consistent with known associations of

> kwashiorkor. Its

> frequent onset after displacement from the breast may

> relate to both infections and substrate deficiency, because breast

> milk is rich

> in N-acetyl glucosamine (GlcNAc) and sulfur-containing amino acids

> (28). It is

> intriguing that consumption of insects, high in chitin GlcNAc,

> appears to

> protect infants against kwashiorkor, which suggests the

> ironic possibility that Western missionaries may have increased the

> incidence

> of kwashiorkor in the early 20th century because of their

> campaign against entomophagy (29). "

> from:

> http://www.ajcn.org/content/89/2/592.long

> Reduced production of sulfated glycosaminoglycans occurs in Zambian

> children

> with kwashiorkor but not marasmus

> also good -

> http://www.icmr.nic.in/ijmr/2009/November/1128.pdf Oedematous

> malnutrition

>

> We'll need to look up those insect chefs that found or take a

> glucosamine

> supplement. Or a good rich bone marrow soup stock for clear liquid

> diets. Fresh

> kind that will gel when it chills.

>

> " Magnesium Food Group " , beans, nuts, seeds, greens, etc all have the

> advantage

> of providing many nutrients so I'm recommending a boost of B's and C

> and E and

> other antioxidants and zinc and other trace minerals and the super

> sugars /

> fibers. We need eight, some of us convert between the forms better

> than other

> people. We all get plenty of glucose and galactose but we also need

> mannose,

> fucose, xylose, N-acetylglucosamine, N-acetylgalactosamine, and

> N-acetylneuraminic acid. Mushrooms are a good source, aloe vera,

> echinacea,

> fenugreek, slippery elm powder, apple, pears . . .

>

> What do horseradish, sweet potatoes and insects have in common? Good

> building

> blocks.

> The cynical side of me believes the Medicare system is being scammed

> but the

> idealistic part of me is glad to have any doctor labeling

> malnutrition by a

> malnutriton label insead of " _____, of unknown origin " .

>

> good night, hope no bed bugs are biting.

>

> Vajda, RD.

> www.GingerJens.com - glycocalcyx - our jelly lining

>

> ________________________________

>

> To: " rd-usa " <rd-usa >

> Sent: Mon, February 21, 2011 3:59:51 PM

> Subject: Re: FW: Hospital chain, under scrutiny, reports

> rare illness

>

> This hospital chain's reporting controversy may be just the catalyst

> for the need for medical nutrition by RDs! Thank you, for

> your information!

>

> Sent from my iPhone

>

> On Feb 21, 2011, at 1:33 PM, Vajda

> wrote:

>

> > Thanks for your comments Pam,

> >

> > I'll continue to look into kwashiokor, but edematous PCM doesn't

> > need to be

> > tropical or infantile. Dietitians do need to step up with evidence

> > regarding

> > what is and is not a nutritional problem.

> >

> > The reason I mentioned the B1 is more to point out that malnutrition

> > is due to a

> > variety of things (and that day the magazine seemed like a house

> > call by a

> > friendly dietitian). Refeeding can make things worse - more sick to

> > the stomach.

> >

> > If giving 'protein and electrolytes' often increases mortality, then

> > I wonder

> > what balance of electrolytes were given and how. Magnesium isn't

> > even in the

> > IOM's " water and electrolytes " report. Just potassium and sodium.

> >

> > I hope the doctor and hosptial chain aren't just billing more and

> > doing the

> > standard care of practice. Edematous PCM is occurring in our

> > hospitals and

> > nursing homes. I don't know the billing, coding permutations. $2700

> > extra

> > dollars for a Dx does seem ridiculous (50% more than $5300).

> >

> > Nephrologists seem to know the most about hydration. I had already

> > been doing a

> > variety of reading on this.

> >

> > http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstract

> > Effect

> > of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting

> i

> > n End-Stage

> > Renal Disease, Nazanin Noori1, D. Kopple1,2Article first

> > published online:

> > 13 APR 2010DOI: 10.1111/j.1525-139X.2010.00705.x

> >

> > http://www.ncbi.nlm.nih.gov/pubmed/19121473 Semin Nephrol. 2009

> > Jan;29(1):39-49.Causes and prevention of protein-energy wasting in

> > chronic

> > kidney failure.Dukkipati R, Kopple JD.

> > Division of Nephrology and Hypertension, Los Angeles Biomedical

> > Research

> > Institute at Harbor-UCLA Medical Center, Torrance, CA 90509, USA.

> > http://www.ncbi.nlm.nih.gov/pubmed/19121477

> > Semin Nephrol. 2009 Jan;29(1):75-84.Nutrition support for the

> > chronically wasted

> > or acutely catabolic chronic kidney disease patient.Ikizler

> > TA.Department of

> > Medicine, Division of Nephrology, Vanderbilt University School of

> > Medicine,

> > Nashville, TN 37232-2372, USA. alp.ikizler@...

> >

> > http://www.ncbi.nlm.nih.gov/pubmed/16129200

> > Am J Kidney Dis. 2005 Sep;46(3):387-405.Multinutrient oral

> > supplements and tube

> > feeding in maintenance dialysis: a systematic review and meta-

> > analysis.Stratton

> > RJ, Bircher G, Fouque D, Stenvinkel P, de Mutsert R, Engfer M, Elia

> > M.Institute

> > of Human Nutrition, University of Southampton, UK. r.j.stratton@...

> >

> > http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed

> >

> > New Insights into the Role of Anabolic Interventions in Dialysis

> > Patients with

> > Protein Energy Wasting

> > Jie Dong and T. Alp Ikizler1 Curr Opin Nephrol Hypertens. Curr Opin

> > Nephrol

> > Hypertens. 2009 November; 18(6): 469–475.doi: 10.1097/MNH.0b013e32

> 83

> > 31489d.

> > " Economic Implications of Nutritional interventions

> > It is also important to assess the impact of nutritional supplements

> > not only

> > in terms of changes in nutritional parameters, but to extrapolate

> > these

> > observations to potential improvements in hospitalization,

> > mortality, and

> > cost-effectiveness. In a recent study, Lacson et al showed that a

> > hypothetical

> > increase in serum albumin concentration in the order of 2 g/L in 50%

> > of the

> > United States dialysis population would be associated with

> > projections of

> > approximately 1400 lives saved, approximately 6000 hospitalizations

> > averted,

> > and approximately $36 million in Medicare cost savings resulting

> > from a

> > reduction of approximately 20,000 hospital days over one year[68].

> > This is a

> > reasonable estimation since 2 g/L increase in serum albumin is the

> > average

> > improvement reported in most nutritional intervention studies. "

> >

> > ***The above paper is suggesting that giving them growth hormones

> > and other

> > anabolic steroids along with protein will help them to stop

> > catabolizing. They

> > have had success with the strategy, but wouldn't magnesium plus

> > protein be

> > cheaper than hormones and protein. One chart that I reviewed was for

> > an anemic

> > woman who is getting erthropoetin hormone injections and CBC blood

> > draws

> > biweekly to monthly. Her hemoglobin goes up temporarily and then

> > falls again and

> > they repeat the expense and needle sticks. If she was nourished,

> > then her bone

> > marrow might want to make blood cells spontaneously instead of by

> > force. The

> > irony is that her body is being forced to produce a few extra blood

> > cells and

> > then we take them out with a blood draw - net result - wasted money

> > and further

> > depletion of her poor body stores.

> >

> > The seniors and other catabolic patients aren't going to heal

> > quickly if we

> > can't get their bodies to retain nutrients in their cells.

> >

> > So lesson for me to take home if I want magnesium to get a fair

> > hearing

> > eventually - get all odd references out of my bibliography and

> > mainly use the

> > Pubmed type - Correct Pam?

> >

> >

> >

> > http://asheducationbook.hematologylibrary.org/cgi/content/full/2010/1/271

> > Marrow

> > Responses to Aging and Inflammation,Anemia in Elderly Patients: An

> > Emerging

> > Problem for the 21st Century, J. Vanasse1,2 and Berliner2

> > " It is

> > estimated that more than 3 million Americans aged 65 yearsand older

> > are anemic.

> > Of the anemic patients, one-third wereidentified to have nutritional

> > deficiency,

> > one-third were diagnosedon the basis of iron studies to have

> anemia of

> > inflammation,and one-third were diagnosed with " unexplained "

> anemia.3A

> > wideethnic disparity was also noted, with non-Hispanic blacks

> > havinga rate of

> > anemia that was three times that of non-Hispanic whites;a finding

> > that is

> > consistent with the results seen in otherstudies.4,5 " " Anemia and

> > inflammation

> > are strongly associated with, and maycontribute to, the

> development of

> > " frailty, " a poorly definedsyndrome of the elderly population

> > associated with

> > weight loss,impaired mobility, generalized weakness, and poor

> > balance.24Some

> > studies have suggested that elevated proinflammatory markersare

> > associated with

> > development of frailty.24 Furthermore, anemiais associated with an

> > increase in

> > nearly all markers of frailtyin elderly populations, suggesting that

> > there may

> > be a linkbetween the pathogenesis of the two syndromes.25 "

> >

> > " Anemia of inflammation (AI) has historically been termed the " anemia

> > of chronic

> > disease " and is most commonly seen in associationwith infection,

> > rheumatologic

> > disorders, malignancy, and otherchronic illnesses. On a biochemical

> > level, it is

> > classicallycharacterized by low serum iron and low iron binding

> > capacityin the

> > setting of an elevated serum ferritin. Although the etiologyof

> > classical AI has

> > been attributed to decreased red cell survival,disordered iron-

> limited

> > erythropoiesis, and progressive EPOresistance of erythroid

> > progenitors, the

> > relative role and interplayof these three mechanisms in the

> > development of

> > anemia remainunknown, as are the potential common pathways that may

> > linkthem. "

> >

> > " In phases 1 and2 of NHANES III, we examined the association between

> > anemiaand

> > vitamin D levels in men and women older than age 60 years(n = 5100)

> > and found

> > that vitamin D deficiency was associatedwith anemia independent of

> > age, sex,

> > race/ethnicity, with theodds for anemia being increased

> > approximately 60% in the

> > presenceof vitamin D deficiency (odds ratio [OR] 1.6; 95% CI

> > [1.37;1.95];P <

> > .05). Using phase 2 data, we next examined the prevalenceof vitamin

> > D deficiency

> > in anemia subtypes in men and womenolder than age 60 years (n =

> > 2657) and found

> > that, among thosewith anemia, vitamin D deficiency was most

> > prevalent among

> > thosewith AI. The risk of AI was significantly increased in

> vitaminD-

> > deficient

> > versus nondeficient participants (OR 1.85; 95% CI[1.64;2.07]; P < .

> > 05). These

> > are the first population-basedstudies demonstrating an association

> > between

> > vitamin D deficiencyand anemia, particularly AI, in an older adult

> > cohort (T.

> > Perlsteinand G. Vanasse, manuscript submitted, 2010) and provide

> > compellingevidence that vitamin D deficiency may be a previously

> > unrecognizedcontributor to the development of anemia in relatively

> > healthyolder

> > individuals and is particularly prevalent among thosewith AI. The

> > potential

> > efficacy of vitamin D in amelioratinginflammatory anemia in elderly

> > patients and

> > the physiologicmechanisms by which vitamin D may abrogate anemia

> > remain tobe

> > studied. " (AI = anemia of inflammation)

> >

> > **trust me - vitamin D not effective at reducing anemia - seen a

> > number of

> > charts - 1000 IU to 4000 IU started a year ago - all still anemic if

> > not worse.

> >

> > R Vajda, R.D.

> > www.GingerJens.com

> >

> > ________________________________

> >

> > To: rd-usa

> > Sent: Mon, February 21, 2011 11:35:08 AM

> > Subject: Re: FW: Hospital chain, under scrutiny, reports

> > rare illness

> >

> > ,

> >

> > With all due respect, one should not use Today's Dietitian as the

> > place to learn the latest science. The information published there

> is

> > not peer reviewed, nor is it systematic. It's what we call a

> > " journalistic review " . That's not a bad thing, I've written for them

> > myself, it's just that you should know the difference.

> >

> > I know you like magnesium as the perpetrator for a number of health

> > conditions, based on your recent posts here. However, kwashiorkor is

> > not protein and electrolyte imbalance, at least not at the root

> cause.

> > In fact, in some research, when you give folks with (real)

> kwashiorkor

> > protein and electrolytes without considering co-morbid conditions,

> you

> > often end up increasing mortality, which we really don't want to do.

> >

> > What's going on here is much more complex; it's a mix of facilities

> > trying to pull as much medicare money their way and RDs not stepping

> > up with evidence to show what is and what is not truly a nutrition

> > problem.

> >

> > I'd urge you to search PubMed for some of the more recent papers on

> > kwashiorkor. Golden from the UK had published some that are

> > very readable. There are others in the tropical medicine journals

> that

> > also talk about some other purported etiologies for kwashiorkor.

> >

> > Regards,

> > pam

> >

> > Pam Charney, PhD, RD

> >

> > Pamela Charney and Associates, LLC

> > consultants in nutrition informatics

> > Transforming Nutrition Care With Informatics

> >

> > pcharney@...

