1. Outline the metabolic changes that occur during starvation/inadequate nutritional intake (not related to disease) that could result in weight loss.
During starvation, carbohydrates are depleted after 24 hours, major substrates for gluconeogenesis are amino acids that come from skeletal muscle protein that breakdown, ketone body concentrations rise during prolonged starvation and result in significant excretion of ketones, and the metabolism allows consistent fuel supply to the brain and other tissues during prolonged starvation.
2. Read the consensus statement of the Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition.
Explain the differences between malnutrition associated with chronic disease and malnutrition associated with acute illness and inflammation.
Malnutrition related to chronic disease is when inflammation is mild to moderate but constant (chronic). An example is rheumatoid arthritis. Malnutrition related to acute illness and inflammation is when the inflammation is acute and at a severe degree. An example is major trauma.
3. Find the current definitions of malnutrition in the United States using the current ICD 10 codes. List all of them and describe the criteria for one of the diagnoses.
Malnutrition includes codes E40-E46 going into a category of type 1 or type 2.
E41 Nutritional marasmus
E42 Marasmic kwashiorkor
E43 Unspecified severe protein-calorie malnutrition
E44 Protein-calorie malnutrition of moderate and mild degree
E45 Retarded development following protein-calorie malnutrition
E46 Unspecified protein-calorie malnutrition
Type 1 excludes: intestinal malabsorption ICD-10-CM Diagnosis Code K90
sequelae of protein-calorie malnutrition ICD-10-CM Diagnosis Code E64.0
Type 2 excludes: nutritional anemia ICD-10-CM Range D50-D53
Starvation ICD-10-CM Diagnosis Code T73.0
4. Current ICD definitions of malnutrition use biochemical markers as a component of the diagnostic criteria. Consider the effect inflammation has on visceral proteins and how that may impact the clinician’s ability to diagnose malnutrition. Discuss the following clinical findings and relate to inflammation and ability to diagnose malnutrition.
a) Why is there down-regulation of albumin synthesis? Relate to positive acute-phase protein for the immune system (antibodies, complement, cytokines, C-reactive protein), clotting (fibrinogen) and wound healing.
Malnutrition or long term starvation can reduce a full positive acute phase protein reaction while reducing the negative part as well by the starvation process itself. This starts the depression of hepatic protein synthesis. Which this moves on to affecting pro-inflammatory cytokines in the brain and the rest of the inflammation process. Albumin is characterized as a negative acute phase protein and is affected by inflammatory conditions and drugs which affects liver function. But there are so many disease processes that alter the level of albumin that it becomes an unreliable serum marker for malnutrition.
b) Why is the production of cytokines such as IL-I, IL-6, and tumor necrosis factor