> > http://www.linkedin.com/in/pamcharney

> >

> >

> >

> > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > electrolyte

> > > imbalance. A Today's Dietitian article a few months age directed

> me

> > > to B1 for

> > > refeeding anorexia - it worked - I was so disoriented, and my

> heart

> > > was fluttery

> > > and weird. The magazine had flipped open to that page and it was a

> > > life saver.

> > > When you are that underfed, there really is no appetite - zinc

> > > deficiency

> > > worsens appetite I believe. The magnesium deficiency adds to the

> > > edema problem

> > > that the lack of albumin causes. Loss of muscle tone, alopecia,

> and

> > > dermatologic

> > > symptoms would all relate to protein deficiency. Getting

> rehydrated

> > > was

> > > necessary before I could swallow much food. When one or two bites

> > > feels like

> > > sawdust it is easy to give up eating and not figure out how to

> start

> > > again.

> > > Rehydration requires magnesium as well as sodium and potassium.

> Many

> > > major

> > > electrolyte brands don't even have magnesium - it was regulated

> out

> > > sometime in

> > > the 20's - 30's.

> > >

> > > I think that that doctor and hospital system is recognizing the

> > > problem I've

> > > been working on - we can't heal and regenerate tissue if we don't

> > > have the

> > > nutrients. As for increased Medicare billing I hope the hospital/

> > > doctor is

> > > figuring out how to use that money to actually nourish the

> starving

> > > seniors and

> > > isn't just bonusing it out to executives.

> > >

> > > Kwashiorkor was more prevalent in starving children countries -

> > > edamatous belly

> > > - but I just saw that in my father-in-law. I couldn't find a

> formula

> > > that didn't

> > > have the high calcium level that throws off absorption. Our

> enteral

> > > feedings

> > > are not based on ratios that the chronically ill can absorb. The

> > > feeding made

> > > him worse, 40 pounds edamatous. So painfully swollen with water

> and

> > > skin

> > > integrity you could poke a fingernail through (it seemed). He is

> > > getting better

> > > finally.

> > >

> > > Providing " Health Shakes " and supplemental formulas that are

> high in

> > > calcium

> > > isn't helping. The problem is not that there is no protein in the

> > > diet or even

> > > in the body - the problem is keeping the protein in the cells and

> > > blood vessels

> > > where it can do some good. Magnesium is what is needed to prevent

> > > the leaky

> > > membranes and in the chronically ill calcium is being

> preferentially

> > > absorbed.

> > >

> > > I want to make sweet potato ginger smoothies boosted with garbanzo

> > > bean puree

> > > for everybody.

> > >

>

>>http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_mal\

nutrition.html

> >l

> > >l

> > >

> > > Protein-Calorie Malnutrition: Overview and Treatment

> > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > diseases, marasmus and kwashiorkor.

> > >

> > > Marasmus is defined simply as chronic deprivation of energy needed

> > > to maintain body weight. Its extreme form is characterized by

> severe

> > > weight loss and cachexia.1 Marasmus is further characterized by

> > > subnormal body temperature, decreased pulse and metabolic rate,

> loss

> > > of skin turgor, constipation, and starvation diarrhea,

> consisting of

> > > frequent, small, mucus-containing stools.2

> > > Kwashiorkor is a somewhat more complex disease. It is

> characterized

> > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > dermatitis.

> > >

> > > Derived from an African term meaning " the disease that occurs when

> > > the next baby is born " , kwashiorkor was initially thought to

> result

> > > from a diet high in calories (mainly carbohydrates, such as

> maize),

> > > yet deficient in protein. However, infection, aflatoxin poisoning,

> > > and oxidative stress may also play causative roles.1,3 Edema, a

> > > defining

> > > characteristic of kwashiorkor, resolves with treatment, despite

> > > continuing hypoalbuminemia, suggesting that the edema is due to

> > > leaky cell membranes, low capillary filtration rates, high

> > > concentrations of free iron, and free radicals that increase

> > capillary

> > > permeability.4 Kwashiorkor is further distinguished from

> marasmus by

> > > the following findings:

> > > * Massive edema of the hands and feet.

> > > * Profound irritability.

> > > * Anorexia.

> > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > * Alopecia or hair discoloration.

> > > * Fatty liver.

> > > * Loss of muscle tone.

> > > * Anemia and low blood concentrations of albumin, glucose,

> > potassium,

> > > and magnesium.5,6

> > > Kwashiorkor may also involve severe, life-threatening

> > hypophosphatemia

> > > (<1.0 mg/dL), which has been found to triple the mortality rate

> when

> > > compared with children who have normal phosphorus levels.7

> > > Treatment

> > > Individuals treated for protein-energy malnutrition are at risk

> for

> > > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > > hypomagnesemia may lead to disturbances in the cardiac,

> neurologic,

> > > gastrointestinal, respiratory, hematologic, skeletal, and

> endocrine

> > > systems. Guidelines have been developed to help prevent these

> > > complications

> > > and to establish a transition to normalcy. Treatment consists of 2

> > > phases: stabilization and rehabilitation.

> > >

> > > The initial (stabilization) phase proceeds from days 1 through

> 7. It

> > > consists of treatment and prevention of hypoglycemia, hypothermia,

> > > dehydration, and infection; correction of electrolyte imbalance

> and

> > > micronutrient deficiencies; and a cautious feeding regimen.

> > >

> > > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > >

> > > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > > Diseases

> > > (Eighth Edition)

> > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > > are common in

> > > underdeveloped countries and in areas in which dietary amino acid

> > > content is

> > > insufficient to satisfy growth requirements. Kwashiorkor typically

> > > occurs at

> > > about age 1, after infants are weaned from breast milk to a

> protein-

> > > deficient

> > > diet of starchy gruels or sugar water, but it can develop at any

> > > time during

> > > the formative years. Marasmus affects infants ages 6 to 18

> months as

> > > a result

> > > of breast-feeding failure, or a debilitating condition such as

> > chronic

> > > diarrhea.

> > >

> > > In industrialized countries, PCM may occur secondary to chronic

> > > metabolic

> > > disease that decreases protein and calorie intake or absorption,

> or

> > > trauma that

> > > increases protein and calorie requirements. In the United States,

> > > PCM is

> > > estimated to occur to some extent in 50% of elderly people in

> > > nursing homes.

> > > Those who aren’t allowed anything by mouth for an extended peri

> od

> > > are at high

> > > risk of developing PCM. Conditions that increase protein-calorie

> > > requirements

> > > include severe burns and injuries, systemic infections, and cancer

> > > (accounts

> > > for the largest group of hospitalized patients with PCM).

> Conditions

> > > that cause

> > > defective utilization of nutrients include malabsorption syndrome,

> > > short-bowel syndrome, and Crohn’s disease.

> > >

> > > Read more at

> > >

> >

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > >

> > > Signs and symptoms

> > > Children with chronic PCM are small for their chronological age

> and

> > > tend to be

> > > physically inactive, mentally apathetic, and susceptible to

> frequent

> > > infections. Anorexia and diarrhea are common.

> > >

> > > In acute PCM, children are small, gaunt, and emaciated, with no

> > > adipose tissue.

> > > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > > reddish-yellow.

> > > Temperature is low; pulse rate and respirations are slowed. Such

> > > children are

> > > weak, irritable, and usually hungry, although they may have

> > > anorexia, with

> > > nausea and vomiting.

> > >

> > > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > > height, but

> > > adipose tissue diminishes as fat metabolizes to meet energy

> demands.

> > > Edema

> > > often masks severe muscle wasting; dry, peeling skin and

> > > hepatomegaly are

> > > common. Patients with secondary PCM show signs similar to

> marasmus,

> > > primarily

> > > loss of adipose tissue and lean body mass, lethargy, and edema.

> > Severe

> > > secondary PCM may cause loss of immunocompetence.

> > >

> > > Diagnosis

> > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > anthropometry

> > > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > > weight change

> > > over time is the best index of nutritional status.

> > >

> > > The following factors support the diagnosis:

> > > â‘ height and weight less than 80% of standard for the patient

> ’s

> > > age and sex,

> > > and below-normal arm circumference and triceps skinfold

> > >

> > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/d

> l)

> > > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > > status by

> > > relating creatinine excretion to height and ideal body weight, to

> > > yield

> > > creatinine-height index.

> > >

> > > R Vajda, R.D.

> > > www.GingerJens.com

> > >

> > > ________________________________

> > >

> > > To: rd-usa ; dhcc@...

> > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > Subject: FW: Hospital chain, under scrutiny, reports rare

> > > illness |

> > > Local News | PE.com | Southern California News | News for Inland

> > > Southern

> > > California

> > >

> > > This is a very interesting article. Aside from the fact that our

> tax

> > > $$ are

> > > now going to our neighbor to the North, what is the accurate

> > > definition of

> > > Kwashiorkor IYO? And how is it diagnosed?

> > >

> > > Digna

> > >

> > > Hospital chain, under scrutiny, reports rare illness |

> > > Local News |

> > > PE.com | Southern California News | News for Inland Southern

> > > California

> > >

> > >

http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > tml

> > >

> > >

[Guest guest]

Oh! I am glad to see the doctors and the hospital coding and Dx for

malnutrition! And I hope they had a good Nutrition Support Team with a RD

that documented the need and MNT given!

On Mon, Feb 21, 2011 at 9:52 PM, Weaver wrote:

> Thanks, ! Like I said before, most illness goes back to the fact

> that nutrients are not being absorbed or utilized which slowly weakens the

> body causing the person's condition to get worse. I do believe that medical

> nutrition is one of the most important screening and treatment options that

> should occur in most patients.

>

> Sent from my iPhone

>

> On Feb 21, 2011, at 8:59 PM, Vajda

> wrote:

>

>

>

> Hello again,

>

> I did a little more homework, good sources give better results - cool - and

>

> found out that bugs are good for preventing kwashiorkor. The chitin is a

> good

> source of glucosamine which is missing from the intestinal lining - the

> research

> team is suggesting that there is a missing enzyme or prior infection in the

>

> subpopulation that get kwashiorkor. It was the same diet, same type of kids

> in

> general but all the ones with kwashiorkor have leakier membranes, worse

> intestinal lining.

>

> We need a different word than refeeding or PCM - it isn't calorie

> malnutrition

> in the case of the chronically ill. It is malabsorption and lack of

> retention.

> Aldosterone is messed up in the kids with kwashiorkor as well so they

> retain

> salt.

>

> " However, using 2 well-characterized stains specific for

> glycan carbohydrates (15) and sulfates (14, 15), we identified a similar

> pattern of reduced sulfated GAG expression throughout the small intestinal

> mucosa. Children with marasmus and persistent diarrhea

> generally showed HSPG expression similar to that of normal European

> children.

> Thus, it is unlikely that nutritional deficiencies causing

> wasting and stunting per se induce this loss. Because sulfated GAGs are now

>

> identified as critical in many aspects of physiology (24), their disruption

> may

> play a role in the signs and pathophysiology of kwashiorkor.

>

> HSPG loss promotes albumin leakage and reduced tissue turgor (9, 14–18, 24,

> 25).

> Although urinary protein loss is rare in kwashiorkor (9), PLE has been

> reported

> and may precipitate disease (26, 27). Although we found normal HSPG in

> marasmic

> kwashiorkor, IEL density was high, which indicated a likely recent

> infection.

> We previously showed that reglycosylation capacity limits PLE after HSPG

> loss

> (16–18) and suggests that these previously marasmic children may have

> suffered

> an acute episode of PLE on infection but were then able to

> reglycosylate to restore the epithelial barrier.

>

> HSPG deficiency is consistent with known associations of kwashiorkor. Its

> frequent onset after displacement from the breast may

> relate to both infections and substrate deficiency, because breast milk is

> rich

> in N-acetyl glucosamine (GlcNAc) and sulfur-containing amino acids (28). It

> is

> intriguing that consumption of insects, high in chitin GlcNAc, appears to

> protect infants against kwashiorkor, which suggests the

> ironic possibility that Western missionaries may have increased the

> incidence

> of kwashiorkor in the early 20th century because of their

> campaign against entomophagy (29). "

> from:

> <http://www.ajcn.org/content/89/2/592.long>

> http://www.ajcn.org/content/89/2/592.long

> Reduced production of sulfated glycosaminoglycans occurs in Zambian

> children

> with kwashiorkor but not marasmus

> also good -

> <http://www.icmr.nic.in/ijmr/2009/November/1128.pdf>

> http://www.icmr.nic.in/ijmr/2009/November/1128.pdf Oedematous malnutrition

>

> We'll need to look up those insect chefs that found or take a

> glucosamine

> supplement. Or a good rich bone marrow soup stock for clear liquid diets.

> Fresh

> kind that will gel when it chills.

>

> " Magnesium Food Group " , beans, nuts, seeds, greens, etc all have the

> advantage

> of providing many nutrients so I'm recommending a boost of B's and C and E

> and

> other antioxidants and zinc and other trace minerals and the super sugars /

>

> fibers. We need eight, some of us convert between the forms better than

> other

> people. We all get plenty of glucose and galactose but we also need

> mannose,

> fucose, xylose, N-acetylglucosamine, N-acetylgalactosamine, and

> N-acetylneuraminic acid. Mushrooms are a good source, aloe vera, echinacea,

>

> fenugreek, slippery elm powder, apple, pears . . .

>

> What do horseradish, sweet potatoes and insects have in common? Good

> building

> blocks.

> The cynical side of me believes the Medicare system is being scammed but

> the

> idealistic part of me is glad to have any doctor labeling malnutrition by a

>

> malnutriton label insead of " _____, of unknown origin " .

>

> good night, hope no bed bugs are biting.

>

> Vajda, RD.

> www.GingerJens.com - glycocalcyx - our jelly lining

>

> ________________________________

>

> To: " <rd-usa%40yahoogroups.com>rd-usa "

<<rd-usa%40yahoogroups.com>

> rd-usa >

> Sent: Mon, February 21, 2011 3:59:51 PM

> Subject: Re: FW: Hospital chain, under scrutiny, reports rare

> illness

>

> This hospital chain's reporting controversy may be just the catalyst

> for the need for medical nutrition by RDs! Thank you, for

> your information!

>

> Sent from my iPhone

>

> On Feb 21, 2011, at 1:33 PM, Vajda < <jennyvajda%40sbcglobal.net>

> jennyvajda@...>

> wrote:

>

> > Thanks for your comments Pam,

> >

> > I'll continue to look into kwashiokor, but edematous PCM doesn't

> > need to be

> > tropical or infantile. Dietitians do need to step up with evidence

> > regarding

> > what is and is not a nutritional problem.

> >

> > The reason I mentioned the B1 is more to point out that malnutrition

> > is due to a

> > variety of things (and that day the magazine seemed like a house

> > call by a

> > friendly dietitian). Refeeding can make things worse - more sick to

> > the stomach.

> >

> > If giving 'protein and electrolytes' often increases mortality, then

> > I wonder

> > what balance of electrolytes were given and how. Magnesium isn't

> > even in the

> > IOM's " water and electrolytes " report. Just potassium and sodium.

> >

> > I hope the doctor and hosptial chain aren't just billing more and

> > doing the

> > standard care of practice. Edematous PCM is occurring in our

> > hospitals and

> > nursing homes. I don't know the billing, coding permutations. $2700

> > extra

> > dollars for a Dx does seem ridiculous (50% more than $5300).

> >

> > Nephrologists seem to know the most about hydration. I had already

> > been doing a

> > variety of reading on this.

> >

> >

> <http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstract>

> http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstract

> > Effect

> > of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting i

> > n End-Stage

> > Renal Disease, Nazanin Noori1, D. Kopple1,2Article first

> > published online:

> > 13 APR 2010DOI: 10.1111/j.1525-139X.2010.00705.x

> >

> > <http://www.ncbi.nlm.nih.gov/pubmed/19121473>

> http://www.ncbi.nlm.nih.gov/pubmed/19121473 Semin Nephrol. 2009

> > Jan;29(1):39-49.Causes and prevention of protein-energy wasting in

> > chronic

> > kidney failure.Dukkipati R, Kopple JD.

> > Division of Nephrology and Hypertension, Los Angeles Biomedical

> > Research

> > Institute at Harbor-UCLA Medical Center, Torrance, CA 90509, USA.

> > <http://www.ncbi.nlm.nih.gov/pubmed/19121477>

> http://www.ncbi.nlm.nih.gov/pubmed/19121477

> > Semin Nephrol. 2009 Jan;29(1):75-84.Nutrition support for the

> > chronically wasted

> > or acutely catabolic chronic kidney disease patient.Ikizler

> > TA.Department of

> > Medicine, Division of Nephrology, Vanderbilt University School of

> > Medicine,

> > Nashville, TN 37232-2372, USA. <alp.ikizler%40vanderbilt.edu>

> alp.ikizler@...

> >

> > <http://www.ncbi.nlm.nih.gov/pubmed/16129200>

> http://www.ncbi.nlm.nih.gov/pubmed/16129200

> > Am J Kidney Dis. 2005 Sep;46(3):387-405.Multinutrient oral

> > supplements and tube

> > feeding in maintenance dialysis: a systematic review and meta-

> > analysis.Stratton

> > RJ, Bircher G, Fouque D, Stenvinkel P, de Mutsert R, Engfer M, Elia

> > M.Institute

> > of Human Nutrition, University of Southampton, UK.

> <r.j.stratton%40soton.ac.uk>r.j.stratton@...

> >

> > <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed>

> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed

> >

> > New Insights into the Role of Anabolic Interventions in Dialysis

> > Patients with

> > Protein Energy Wasting

> > Jie Dong and T. Alp Ikizler1 Curr Opin Nephrol Hypertens. Curr Opin

> > Nephrol

> > Hypertens. 2009 November; 18(6): 469–475.doi: 10.1097/MNH.0b013e3283

> > 31489d.

> > " Economic Implications of Nutritional interventions

> > It is also important to assess the impact of nutritional supplements

> > not only

> > in terms of changes in nutritional parameters, but to extrapolate

> > these

> > observations to potential improvements in hospitalization,

> > mortality, and

> > cost-effectiveness. In a recent study, Lacson et al showed that a

> > hypothetical

> > increase in serum albumin concentration in the order of 2 g/L in 50%

> > of the

> > United States dialysis population would be associated with

> > projections of

> > approximately 1400 lives saved, approximately 6000 hospitalizations

> > averted,

> > and approximately $36 million in Medicare cost savings resulting

> > from a

> > reduction of approximately 20,000 hospital days over one year[68].

> > This is a

> > reasonable estimation since 2 g/L increase in serum albumin is the

> > average

> > improvement reported in most nutritional intervention studies. "

> >

> > ***The above paper is suggesting that giving them growth hormones

> > and other

> > anabolic steroids along with protein will help them to stop

> > catabolizing. They

> > have had success with the strategy, but wouldn't magnesium plus

> > protein be

> > cheaper than hormones and protein. One chart that I reviewed was for

> > an anemic

> > woman who is getting erthropoetin hormone injections and CBC blood

> > draws

> > biweekly to monthly. Her hemoglobin goes up temporarily and then

> > falls again and

> > they repeat the expense and needle sticks. If she was nourished,

> > then her bone

> > marrow might want to make blood cells spontaneously instead of by

> > force. The

> > irony is that her body is being forced to produce a few extra blood

> > cells and

> > then we take them out with a blood draw - net result - wasted money

> > and further

> > depletion of her poor body stores.

> >

> > The seniors and other catabolic patients aren't going to heal

> > quickly if we

> > can't get their bodies to retain nutrients in their cells.

> >

> > So lesson for me to take home if I want magnesium to get a fair

> > hearing

> > eventually - get all odd references out of my bibliography and

> > mainly use the

> > Pubmed type - Correct Pam?

> >

> >

> >

> >

> <http://asheducationbook.hematologylibrary.org/cgi/content/full/2010/1/271>

> http://asheducationbook.hematologylibrary.org/cgi/content/full/2010/1/271

> > Marrow

> > Responses to Aging and Inflammation,Anemia in Elderly Patients: An

> > Emerging

> > Problem for the 21st Century, J. Vanasse1,2 and Berliner2

> > " It is

> > estimated that more than 3 million Americans aged 65 yearsand older

> > are anemic.

> > Of the anemic patients, one-third wereidentified to have nutritional

> > deficiency,

> > one-third were diagnosedon the basis of iron studies to have anemia of

> > inflammation,and one-third were diagnosed with " unexplained " anemia.3A

> > wideethnic disparity was also noted, with non-Hispanic blacks

> > havinga rate of

> > anemia that was three times that of non-Hispanic whites;a finding

> > that is

> > consistent with the results seen in otherstudies.4,5 " " Anemia and

> > inflammation

> > are strongly associated with, and maycontribute to, the development of

> > " frailty, " a poorly definedsyndrome of the elderly population

> > associated with

> > weight loss,impaired mobility, generalized weakness, and poor

> > balance.24Some

> > studies have suggested that elevated proinflammatory markersare

> > associated with

> > development of frailty.24 Furthermore, anemiais associated with an

> > increase in

> > nearly all markers of frailtyin elderly populations, suggesting that

> > there may

> > be a linkbetween the pathogenesis of the two syndromes.25 "

> >

> > " Anemia of inflammation (AI) has historically been termed the " anemia

> > of chronic

> > disease " and is most commonly seen in associationwith infection,

> > rheumatologic

> > disorders, malignancy, and otherchronic illnesses. On a biochemical

> > level, it is

> > classicallycharacterized by low serum iron and low iron binding

> > capacityin the

> > setting of an elevated serum ferritin. Although the etiologyof

> > classical AI has

> > been attributed to decreased red cell survival,disordered iron-limited

> > erythropoiesis, and progressive EPOresistance of erythroid

> > progenitors, the

> > relative role and interplayof these three mechanisms in the

> > development of

> > anemia remainunknown, as are the potential common pathways that may

> > linkthem. "

> >

> > " In phases 1 and2 of NHANES III, we examined the association between

> > anemiaand

> > vitamin D levels in men and women older than age 60 years(n = 5100)

> > and found

> > that vitamin D deficiency was associatedwith anemia independent of

> > age, sex,

> > race/ethnicity, with theodds for anemia being increased

> > approximately 60% in the

> > presenceof vitamin D deficiency (odds ratio [OR] 1.6; 95% CI

> > [1.37;1.95];P <

> > .05). Using phase 2 data, we next examined the prevalenceof vitamin

> > D deficiency

> > in anemia subtypes in men and womenolder than age 60 years (n =

> > 2657) and found

> > that, among thosewith anemia, vitamin D deficiency was most

> > prevalent among

> > thosewith AI. The risk of AI was significantly increased in vitaminD-

> > deficient

> > versus nondeficient participants (OR 1.85; 95% CI[1.64;2.07]; P < .

> > 05). These

> > are the first population-basedstudies demonstrating an association

> > between

> > vitamin D deficiencyand anemia, particularly AI, in an older adult

> > cohort (T.

> > Perlsteinand G. Vanasse, manuscript submitted, 2010) and provide

> > compellingevidence that vitamin D deficiency may be a previously

> > unrecognizedcontributor to the development of anemia in relatively

> > healthyolder

> > individuals and is particularly prevalent among thosewith AI. The

> > potential

> > efficacy of vitamin D in amelioratinginflammatory anemia in elderly

> > patients and

> > the physiologicmechanisms by which vitamin D may abrogate anemia

> > remain tobe

> > studied. " (AI = anemia of inflammation)

> >

> > **trust me - vitamin D not effective at reducing anemia - seen a

> > number of

> > charts - 1000 IU to 4000 IU started a year ago - all still anemic if

> > not worse.

> >

> > R Vajda, R.D.

> > <http://www.GingerJens.com>www.GingerJens.com

> >

> > ________________________________

> >

> > To: <rd-usa%40yahoogroups.com>rd-usa

> > Sent: Mon, February 21, 2011 11:35:08 AM

> > Subject: Re: FW: Hospital chain, under scrutiny, reports

> > rare illness

> >

> > ,

> >

> > With all due respect, one should not use Today's Dietitian as the

> > place to learn the latest science. The information published there is

> > not peer reviewed, nor is it systematic. It's what we call a

> > " journalistic review " . That's not a bad thing, I've written for them

> > myself, it's just that you should know the difference.

> >

> > I know you like magnesium as the perpetrator for a number of health

> > conditions, based on your recent posts here. However, kwashiorkor is

> > not protein and electrolyte imbalance, at least not at the root cause.

> > In fact, in some research, when you give folks with (real) kwashiorkor

> > protein and electrolytes without considering co-morbid conditions, you

> > often end up increasing mortality, which we really don't want to do.

> >

> > What's going on here is much more complex; it's a mix of facilities

> > trying to pull as much medicare money their way and RDs not stepping

> > up with evidence to show what is and what is not truly a nutrition

> > problem.

> >

> > I'd urge you to search PubMed for some of the more recent papers on

> > kwashiorkor. Golden from the UK had published some that are

> > very readable. There are others in the tropical medicine journals that

> > also talk about some other purported etiologies for kwashiorkor.

> >

> > Regards,

> > pam

> >

> > Pam Charney, PhD, RD

> >

> > Pamela Charney and Associates, LLC

> > consultants in nutrition informatics

> > Transforming Nutrition Care With Informatics

> >

> > <pcharney%40mac.com>pcharney@...

> > <http://www.linkedin.com/in/pamcharney>

> http://www.linkedin.com/in/pamcharney

> >

> >

> >

> > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > electrolyte

> > > imbalance. A Today's Dietitian article a few months age directed me

> > > to B1 for

> > > refeeding anorexia - it worked - I was so disoriented, and my heart

> > > was fluttery

> > > and weird. The magazine had flipped open to that page and it was a

> > > life saver.

> > > When you are that underfed, there really is no appetite - zinc

> > > deficiency

> > > worsens appetite I believe. The magnesium deficiency adds to the

> > > edema problem

> > > that the lack of albumin causes. Loss of muscle tone, alopecia, and

> > > dermatologic

> > > symptoms would all relate to protein deficiency. Getting rehydrated

> > > was

> > > necessary before I could swallow much food. When one or two bites

> > > feels like

> > > sawdust it is easy to give up eating and not figure out how to start

> > > again.

> > > Rehydration requires magnesium as well as sodium and potassium. Many

> > > major

> > > electrolyte brands don't even have magnesium - it was regulated out

> > > sometime in

> > > the 20's - 30's.

> > >

> > > I think that that doctor and hospital system is recognizing the

> > > problem I've

> > > been working on - we can't heal and regenerate tissue if we don't

> > > have the

> > > nutrients. As for increased Medicare billing I hope the hospital/

> > > doctor is

> > > figuring out how to use that money to actually nourish the starving

> > > seniors and

> > > isn't just bonusing it out to executives.

> > >

> > > Kwashiorkor was more prevalent in starving children countries -

> > > edamatous belly

> > > - but I just saw that in my father-in-law. I couldn't find a formula

> > > that didn't

> > > have the high calcium level that throws off absorption. Our enteral

> > > feedings

> > > are not based on ratios that the chronically ill can absorb. The

> > > feeding made

> > > him worse, 40 pounds edamatous. So painfully swollen with water and

> > > skin

> > > integrity you could poke a fingernail through (it seemed). He is

> > > getting better

> > > finally.

> > >

> > > Providing " Health Shakes " and supplemental formulas that are high in

> > > calcium

> > > isn't helping. The problem is not that there is no protein in the

> > > diet or even

> > > in the body - the problem is keeping the protein in the cells and

> > > blood vessels

> > > where it can do some good. Magnesium is what is needed to prevent

> > > the leaky

> > > membranes and in the chronically ill calcium is being preferentially

> > > absorbed.

> > >

> > > I want to make sweet potato ginger smoothies boosted with garbanzo

> > > bean puree

> > > for everybody.

> > >

>

>><http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_ma\

lnutrition.html>

>

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> >l

> > >l

> > >

> > > Protein-Calorie Malnutrition: Overview and Treatment

> > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > diseases, marasmus and kwashiorkor.

> > >

> > > Marasmus is defined simply as chronic deprivation of energy needed

> > > to maintain body weight. Its extreme form is characterized by severe

> > > weight loss and cachexia.1 Marasmus is further characterized by

> > > subnormal body temperature, decreased pulse and metabolic rate, loss

> > > of skin turgor, constipation, and starvation diarrhea, consisting of

> > > frequent, small, mucus-containing stools.2

> > > Kwashiorkor is a somewhat more complex disease. It is characterized

> > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > dermatitis.

> > >

> > > Derived from an African term meaning " the disease that occurs when

> > > the next baby is born " , kwashiorkor was initially thought to result

> > > from a diet high in calories (mainly carbohydrates, such as maize),

> > > yet deficient in protein. However, infection, aflatoxin poisoning,

> > > and oxidative stress may also play causative roles.1,3 Edema, a

> > > defining

> > > characteristic of kwashiorkor, resolves with treatment, despite

> > > continuing hypoalbuminemia, suggesting that the edema is due to

> > > leaky cell membranes, low capillary filtration rates, high

> > > concentrations of free iron, and free radicals that increase

> > capillary

> > > permeability.4 Kwashiorkor is further distinguished from marasmus by

> > > the following findings:

> > > * Massive edema of the hands and feet.

> > > * Profound irritability.

> > > * Anorexia.

> > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > * Alopecia or hair discoloration.

> > > * Fatty liver.

> > > * Loss of muscle tone.

> > > * Anemia and low blood concentrations of albumin, glucose,

> > potassium,

> > > and magnesium.5,6

> > > Kwashiorkor may also involve severe, life-threatening

> > hypophosphatemia

> > > (<1.0 mg/dL), which has been found to triple the mortality rate when

> > > compared with children who have normal phosphorus levels.7

> > > Treatment

> > > Individuals treated for protein-energy malnutrition are at risk for

> > > refeeding syndrome, in which hypophosphatemia, hypokalemia, and

> > > hypomagnesemia may lead to disturbances in the cardiac, neurologic,

> > > gastrointestinal, respiratory, hematologic, skeletal, and endocrine

> > > systems. Guidelines have been developed to help prevent these

> > > complications

> > > and to establish a transition to normalcy. Treatment consists of 2

> > > phases: stabilization and rehabilitation.

> > >

> > > The initial (stabilization) phase proceeds from days 1 through 7. It

> > > consists of treatment and prevention of hypoglycemia, hypothermia,

> > > dehydration, and infection; correction of electrolyte imbalance and

> > > micronutrient deficiencies; and a cautious feeding regimen.

> > >

> > > <http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm>

> http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > >

> > > Protein-calorie malnutrition: Excerpt from Professional Guide to

> > > Diseases

> > > (Eighth Edition)

> > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous PCM)

> > > are common in

> > > underdeveloped countries and in areas in which dietary amino acid

> > > content is

> > > insufficient to satisfy growth requirements. Kwashiorkor typically

> > > occurs at

> > > about age 1, after infants are weaned from breast milk to a protein-

> > > deficient

> > > diet of starchy gruels or sugar water, but it can develop at any

> > > time during

> > > the formative years. Marasmus affects infants ages 6 to 18 months as

> > > a result

> > > of breast-feeding failure, or a debilitating condition such as

> > chronic

> > > diarrhea.

> > >

> > > In industrialized countries, PCM may occur secondary to chronic

> > > metabolic

> > > disease that decreases protein and calorie intake or absorption, or

> > > trauma that

> > > increases protein and calorie requirements. In the United States,

> > > PCM is

> > > estimated to occur to some extent in 50% of elderly people in

> > > nursing homes.

> > > Those who aren’t allowed anything by mouth for an extended period

> > > are at high

> > > risk of developing PCM. Conditions that increase protein-calorie

> > > requirements

> > > include severe burns and injuries, systemic infections, and cancer

> > > (accounts

> > > for the largest group of hospitalized patients with PCM). Conditions

> > > that cause

> > > defective utilization of nutrients include malabsorption syndrome,

> > > short-bowel syndrome, and Crohn’s disease.

> > >

> > > Read more at

> > >

> >

>

<http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink\

>

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > >

> > > Signs and symptoms

> > > Children with chronic PCM are small for their chronological age and

> > > tend to be

> > > physically inactive, mentally apathetic, and susceptible to frequent

> > > infections. Anorexia and diarrhea are common.

> > >

> > > In acute PCM, children are small, gaunt, and emaciated, with no

> > > adipose tissue.

> > > Skin is dry and “baggy,†and hair is sparse and dull brown or

> > > reddish-yellow.

> > > Temperature is low; pulse rate and respirations are slowed. Such

> > > children are

> > > weak, irritable, and usually hungry, although they may have

> > > anorexia, with

> > > nausea and vomiting.

> > >

> > > Unlike marasmus, chronic kwashiorkor allows the patient to grow in

> > > height, but

> > > adipose tissue diminishes as fat metabolizes to meet energy demands.

> > > Edema

> > > often masks severe muscle wasting; dry, peeling skin and

> > > hepatomegaly are

> > > common. Patients with secondary PCM show signs similar to marasmus,

> > > primarily

> > > loss of adipose tissue and lean body mass, lethargy, and edema.

> > Severe

> > > secondary PCM may cause loss of immunocompetence.

> > >

> > > Diagnosis

> > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > anthropometry

> > > confirm PCM. If the patient doesn’t suffer from fluid retention,

> > > weight change

> > > over time is the best index of nutritional status.

> > >

> > > The following factors support the diagnosis:

> > > ①height and weight less than 80% of standard for the patient’s

> > > age and sex,

> > > and below-normal arm circumference and triceps skinfold

> > >

> > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)

> > > â‘ urinary creatinine (24-hour) level used to show lean body mass

> > > status by

> > > relating creatinine excretion to height and ideal body weight, to

> > > yield

> > > creatinine-height index.

> > >

> > > R Vajda, R.D.

> > > <http://www.GingerJens.com>www.GingerJens.com

> > >

> > > ________________________________

> > > From: Digna Cassens < <dignacassens%40roadrunner.com>

> dignacassens@...>

> > > To: <rd-usa%40yahoogroups.com>rd-usa ;

> <dhcc%40mail-list.com>dhcc@...

> > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > Subject: FW: Hospital chain, under scrutiny, reports rare

> > > illness |

> > > Local News | PE.com | Southern California News | News for Inland

> > > Southern

> > > California

> > >

> > > This is a very interesting article. Aside from the fact that our tax

> > > $$ are

> > > now going to our neighbor to the North, what is the accurate

> > > definition of

> > > Kwashiorkor IYO? And how is it diagnosed?

> > >

> > > Digna

> > >

> > > Hospital chain, under scrutiny, reports rare illness |

> > > Local News |

> > > PE.com | Southern California News | News for Inland Southern

> > > California

> > >

> > >

> <http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h>

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > tml

> > >

> > >

[Guest guest]

How is PubMed influenced by money and politics? PubMed is simply a

database consisting of papers from biomedical journals. At this time,

there are something like 4800 journals publishing; I forget how many

are indexed in PubMed. There are criteria that must be met for a

journal to be indexed in PubMed. I think you confuse the research and

researchers themselves with the database in which papers are indexed.

PubMed is not the only database that can be used to search the

literature, as I'm sure you're aware. There's CINAHL, ERIC, OVID, and

many others. The NLM makes their databases available at no cost. If

you go to the gateway, you can also find access to the gene database,

protein sequencing (ever want to know the amino acid sequence of many

proteins? It's in there. For free), patient education materials (very

well done materials, I might add) and also free.

PubMed is a free service of the National Library of Medicine. The NLM

also makes available a repository of open access publications as well,

recognizing that not everyone has access to a medical library. PubMed

Central is growing every day, particularly since about 6 or 7 years

ago, the NIH made is mandatory for researchers who are funded by NIH

money to publish in PubMed Central (if they're research meets peer

review criteria). Many also use Google Scholar as their search engine

of choice for retrieving information in the biomedical literature.

While I use both, because I've been trained on PubMed and teach

PubMed, I'm more comfortable there.

When I teach research methods and information retrieval, we start with

the phrase " Caveat lector " or Let the reader beware. It's up to you,

the reader to make sure that what you are reading meets criteria. The

peer review process does the first step for you. I've been a reviewer

for a number of scientific journals. When asked to review a paper,

which can take many hours, we review the purpose, specific aims,

methodology, appearance of bias (commercial or simply that the author

wanted to get a certain outcome and so, got that outcome), results

reporting, and appropriateness of conclusions.

There is no way we'll ever get away with no industry funded research.

In the not so distant past, you'd see a definite publication bias in

that industry would squelch results that did not meet their commercial

aims. More recently, while they can certainly choose to not publish,

all research must be included in the clinical research database. So,

you can search to see who is doing research, what the status of the

study is, who is doing it, and if it's been published or not. At the

end of the day, it's the reader's responsibility to determine external

validity of any research you read. And no, you cannot say it's not

good research if it simply doesn't say what you want. That's called

being open-minded!

For those who are interested, I teach a graduate level course on

Nutrition Informatics every other year for UMDNJ. We cover much of

this material.

I fully agree that everyone needs access to healthcare.

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Pam, I agree with what you are saying! PubMed is the best source but

> it also had been influenced by money and politics. There has been some

> positive changes in the science publishing community and journals

> since now most disclose funding. Science is sometimes backwards or

> after the fact. The example is HIV. First it did not exist and was

> missed Dx as other diseases since 1950s or longer, then it was a

> syndrome, then a virus and then labeled HIV/AIDS. Gulf War syndrome is

> similar and when there is no money or explanation it stays a syndrome.

> These viruses and syndromes cause hypermetabolic conditions and slow

> malabsorption leading to malnutrition. Medical nutrition is an art and

> a science! Today's science, medicine, definitions and more change all

> the time! Your giving an example of it. Big business is in everything

> now, including academia! Special interests trumps what is best for the

> patient or student. Bottom line is that if Americans are not given the

> opportunity to see a RD and a MD for regular check ups and care,

> healthcare cost shall rise and rise bankrupting our country. Time

> needs to be spent on basic care. My opinion, more than 90% healthcare

> starts with medical nutrition! This message is not getting to

> Americans!

>

> Sent from my iPhone

>

>

>

> > ,

> >

> > The research is not backwards, although I'm not sure what you mean

> by

> > that. Research is what is it. I'm in complete agreement with you

> > regarding the connection between nutrition and chronic illness,

> > however, kwashiorkor is not malnutrition as we have been taught in

> the

> > past.

> >

> > When I talk about increased mortality with refeeding folks with

> > kwashiorkor, I am not talking about the " refeeding syndrome " (that

> is

> > really an iatrogenic complication, not a condition) that most of us

> > might have seen in hospitals. That " refeeding syndrome " is an acute

> > hypophosphatemia, hypokalemia, and not quite as severe

> hypomagnesemia

> > along with pulmonary and cardiac complications seen when one

> provides

> > carbohydrates in excess of capacity for cellular uptake and

> > utilization.

> >

> > Malnutrition does not equal malabsorption, nor does it equal

> > hypermetabolism. All are separate but can interact when present

> > concurrently. I think it behooves us to approach this from a

> science-

> > based perspective. The National Library of Medicine (NLM) offers the

> > free search engine, PubMed that can be used to search for literature

> > that has been peer-reviewed.

> >

> > Pam Charney, PhD, RD

> >

> > Pamela Charney and Associates, LLC

> > consultants in nutrition informatics

> > Transforming Nutrition Care With Informatics

> >

> > pcharney@...

> > http://www.linkedin.com/in/pamcharney

> >

> >

> >

> > > Pam, The research is backwards and not pure science. Like you

> > stated,

> > > it is money or politics at play here. Malnutrition is a slow

> > occuring

> > > process in which once it gets to a certain point, it starts the

> slow

> > > cycle of illness leading to chronic illness and organ failure. You

> > are

> > > right, when illness due to this malnutrition occurs, refeeding

> could

> > > be dangerous and even deadly. As with everything in life, timing

> is

> > > everything. It is really the denial of malnutrition, malabsorption

> > and

> > > hypermetabolism that is the problem!

> > >

> > > Sent from my iPhone

> > >

> > > On Feb 21, 2011, at 11:35 AM, Pam Charney

> wrote:

> > >

> > > > ,

> > > >

> > > > With all due respect, one should not use Today's Dietitian as

> the

> > > > place to learn the latest science. The information published

> there

> > > is

> > > > not peer reviewed, nor is it systematic. It's what we call a

> > > > " journalistic review " . That's not a bad thing, I've written for

> > them

> > > > myself, it's just that you should know the difference.

> > > >

> > > > I know you like magnesium as the perpetrator for a number of

> > health

> > > > conditions, based on your recent posts here. However,

> > kwashiorkor is

> > > > not protein and electrolyte imbalance, at least not at the root

> > > cause.

> > > > In fact, in some research, when you give folks with (real)

> > > kwashiorkor

> > > > protein and electrolytes without considering co-morbid

> conditions,

> > > you

> > > > often end up increasing mortality, which we really don't want to

> > do.

> > > >

> > > > What's going on here is much more complex; it's a mix of

> > facilities

> > > > trying to pull as much medicare money their way and RDs not

> > stepping

> > > > up with evidence to show what is and what is not truly a

> nutrition

> > > > problem.

> > > >

> > > > I'd urge you to search PubMed for some of the more recent papers

> > on

> > > > kwashiorkor. Golden from the UK had published some that

> > are

> > > > very readable. There are others in the tropical medicine

> journals

> > > that

> > > > also talk about some other purported etiologies for kwashiorkor.

> > > >

> > > > Regards,

> > > > pam

> > > >

> > > > Pam Charney, PhD, RD

> > > >

> > > > Pamela Charney and Associates, LLC

> > > > consultants in nutrition informatics

> > > > Transforming Nutrition Care With Informatics

> > > >

> > > > pcharney@...

> > > > http://www.linkedin.com/in/pamcharney

> > > >

> > > >

> > > >

> > > > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > > > electrolyte

> > > > > imbalance. A Today's Dietitian article a few months age

> directed

> > > me

> > > > > to B1 for

> > > > > refeeding anorexia - it worked - I was so disoriented, and my

> > > heart

> > > > > was fluttery

> > > > > and weird. The magazine had flipped open to that page and it

> > was a

> > > > > life saver.

> > > > > When you are that underfed, there really is no appetite - zinc

> > > > > deficiency

> > > > > worsens appetite I believe. The magnesium deficiency adds to

> the

> > > > > edema problem

> > > > > that the lack of albumin causes. Loss of muscle tone,

> alopecia,

> > > and

> > > > > dermatologic

> > > > > symptoms would all relate to protein deficiency. Getting

> > > rehydrated

> > > > > was

> > > > > necessary before I could swallow much food. When one or two

> > bites

> > > > > feels like

> > > > > sawdust it is easy to give up eating and not figure out how to

> > > start

> > > > > again.

> > > > > Rehydration requires magnesium as well as sodium and

> potassium.

> > > Many

> > > > > major

> > > > > electrolyte brands don't even have magnesium - it was

> regulated

> > > out

> > > > > sometime in

> > > > > the 20's - 30's.

> > > > >

> > > > > I think that that doctor and hospital system is recognizing

> the

> > > > > problem I've

> > > > > been working on - we can't heal and regenerate tissue if we

> > don't

> > > > > have the

> > > > > nutrients. As for increased Medicare billing I hope the

> > hospital/

> > > > > doctor is

> > > > > figuring out how to use that money to actually nourish the

> > > starving

> > > > > seniors and

> > > > > isn't just bonusing it out to executives.

> > > > >

> > > > > Kwashiorkor was more prevalent in starving children

> countries -

> > > > > edamatous belly

> > > > > - but I just saw that in my father-in-law. I couldn't find a

> > > formula

> > > > > that didn't

> > > > > have the high calcium level that throws off absorption. Our

> > > enteral

> > > > > feedings

> > > > > are not based on ratios that the chronically ill can absorb.

> The

> > > > > feeding made

> > > > > him worse, 40 pounds edamatous. So painfully swollen with

> water

> > > and

> > > > > skin

> > > > > integrity you could poke a fingernail through (it seemed).

> He is

> > > > > getting better

> > > > > finally.

> > > > >

> > > > > Providing " Health Shakes " and supplemental formulas that are

> > > high in

> > > > > calcium

> > > > > isn't helping. The problem is not that there is no protein in

> > the

> > > > > diet or even

> > > > > in the body - the problem is keeping the protein in the cells

> > and

> > > > > blood vessels

> > > > > where it can do some good. Magnesium is what is needed to

> > prevent

> > > > > the leaky

> > > > > membranes and in the chronically ill calcium is being

> > > preferentially

> > > > > absorbed.

> > > > >

> > > > > I want to make sweet potato ginger smoothies boosted with

> > garbanzo

> > > > > bean puree

> > > > > for everybody.

> > > > >

> > > > >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> > > > >

> > > > > Protein-Calorie Malnutrition: Overview and Treatment

> > > > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > > > diseases, marasmus and kwashiorkor.

> > > > >

> > > > > Marasmus is defined simply as chronic deprivation of energy

> > needed

> > > > > to maintain body weight. Its extreme form is characterized by

> > > severe

> > > > > weight loss and cachexia.1 Marasmus is further characterized

> by

> > > > > subnormal body temperature, decreased pulse and metabolic

> rate,

> > > loss

> > > > > of skin turgor, constipation, and starvation diarrhea,

> > > consisting of

> > > > > frequent, small, mucus-containing stools.2

> > > > > Kwashiorkor is a somewhat more complex disease. It is

> > > characterized

> > > > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > > > dermatitis.

> > > > >

> > > > > Derived from an African term meaning " the disease that occurs

> > when

> > > > > the next baby is born " , kwashiorkor was initially thought to

> > > result

> > > > > from a diet high in calories (mainly carbohydrates, such as

> > > maize),

> > > > > yet deficient in protein. However, infection, aflatoxin

> > poisoning,

> > > > > and oxidative stress may also play causative roles.1,3

> Edema, a

> > > > > defining

> > > > > characteristic of kwashiorkor, resolves with treatment,

> despite

> > > > > continuing hypoalbuminemia, suggesting that the edema is due

> to

> > > > > leaky cell membranes, low capillary filtration rates, high

> > > > > concentrations of free iron, and free radicals that increase

> > > > capillary

> > > > > permeability.4 Kwashiorkor is further distinguished from

> > > marasmus by

> > > > > the following findings:

> > > > > * Massive edema of the hands and feet.

> > > > > * Profound irritability.

> > > > > * Anorexia.

> > > > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > > > * Alopecia or hair discoloration.

> > > > > * Fatty liver.

> > > > > * Loss of muscle tone.

> > > > > * Anemia and low blood concentrations of albumin, glucose,

> > > > potassium,

> > > > > and magnesium.5,6

> > > > > Kwashiorkor may also involve severe, life-threatening

> > > > hypophosphatemia

> > > > > (<1.0 mg/dL), which has been found to triple the mortality

> rate

> > > when

> > > > > compared with children who have normal phosphorus levels.7

> > > > > Treatment

> > > > > Individuals treated for protein-energy malnutrition are at

> risk

> > > for

> > > > > refeeding syndrome, in which hypophosphatemia, hypokalemia,

> and

> > > > > hypomagnesemia may lead to disturbances in the cardiac,

> > > neurologic,

> > > > > gastrointestinal, respiratory, hematologic, skeletal, and

> > > endocrine

> > > > > systems. Guidelines have been developed to help prevent these

> > > > > complications

> > > > > and to establish a transition to normalcy. Treatment consists

> > of 2

> > > > > phases: stabilization and rehabilitation.

> > > > >

> > > > > The initial (stabilization) phase proceeds from days 1 through

> > > 7. It

> > > > > consists of treatment and prevention of hypoglycemia,

> > hypothermia,

> > > > > dehydration, and infection; correction of electrolyte

> imbalance

> > > and

> > > > > micronutrient deficiencies; and a cautious feeding regimen.

> > > > >

> > > > > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > > > >

> > > > > Protein-calorie malnutrition: Excerpt from Professional

> Guide to

> > > > > Diseases

> > > > > (Eighth Edition)

> > > > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous

> > PCM)

> > > > > are common in

> > > > > underdeveloped countries and in areas in which dietary amino

> > acid

> > > > > content is

> > > > > insufficient to satisfy growth requirements. Kwashiorkor

> > typically

> > > > > occurs at

> > > > > about age 1, after infants are weaned from breast milk to a

> > > protein-

> > > > > deficient

> > > > > diet of starchy gruels or sugar water, but it can develop at

> any

> > > > > time during

> > > > > the formative years. Marasmus affects infants ages 6 to 18

> > > months as

> > > > > a result

> > > > > of breast-feeding failure, or a debilitating condition such as

> > > > chronic

> > > > > diarrhea.

> > > > >

> > > > > In industrialized countries, PCM may occur secondary to

> chronic

> > > > > metabolic

> > > > > disease that decreases protein and calorie intake or

> absorption,

> > > or

> > > > > trauma that

> > > > > increases protein and calorie requirements. In the United

> > States,

> > > > > PCM is

> > > > > estimated to occur to some extent in 50% of elderly people in

> > > > > nursing homes.

> > > > > Those who aren’t allowed anything by mouth for an extended

> > > period

> > > > > are at high

> > > > > risk of developing PCM. Conditions that increase protein-

> calorie

> > > > > requirements

> > > > > include severe burns and injuries, systemic infections, and

> > cancer

> > > > > (accounts

> > > > > for the largest group of hospitalized patients with PCM).

> > > Conditions

> > > > > that cause

> > > > > defective utilization of nutrients include malabsorption

> > syndrome,

> > > > > short-bowel syndrome, and Crohn’s disease.

> > > > >

> > > > > Read more at

> > > > >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > > > >

> > > > > Signs and symptoms

> > > > > Children with chronic PCM are small for their chronological

> age

> > > and

> > > > > tend to be

> > > > > physically inactive, mentally apathetic, and susceptible to

> > > frequent

> > > > > infections. Anorexia and diarrhea are common.

> > > > >

> > > > > In acute PCM, children are small, gaunt, and emaciated, with

> no

> > > > > adipose tissue.

> > > > > Skin is dry and “baggy,†and hair is sparse and dull brown

> > or

> > > > > reddish-yellow.

> > > > > Temperature is low; pulse rate and respirations are slowed.

> Such

> > > > > children are

> > > > > weak, irritable, and usually hungry, although they may have

> > > > > anorexia, with

> > > > > nausea and vomiting.

> > > > >

> > > > > Unlike marasmus, chronic kwashiorkor allows the patient to

> > grow in

> > > > > height, but

> > > > > adipose tissue diminishes as fat metabolizes to meet energy

> > > demands.

> > > > > Edema

> > > > > often masks severe muscle wasting; dry, peeling skin and

> > > > > hepatomegaly are

> > > > > common. Patients with secondary PCM show signs similar to

> > > marasmus,

> > > > > primarily

> > > > > loss of adipose tissue and lean body mass, lethargy, and

> edema.

> > > > Severe

> > > > > secondary PCM may cause loss of immunocompetence.

> > > > >

> > > > > Diagnosis

> > > > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > > > anthropometry

> > > > > confirm PCM. If the patient doesn’t suffer from fluid

> retentio

> > n,

> > > > > weight change

> > > > > over time is the best index of nutritional status.

> > > > >

> > > > > The following factors support the diagnosis:

> > > > > â‘ height and weight less than 80% of standard for the

> > > patient’s

> > > > > age and sex,

> > > > > and below-normal arm circumference and triceps skinfold

> > > > >

> > > > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3

> > g/

> > > dl)

> > > > > â‘ urinary creatinine (24-hour) level used to show lean body

> ma

> > ss

> > > > > status by

> > > > > relating creatinine excretion to height and ideal body weight,

> > to

> > > > > yield

> > > > > creatinine-height index.

> > > > >

> > > > > R Vajda, R.D.

> > > > > www.GingerJens.com

> > > > >

> > > > > ________________________________

> > > > >

> > > > > To: rd-usa ; dhcc@...

> > > > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > > > Subject: FW: Hospital chain, under scrutiny, reports

> > rare

> > > > > illness |

> > > > > Local News | PE.com | Southern California News | News for

> Inland

> > > > > Southern

> > > > > California

> > > > >

> > > > > This is a very interesting article. Aside from the fact that

> our

> > > tax

> > > > > $$ are

> > > > > now going to our neighbor to the North, what is the accurate

> > > > > definition of

> > > > > Kwashiorkor IYO? And how is it diagnosed?

> > > > >

> > > > > Digna

> > > > >

> > > > > Hospital chain, under scrutiny, reports rare

> illness |

> > > > > Local News |

> > > > > PE.com | Southern California News | News for Inland Southern

> > > > > California

> > > > >

> > > > >

http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > > > tml

> > > > >

> > > > >

[Guest guest]

How is PubMed influenced by money and politics? PubMed is simply a

database consisting of papers from biomedical journals. At this time,

there are something like 4800 journals publishing; I forget how many

are indexed in PubMed. There are criteria that must be met for a

journal to be indexed in PubMed. I think you confuse the research and

researchers themselves with the database in which papers are indexed.

PubMed is not the only database that can be used to search the

literature, as I'm sure you're aware. There's CINAHL, ERIC, OVID, and

many others. The NLM makes their databases available at no cost. If

you go to the gateway, you can also find access to the gene database,

protein sequencing (ever want to know the amino acid sequence of many

proteins? It's in there. For free), patient education materials (very

well done materials, I might add) and also free.

PubMed is a free service of the National Library of Medicine. The NLM

also makes available a repository of open access publications as well,

recognizing that not everyone has access to a medical library. PubMed

Central is growing every day, particularly since about 6 or 7 years

ago, the NIH made is mandatory for researchers who are funded by NIH

money to publish in PubMed Central (if they're research meets peer

review criteria). Many also use Google Scholar as their search engine

of choice for retrieving information in the biomedical literature.

While I use both, because I've been trained on PubMed and teach

PubMed, I'm more comfortable there.

When I teach research methods and information retrieval, we start with

the phrase " Caveat lector " or Let the reader beware. It's up to you,

the reader to make sure that what you are reading meets criteria. The

peer review process does the first step for you. I've been a reviewer

for a number of scientific journals. When asked to review a paper,

which can take many hours, we review the purpose, specific aims,

methodology, appearance of bias (commercial or simply that the author

wanted to get a certain outcome and so, got that outcome), results

reporting, and appropriateness of conclusions.

There is no way we'll ever get away with no industry funded research.

In the not so distant past, you'd see a definite publication bias in

that industry would squelch results that did not meet their commercial

aims. More recently, while they can certainly choose to not publish,

all research must be included in the clinical research database. So,

you can search to see who is doing research, what the status of the

study is, who is doing it, and if it's been published or not. At the

end of the day, it's the reader's responsibility to determine external

validity of any research you read. And no, you cannot say it's not

good research if it simply doesn't say what you want. That's called

being open-minded!

For those who are interested, I teach a graduate level course on

Nutrition Informatics every other year for UMDNJ. We cover much of

this material.

I fully agree that everyone needs access to healthcare.

Pam Charney, PhD, RD

Pamela Charney and Associates, LLC

consultants in nutrition informatics

Transforming Nutrition Care With Informatics

pcharney@...

http://www.linkedin.com/in/pamcharney

> Pam, I agree with what you are saying! PubMed is the best source but

> it also had been influenced by money and politics. There has been some

> positive changes in the science publishing community and journals

> since now most disclose funding. Science is sometimes backwards or

> after the fact. The example is HIV. First it did not exist and was

> missed Dx as other diseases since 1950s or longer, then it was a

> syndrome, then a virus and then labeled HIV/AIDS. Gulf War syndrome is

> similar and when there is no money or explanation it stays a syndrome.

> These viruses and syndromes cause hypermetabolic conditions and slow

> malabsorption leading to malnutrition. Medical nutrition is an art and

> a science! Today's science, medicine, definitions and more change all

> the time! Your giving an example of it. Big business is in everything

> now, including academia! Special interests trumps what is best for the

> patient or student. Bottom line is that if Americans are not given the

> opportunity to see a RD and a MD for regular check ups and care,

> healthcare cost shall rise and rise bankrupting our country. Time

> needs to be spent on basic care. My opinion, more than 90% healthcare

> starts with medical nutrition! This message is not getting to

> Americans!

>

> Sent from my iPhone

>

>

>

> > ,

> >

> > The research is not backwards, although I'm not sure what you mean

> by

> > that. Research is what is it. I'm in complete agreement with you

> > regarding the connection between nutrition and chronic illness,

> > however, kwashiorkor is not malnutrition as we have been taught in

> the

> > past.

> >

> > When I talk about increased mortality with refeeding folks with

> > kwashiorkor, I am not talking about the " refeeding syndrome " (that

> is

> > really an iatrogenic complication, not a condition) that most of us

> > might have seen in hospitals. That " refeeding syndrome " is an acute

> > hypophosphatemia, hypokalemia, and not quite as severe

> hypomagnesemia

> > along with pulmonary and cardiac complications seen when one

> provides

> > carbohydrates in excess of capacity for cellular uptake and

> > utilization.

> >

> > Malnutrition does not equal malabsorption, nor does it equal

> > hypermetabolism. All are separate but can interact when present

> > concurrently. I think it behooves us to approach this from a

> science-

> > based perspective. The National Library of Medicine (NLM) offers the

> > free search engine, PubMed that can be used to search for literature

> > that has been peer-reviewed.

> >

> > Pam Charney, PhD, RD

> >

> > Pamela Charney and Associates, LLC

> > consultants in nutrition informatics

> > Transforming Nutrition Care With Informatics

> >

> > pcharney@...

> > http://www.linkedin.com/in/pamcharney

> >

> >

> >

> > > Pam, The research is backwards and not pure science. Like you

> > stated,

> > > it is money or politics at play here. Malnutrition is a slow

> > occuring

> > > process in which once it gets to a certain point, it starts the

> slow

> > > cycle of illness leading to chronic illness and organ failure. You

> > are

> > > right, when illness due to this malnutrition occurs, refeeding

> could

> > > be dangerous and even deadly. As with everything in life, timing

> is

> > > everything. It is really the denial of malnutrition, malabsorption

> > and

> > > hypermetabolism that is the problem!

> > >

> > > Sent from my iPhone

> > >

> > > On Feb 21, 2011, at 11:35 AM, Pam Charney

> wrote:

> > >

> > > > ,

> > > >

> > > > With all due respect, one should not use Today's Dietitian as

> the

> > > > place to learn the latest science. The information published

> there

> > > is

> > > > not peer reviewed, nor is it systematic. It's what we call a

> > > > " journalistic review " . That's not a bad thing, I've written for

> > them

> > > > myself, it's just that you should know the difference.

> > > >

> > > > I know you like magnesium as the perpetrator for a number of

> > health

> > > > conditions, based on your recent posts here. However,

> > kwashiorkor is

> > > > not protein and electrolyte imbalance, at least not at the root

> > > cause.

> > > > In fact, in some research, when you give folks with (real)

> > > kwashiorkor

> > > > protein and electrolytes without considering co-morbid

> conditions,

> > > you

> > > > often end up increasing mortality, which we really don't want to

> > do.

> > > >

> > > > What's going on here is much more complex; it's a mix of

> > facilities

> > > > trying to pull as much medicare money their way and RDs not

> > stepping

> > > > up with evidence to show what is and what is not truly a

> nutrition

> > > > problem.

> > > >

> > > > I'd urge you to search PubMed for some of the more recent papers

> > on

> > > > kwashiorkor. Golden from the UK had published some that

> > are

> > > > very readable. There are others in the tropical medicine

> journals

> > > that

> > > > also talk about some other purported etiologies for kwashiorkor.

> > > >

> > > > Regards,

> > > > pam

> > > >

> > > > Pam Charney, PhD, RD

> > > >

> > > > Pamela Charney and Associates, LLC

> > > > consultants in nutrition informatics

> > > > Transforming Nutrition Care With Informatics

> > > >

> > > > pcharney@...

> > > > http://www.linkedin.com/in/pamcharney

> > > >

> > > >

> > > >

> > > > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > > > electrolyte

> > > > > imbalance. A Today's Dietitian article a few months age

> directed

> > > me

> > > > > to B1 for

> > > > > refeeding anorexia - it worked - I was so disoriented, and my

> > > heart

> > > > > was fluttery

> > > > > and weird. The magazine had flipped open to that page and it

> > was a

> > > > > life saver.

> > > > > When you are that underfed, there really is no appetite - zinc

> > > > > deficiency

> > > > > worsens appetite I believe. The magnesium deficiency adds to

> the

> > > > > edema problem

> > > > > that the lack of albumin causes. Loss of muscle tone,

> alopecia,

> > > and

> > > > > dermatologic

> > > > > symptoms would all relate to protein deficiency. Getting

> > > rehydrated

> > > > > was

> > > > > necessary before I could swallow much food. When one or two

> > bites

> > > > > feels like

> > > > > sawdust it is easy to give up eating and not figure out how to

> > > start

> > > > > again.

> > > > > Rehydration requires magnesium as well as sodium and

> potassium.

> > > Many

> > > > > major

> > > > > electrolyte brands don't even have magnesium - it was

> regulated

> > > out

> > > > > sometime in

> > > > > the 20's - 30's.

> > > > >

> > > > > I think that that doctor and hospital system is recognizing

> the

> > > > > problem I've

> > > > > been working on - we can't heal and regenerate tissue if we

> > don't

> > > > > have the

> > > > > nutrients. As for increased Medicare billing I hope the

> > hospital/

> > > > > doctor is

> > > > > figuring out how to use that money to actually nourish the

> > > starving

> > > > > seniors and

> > > > > isn't just bonusing it out to executives.

> > > > >

> > > > > Kwashiorkor was more prevalent in starving children

> countries -

> > > > > edamatous belly

> > > > > - but I just saw that in my father-in-law. I couldn't find a

> > > formula

> > > > > that didn't

> > > > > have the high calcium level that throws off absorption. Our

> > > enteral

> > > > > feedings

> > > > > are not based on ratios that the chronically ill can absorb.

> The

> > > > > feeding made

> > > > > him worse, 40 pounds edamatous. So painfully swollen with

> water

> > > and

> > > > > skin

> > > > > integrity you could poke a fingernail through (it seemed).

> He is

> > > > > getting better

> > > > > finally.

> > > > >

> > > > > Providing " Health Shakes " and supplemental formulas that are

> > > high in

> > > > > calcium

> > > > > isn't helping. The problem is not that there is no protein in

> > the

> > > > > diet or even

> > > > > in the body - the problem is keeping the protein in the cells

> > and

> > > > > blood vessels

> > > > > where it can do some good. Magnesium is what is needed to

> > prevent

> > > > > the leaky

> > > > > membranes and in the chronically ill calcium is being

> > > preferentially

> > > > > absorbed.

> > > > >

> > > > > I want to make sweet potato ginger smoothies boosted with

> > garbanzo

> > > > > bean puree

> > > > > for everybody.

> > > > >

> > > > >

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> > > > >

> > > > > Protein-Calorie Malnutrition: Overview and Treatment

> > > > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > > > diseases, marasmus and kwashiorkor.

> > > > >

> > > > > Marasmus is defined simply as chronic deprivation of energy

> > needed

> > > > > to maintain body weight. Its extreme form is characterized by

> > > severe

> > > > > weight loss and cachexia.1 Marasmus is further characterized

> by

> > > > > subnormal body temperature, decreased pulse and metabolic

> rate,

> > > loss

> > > > > of skin turgor, constipation, and starvation diarrhea,

> > > consisting of

> > > > > frequent, small, mucus-containing stools.2

> > > > > Kwashiorkor is a somewhat more complex disease. It is

> > > characterized

> > > > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > > > dermatitis.

> > > > >

> > > > > Derived from an African term meaning " the disease that occurs

> > when

> > > > > the next baby is born " , kwashiorkor was initially thought to

> > > result

> > > > > from a diet high in calories (mainly carbohydrates, such as

> > > maize),

> > > > > yet deficient in protein. However, infection, aflatoxin

> > poisoning,

> > > > > and oxidative stress may also play causative roles.1,3

> Edema, a

> > > > > defining

> > > > > characteristic of kwashiorkor, resolves with treatment,

> despite

> > > > > continuing hypoalbuminemia, suggesting that the edema is due

> to

> > > > > leaky cell membranes, low capillary filtration rates, high

> > > > > concentrations of free iron, and free radicals that increase

> > > > capillary

> > > > > permeability.4 Kwashiorkor is further distinguished from

> > > marasmus by

> > > > > the following findings:

> > > > > * Massive edema of the hands and feet.

> > > > > * Profound irritability.

> > > > > * Anorexia.

> > > > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > > > * Alopecia or hair discoloration.

> > > > > * Fatty liver.

> > > > > * Loss of muscle tone.

> > > > > * Anemia and low blood concentrations of albumin, glucose,

> > > > potassium,

> > > > > and magnesium.5,6

> > > > > Kwashiorkor may also involve severe, life-threatening

> > > > hypophosphatemia

> > > > > (<1.0 mg/dL), which has been found to triple the mortality

> rate

> > > when

> > > > > compared with children who have normal phosphorus levels.7

> > > > > Treatment

> > > > > Individuals treated for protein-energy malnutrition are at

> risk

> > > for

> > > > > refeeding syndrome, in which hypophosphatemia, hypokalemia,

> and

> > > > > hypomagnesemia may lead to disturbances in the cardiac,

> > > neurologic,

> > > > > gastrointestinal, respiratory, hematologic, skeletal, and

> > > endocrine

> > > > > systems. Guidelines have been developed to help prevent these

> > > > > complications

> > > > > and to establish a transition to normalcy. Treatment consists

> > of 2

> > > > > phases: stabilization and rehabilitation.

> > > > >

> > > > > The initial (stabilization) phase proceeds from days 1 through

> > > 7. It

> > > > > consists of treatment and prevention of hypoglycemia,

> > hypothermia,

> > > > > dehydration, and infection; correction of electrolyte

> imbalance

> > > and

> > > > > micronutrient deficiencies; and a cautious feeding regimen.

> > > > >

> > > > > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > > > >

> > > > > Protein-calorie malnutrition: Excerpt from Professional

> Guide to

> > > > > Diseases

> > > > > (Eighth Edition)

> > > > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous

> > PCM)

> > > > > are common in

> > > > > underdeveloped countries and in areas in which dietary amino

> > acid

> > > > > content is

> > > > > insufficient to satisfy growth requirements. Kwashiorkor

> > typically

> > > > > occurs at

> > > > > about age 1, after infants are weaned from breast milk to a

> > > protein-

> > > > > deficient

> > > > > diet of starchy gruels or sugar water, but it can develop at

> any

> > > > > time during

> > > > > the formative years. Marasmus affects infants ages 6 to 18

> > > months as

> > > > > a result

> > > > > of breast-feeding failure, or a debilitating condition such as

> > > > chronic

> > > > > diarrhea.

> > > > >

> > > > > In industrialized countries, PCM may occur secondary to

> chronic

> > > > > metabolic

> > > > > disease that decreases protein and calorie intake or

> absorption,

> > > or

> > > > > trauma that

> > > > > increases protein and calorie requirements. In the United

> > States,

> > > > > PCM is

> > > > > estimated to occur to some extent in 50% of elderly people in

> > > > > nursing homes.

> > > > > Those who aren’t allowed anything by mouth for an extended

> > > period

> > > > > are at high

> > > > > risk of developing PCM. Conditions that increase protein-

> calorie

> > > > > requirements

> > > > > include severe burns and injuries, systemic infections, and

> > cancer

> > > > > (accounts

> > > > > for the largest group of hospitalized patients with PCM).

> > > Conditions

> > > > > that cause

> > > > > defective utilization of nutrients include malabsorption

> > syndrome,

> > > > > short-bowel syndrome, and Crohn’s disease.

> > > > >

> > > > > Read more at

> > > > >

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > > > >

> > > > > Signs and symptoms

> > > > > Children with chronic PCM are small for their chronological

> age

> > > and

> > > > > tend to be

> > > > > physically inactive, mentally apathetic, and susceptible to

> > > frequent

> > > > > infections. Anorexia and diarrhea are common.

> > > > >

> > > > > In acute PCM, children are small, gaunt, and emaciated, with

> no

> > > > > adipose tissue.

> > > > > Skin is dry and “baggy,†and hair is sparse and dull brown

> > or

> > > > > reddish-yellow.

> > > > > Temperature is low; pulse rate and respirations are slowed.

> Such

> > > > > children are

> > > > > weak, irritable, and usually hungry, although they may have

> > > > > anorexia, with

> > > > > nausea and vomiting.

> > > > >

> > > > > Unlike marasmus, chronic kwashiorkor allows the patient to

> > grow in

> > > > > height, but

> > > > > adipose tissue diminishes as fat metabolizes to meet energy

> > > demands.

> > > > > Edema

> > > > > often masks severe muscle wasting; dry, peeling skin and

> > > > > hepatomegaly are

> > > > > common. Patients with secondary PCM show signs similar to

> > > marasmus,

> > > > > primarily

> > > > > loss of adipose tissue and lean body mass, lethargy, and

> edema.

> > > > Severe

> > > > > secondary PCM may cause loss of immunocompetence.

> > > > >

> > > > > Diagnosis

> > > > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > > > anthropometry

> > > > > confirm PCM. If the patient doesn’t suffer from fluid

> retentio

> > n,

> > > > > weight change

> > > > > over time is the best index of nutritional status.

> > > > >

> > > > > The following factors support the diagnosis:

> > > > > â‘ height and weight less than 80% of standard for the

> > > patient’s

> > > > > age and sex,

> > > > > and below-normal arm circumference and triceps skinfold

> > > > >

> > > > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3

> > g/

> > > dl)

> > > > > â‘ urinary creatinine (24-hour) level used to show lean body

> ma

> > ss

> > > > > status by

> > > > > relating creatinine excretion to height and ideal body weight,

> > to

> > > > > yield

> > > > > creatinine-height index.

> > > > >

> > > > > R Vajda, R.D.

> > > > > www.GingerJens.com

> > > > >

> > > > > ________________________________

> > > > >

> > > > > To: rd-usa ; dhcc@...

> > > > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > > > Subject: FW: Hospital chain, under scrutiny, reports

> > rare

> > > > > illness |

> > > > > Local News | PE.com | Southern California News | News for

> Inland

> > > > > Southern

> > > > > California

> > > > >

> > > > > This is a very interesting article. Aside from the fact that

> our

> > > tax

> > > > > $$ are

> > > > > now going to our neighbor to the North, what is the accurate

> > > > > definition of

> > > > > Kwashiorkor IYO? And how is it diagnosed?

> > > > >

> > > > > Digna

> > > > >

> > > > > Hospital chain, under scrutiny, reports rare

> illness |

> > > > > Local News |

> > > > > PE.com | Southern California News | News for Inland Southern

> > > > > California

> > > > >

> > > > >

http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > > > tml

> > > > >

> > > > >

[Guest guest]

Thanks and I agree with everything you stated especially in the last

paragraph ... " In the not so distant past, you'd see a definite publication

bias in

that industry would squelch results that did not meet their commercial

aims. More recently, while they can certainly choose to not publish,

all research must be included in the clinical research database. " And that

not so distant past was just a few years ago!

>

>

> How is PubMed influenced by money and politics? PubMed is simply a

> database consisting of papers from biomedical journals. At this time,

> there are something like 4800 journals publishing; I forget how many

> are indexed in PubMed. There are criteria that must be met for a

> journal to be indexed in PubMed. I think you confuse the research and

> researchers themselves with the database in which papers are indexed.

> PubMed is not the only database that can be used to search the

> literature, as I'm sure you're aware. There's CINAHL, ERIC, OVID, and

> many others. The NLM makes their databases available at no cost. If

> you go to the gateway, you can also find access to the gene database,

> protein sequencing (ever want to know the amino acid sequence of many

> proteins? It's in there. For free), patient education materials (very

> well done materials, I might add) and also free.

>

> PubMed is a free service of the National Library of Medicine. The NLM

> also makes available a repository of open access publications as well,

> recognizing that not everyone has access to a medical library. PubMed

> Central is growing every day, particularly since about 6 or 7 years

> ago, the NIH made is mandatory for researchers who are funded by NIH

> money to publish in PubMed Central (if they're research meets peer

> review criteria). Many also use Google Scholar as their search engine

> of choice for retrieving information in the biomedical literature.

> While I use both, because I've been trained on PubMed and teach

> PubMed, I'm more comfortable there.

>

> When I teach research methods and information retrieval, we start with

> the phrase " Caveat lector " or Let the reader beware. It's up to you,

> the reader to make sure that what you are reading meets criteria. The

> peer review process does the first step for you. I've been a reviewer

> for a number of scientific journals. When asked to review a paper,

> which can take many hours, we review the purpose, specific aims,

> methodology, appearance of bias (commercial or simply that the author

> wanted to get a certain outcome and so, got that outcome), results

> reporting, and appropriateness of conclusions.

>

> There is no way we'll ever get away with no industry funded research.

> In the not so distant past, you'd see a definite publication bias in

> that industry would squelch results that did not meet their commercial

> aims. More recently, while they can certainly choose to not publish,

> all research must be included in the clinical research database. So,

> you can search to see who is doing research, what the status of the

> study is, who is doing it, and if it's been published or not. At the

> end of the day, it's the reader's responsibility to determine external

> validity of any research you read. And no, you cannot say it's not

> good research if it simply doesn't say what you want. That's called

> being open-minded!

>

> For those who are interested, I teach a graduate level course on

> Nutrition Informatics every other year for UMDNJ. We cover much of

> this material.

>

> I fully agree that everyone needs access to healthcare.

>

>

> Pam Charney, PhD, RD

>

> Pamela Charney and Associates, LLC

> consultants in nutrition informatics

> Transforming Nutrition Care With Informatics

>

> pcharney@...

> http://www.linkedin.com/in/pamcharney

>

>

>

> > Pam, I agree with what you are saying! PubMed is the best source but

> > it also had been influenced by money and politics. There has been some

> > positive changes in the science publishing community and journals

> > since now most disclose funding. Science is sometimes backwards or

> > after the fact. The example is HIV. First it did not exist and was

> > missed Dx as other diseases since 1950s or longer, then it was a

> > syndrome, then a virus and then labeled HIV/AIDS. Gulf War syndrome is

> > similar and when there is no money or explanation it stays a syndrome.

> > These viruses and syndromes cause hypermetabolic conditions and slow

> > malabsorption leading to malnutrition. Medical nutrition is an art and

> > a science! Today's science, medicine, definitions and more change all

> > the time! Your giving an example of it. Big business is in everything

> > now, including academia! Special interests trumps what is best for the

> > patient or student. Bottom line is that if Americans are not given the

> > opportunity to see a RD and a MD for regular check ups and care,

> > healthcare cost shall rise and rise bankrupting our country. Time

> > needs to be spent on basic care. My opinion, more than 90% healthcare

> > starts with medical nutrition! This message is not getting to

> > Americans!

> >

> > Sent from my iPhone

> >

> >

> >

> > > ,

> > >

> > > The research is not backwards, although I'm not sure what you mean

> > by

> > > that. Research is what is it. I'm in complete agreement with you

> > > regarding the connection between nutrition and chronic illness,

> > > however, kwashiorkor is not malnutrition as we have been taught in

> > the

> > > past.

> > >

> > > When I talk about increased mortality with refeeding folks with

> > > kwashiorkor, I am not talking about the " refeeding syndrome " (that

> > is

> > > really an iatrogenic complication, not a condition) that most of us

> > > might have seen in hospitals. That " refeeding syndrome " is an acute

> > > hypophosphatemia, hypokalemia, and not quite as severe

> > hypomagnesemia

> > > along with pulmonary and cardiac complications seen when one

> > provides

> > > carbohydrates in excess of capacity for cellular uptake and

> > > utilization.

> > >

> > > Malnutrition does not equal malabsorption, nor does it equal

> > > hypermetabolism. All are separate but can interact when present

> > > concurrently. I think it behooves us to approach this from a

> > science-

> > > based perspective. The National Library of Medicine (NLM) offers the

> > > free search engine, PubMed that can be used to search for literature

> > > that has been peer-reviewed.

> > >

> > > Pam Charney, PhD, RD

> > >

> > > Pamela Charney and Associates, LLC

> > > consultants in nutrition informatics

> > > Transforming Nutrition Care With Informatics

> > >

> > > pcharney@...

> > > http://www.linkedin.com/in/pamcharney

> > >

> > >

> > >

> > > > Pam, The research is backwards and not pure science. Like you

> > > stated,

> > > > it is money or politics at play here. Malnutrition is a slow

> > > occuring

> > > > process in which once it gets to a certain point, it starts the

> > slow

> > > > cycle of illness leading to chronic illness and organ failure. You

> > > are

> > > > right, when illness due to this malnutrition occurs, refeeding

> > could

> > > > be dangerous and even deadly. As with everything in life, timing

> > is

> > > > everything. It is really the denial of malnutrition, malabsorption

> > > and

> > > > hypermetabolism that is the problem!

> > > >

> > > > Sent from my iPhone

> > > >

> > > > On Feb 21, 2011, at 11:35 AM, Pam Charney

> > wrote:

> > > >

> > > > > ,

> > > > >

> > > > > With all due respect, one should not use Today's Dietitian as

> > the

> > > > > place to learn the latest science. The information published

> > there

> > > > is

> > > > > not peer reviewed, nor is it systematic. It's what we call a

> > > > > " journalistic review " . That's not a bad thing, I've written for

> > > them

> > > > > myself, it's just that you should know the difference.

> > > > >

> > > > > I know you like magnesium as the perpetrator for a number of

> > > health

> > > > > conditions, based on your recent posts here. However,

> > > kwashiorkor is

> > > > > not protein and electrolyte imbalance, at least not at the root

> > > > cause.

> > > > > In fact, in some research, when you give folks with (real)

> > > > kwashiorkor

> > > > > protein and electrolytes without considering co-morbid

> > conditions,

> > > > you

> > > > > often end up increasing mortality, which we really don't want to

> > > do.

> > > > >

> > > > > What's going on here is much more complex; it's a mix of

> > > facilities

> > > > > trying to pull as much medicare money their way and RDs not

> > > stepping

> > > > > up with evidence to show what is and what is not truly a

> > nutrition

> > > > > problem.

> > > > >

> > > > > I'd urge you to search PubMed for some of the more recent papers

> > > on

> > > > > kwashiorkor. Golden from the UK had published some that

> > > are

> > > > > very readable. There are others in the tropical medicine

> > journals

> > > > that

> > > > > also talk about some other purported etiologies for kwashiorkor.

> > > > >

> > > > > Regards,

> > > > > pam

> > > > >

> > > > > Pam Charney, PhD, RD

> > > > >

> > > > > Pamela Charney and Associates, LLC

> > > > > consultants in nutrition informatics

> > > > > Transforming Nutrition Care With Informatics

> > > > >

> > > > > pcharney@...

> > > > > http://www.linkedin.com/in/pamcharney

> > > > >

> > > > >

> > > > >

> > > > > > Marasmus is starvation, kwashiorkor is protein starvation and

> > > > > > electrolyte

> > > > > > imbalance. A Today's Dietitian article a few months age

> > directed

> > > > me

> > > > > > to B1 for

> > > > > > refeeding anorexia - it worked - I was so disoriented, and my

> > > > heart

> > > > > > was fluttery

> > > > > > and weird. The magazine had flipped open to that page and it

> > > was a

> > > > > > life saver.

> > > > > > When you are that underfed, there really is no appetite - zinc

> > > > > > deficiency

> > > > > > worsens appetite I believe. The magnesium deficiency adds to

> > the

> > > > > > edema problem

> > > > > > that the lack of albumin causes. Loss of muscle tone,

> > alopecia,

> > > > and

> > > > > > dermatologic

> > > > > > symptoms would all relate to protein deficiency. Getting

> > > > rehydrated

> > > > > > was

> > > > > > necessary before I could swallow much food. When one or two

> > > bites

> > > > > > feels like

> > > > > > sawdust it is easy to give up eating and not figure out how to

> > > > start

> > > > > > again.

> > > > > > Rehydration requires magnesium as well as sodium and

> > potassium.

> > > > Many

> > > > > > major

> > > > > > electrolyte brands don't even have magnesium - it was

> > regulated

> > > > out

> > > > > > sometime in

> > > > > > the 20's - 30's.

> > > > > >

> > > > > > I think that that doctor and hospital system is recognizing

> > the

> > > > > > problem I've

> > > > > > been working on - we can't heal and regenerate tissue if we

> > > don't

> > > > > > have the

> > > > > > nutrients. As for increased Medicare billing I hope the

> > > hospital/

> > > > > > doctor is

> > > > > > figuring out how to use that money to actually nourish the

> > > > starving

> > > > > > seniors and

> > > > > > isn't just bonusing it out to executives.

> > > > > >

> > > > > > Kwashiorkor was more prevalent in starving children

> > countries -

> > > > > > edamatous belly

> > > > > > - but I just saw that in my father-in-law. I couldn't find a

> > > > formula

> > > > > > that didn't

> > > > > > have the high calcium level that throws off absorption. Our

> > > > enteral

> > > > > > feedings

> > > > > > are not based on ratios that the chronically ill can absorb.

> > The

> > > > > > feeding made

> > > > > > him worse, 40 pounds edamatous. So painfully swollen with

> > water

> > > > and

> > > > > > skin

> > > > > > integrity you could poke a fingernail through (it seemed).

> > He is

> > > > > > getting better

> > > > > > finally.

> > > > > >

> > > > > > Providing " Health Shakes " and supplemental formulas that are

> > > > high in

> > > > > > calcium

> > > > > > isn't helping. The problem is not that there is no protein in

> > > the

> > > > > > diet or even

> > > > > > in the body - the problem is keeping the protein in the cells

> > > and

> > > > > > blood vessels

> > > > > > where it can do some good. Magnesium is what is needed to

> > > prevent

> > > > > > the leaky

> > > > > > membranes and in the chronically ill calcium is being

> > > > preferentially

> > > > > > absorbed.

> > > > > >

> > > > > > I want to make sweet potato ginger smoothies boosted with

> > > garbanzo

> > > > > > bean puree

> > > > > > for everybody.

> > > > > >

> > > > > >

>

http://www.nutritionmd.org/health_care_providers/general_nutrition/protein_malnu\

trition.html

> > > > > >

> > > > > > Protein-Calorie Malnutrition: Overview and Treatment

> > > > > > Protein-calorie malnutritionresults in 2 similar but distinct

> > > > > > diseases, marasmus and kwashiorkor.

> > > > > >

> > > > > > Marasmus is defined simply as chronic deprivation of energy

> > > needed

> > > > > > to maintain body weight. Its extreme form is characterized by

> > > > severe

> > > > > > weight loss and cachexia.1 Marasmus is further characterized

> > by

> > > > > > subnormal body temperature, decreased pulse and metabolic

> > rate,

> > > > loss

> > > > > > of skin turgor, constipation, and starvation diarrhea,

> > > > consisting of

> > > > > > frequent, small, mucus-containing stools.2

> > > > > > Kwashiorkor is a somewhat more complex disease. It is

> > > > characterized

> > > > > > by edema, low capillary-filtration rate, hypoalbuminemia, and

> > > > > > dermatitis.

> > > > > >

> > > > > > Derived from an African term meaning " the disease that occurs

> > > when

> > > > > > the next baby is born " , kwashiorkor was initially thought to

> > > > result

> > > > > > from a diet high in calories (mainly carbohydrates, such as

> > > > maize),

> > > > > > yet deficient in protein. However, infection, aflatoxin

> > > poisoning,

> > > > > > and oxidative stress may also play causative roles.1,3

> > Edema, a

> > > > > > defining

> > > > > > characteristic of kwashiorkor, resolves with treatment,

> > despite

> > > > > > continuing hypoalbuminemia, suggesting that the edema is due

> > to

> > > > > > leaky cell membranes, low capillary filtration rates, high

> > > > > > concentrations of free iron, and free radicals that increase

> > > > > capillary

> > > > > > permeability.4 Kwashiorkor is further distinguished from

> > > > marasmus by

> > > > > > the following findings:

> > > > > > * Massive edema of the hands and feet.

> > > > > > * Profound irritability.

> > > > > > * Anorexia.

> > > > > > * Dermatologic symptoms (desquamative rash, hypopigmentation).

> > > > > > * Alopecia or hair discoloration.

> > > > > > * Fatty liver.

> > > > > > * Loss of muscle tone.

> > > > > > * Anemia and low blood concentrations of albumin, glucose,

> > > > > potassium,

> > > > > > and magnesium.5,6

> > > > > > Kwashiorkor may also involve severe, life-threatening

> > > > > hypophosphatemia

> > > > > > (<1.0 mg/dL), which has been found to triple the mortality

> > rate

> > > > when

> > > > > > compared with children who have normal phosphorus levels.7

> > > > > > Treatment

> > > > > > Individuals treated for protein-energy malnutrition are at

> > risk

> > > > for

> > > > > > refeeding syndrome, in which hypophosphatemia, hypokalemia,

> > and

> > > > > > hypomagnesemia may lead to disturbances in the cardiac,

> > > > neurologic,

> > > > > > gastrointestinal, respiratory, hematologic, skeletal, and

> > > > endocrine

> > > > > > systems. Guidelines have been developed to help prevent these

> > > > > > complications

> > > > > > and to establish a transition to normalcy. Treatment consists

> > > of 2

> > > > > > phases: stabilization and rehabilitation.

> > > > > >

> > > > > > The initial (stabilization) phase proceeds from days 1 through

> > > > 7. It

> > > > > > consists of treatment and prevention of hypoglycemia,

> > > hypothermia,

> > > > > > dehydration, and infection; correction of electrolyte

> > imbalance

> > > > and

> > > > > > micronutrient deficiencies; and a cautious feeding regimen.

> > > > > >

> > > > > > http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm

> > > > > >

> > > > > > Protein-calorie malnutrition: Excerpt from Professional

> > Guide to

> > > > > > Diseases

> > > > > > (Eighth Edition)

> > > > > > " Both kwashiorkor (edematous PCM) and marasmus (nonedematous

> > > PCM)

> > > > > > are common in

> > > > > > underdeveloped countries and in areas in which dietary amino

> > > acid

> > > > > > content is

> > > > > > insufficient to satisfy growth requirements. Kwashiorkor

> > > typically

> > > > > > occurs at

> > > > > > about age 1, after infants are weaned from breast milk to a

> > > > protein-

> > > > > > deficient

> > > > > > diet of starchy gruels or sugar water, but it can develop at

> > any

> > > > > > time during

> > > > > > the formative years. Marasmus affects infants ages 6 to 18

> > > > months as

> > > > > > a result

> > > > > > of breast-feeding failure, or a debilitating condition such as

> > > > > chronic

> > > > > > diarrhea.

> > > > > >

> > > > > > In industrialized countries, PCM may occur secondary to

> > chronic

> > > > > > metabolic

> > > > > > disease that decreases protein and calorie intake or

> > absorption,

> > > > or

> > > > > > trauma that

> > > > > > increases protein and calorie requirements. In the United

> > > States,

> > > > > > PCM is

> > > > > > estimated to occur to some extent in 50% of elderly people in

> > > > > > nursing homes.

> > > > > > Those who aren’t allowed anything by mouth for an extended

> > > > period

> > > > > > are at high

> > > > > > risk of developing PCM. Conditions that increase protein-

> > calorie

> > > > > > requirements

> > > > > > include severe burns and injuries, systemic infections, and

> > > cancer

> > > > > > (accounts

> > > > > > for the largest group of hospitalized patients with PCM).

> > > > Conditions

> > > > > > that cause

> > > > > > defective utilization of nutrients include malabsorption

> > > syndrome,

> > > > > > short-bowel syndrome, and Crohn’s disease.

> > > > > >

> > > > > > Read more at

> > > > > >

>

http://www.wrongdiagnosis.com/k/kwashiorkor/book-diseases-7a.htm?ktrack=kcplink

> > > > > >

> > > > > > Signs and symptoms

> > > > > > Children with chronic PCM are small for their chronological

> > age

> > > > and

> > > > > > tend to be

> > > > > > physically inactive, mentally apathetic, and susceptible to

> > > > frequent

> > > > > > infections. Anorexia and diarrhea are common.

> > > > > >

> > > > > > In acute PCM, children are small, gaunt, and emaciated, with

> > no

> > > > > > adipose tissue.

> > > > > > Skin is dry and “baggy,†and hair is sparse and dull brown

> > > or

> > > > > > reddish-yellow.

> > > > > > Temperature is low; pulse rate and respirations are slowed.

> > Such

> > > > > > children are

> > > > > > weak, irritable, and usually hungry, although they may have

> > > > > > anorexia, with

> > > > > > nausea and vomiting.

> > > > > >

> > > > > > Unlike marasmus, chronic kwashiorkor allows the patient to

> > > grow in

> > > > > > height, but

> > > > > > adipose tissue diminishes as fat metabolizes to meet energy

> > > > demands.

> > > > > > Edema

> > > > > > often masks severe muscle wasting; dry, peeling skin and

> > > > > > hepatomegaly are

> > > > > > common. Patients with secondary PCM show signs similar to

> > > > marasmus,

> > > > > > primarily

> > > > > > loss of adipose tissue and lean body mass, lethargy, and

> > edema.

> > > > > Severe

> > > > > > secondary PCM may cause loss of immunocompetence.

> > > > > >

> > > > > > Diagnosis

> > > > > > CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and

> > > > > > anthropometry

> > > > > > confirm PCM. If the patient doesn’t suffer from fluid

> > retentio

> > > n,

> > > > > > weight change

> > > > > > over time is the best index of nutritional status.

> > > > > >

> > > > > > The following factors support the diagnosis:

> > > > > > â‘ height and weight less than 80% of standard for the

> > > > patient’s

> > > > > > age and sex,

> > > > > > and below-normal arm circumference and triceps skinfold

> > > > > >

> > > > > > â‘ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3

> > > g/

> > > > dl)

> > > > > > â‘ urinary creatinine (24-hour) level used to show lean body

> > ma

> > > ss

> > > > > > status by

> > > > > > relating creatinine excretion to height and ideal body weight,

> > > to

> > > > > > yield

> > > > > > creatinine-height index.

> > > > > >

> > > > > > R Vajda, R.D.

> > > > > > www.GingerJens.com

> > > > > >

> > > > > > ________________________________

> > > > > >

> > > > > > To: rd-usa ; dhcc@...

> > > > > > Sent: Sun, February 20, 2011 8:50:58 PM

> > > > > > Subject: FW: Hospital chain, under scrutiny, reports

> > > rare

> > > > > > illness |

> > > > > > Local News | PE.com | Southern California News | News for

> > Inland

> > > > > > Southern

> > > > > > California

> > > > > >

> > > > > > This is a very interesting article. Aside from the fact that

> > our

> > > > tax

> > > > > > $$ are

> > > > > > now going to our neighbor to the North, what is the accurate

> > > > > > definition of

> > > > > > Kwashiorkor IYO? And how is it diagnosed?

> > > > > >

> > > > > > Digna

> > > > > >

> > > > > > Hospital chain, under scrutiny, reports rare

> > illness |

> > > > > > Local News |

> > > > > > PE.com | Southern California News | News for Inland Southern

> > > > > > California

> > > > > >

> > > > > >

> http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.h

> > > > > > tml

> > > > > >

> > > > > >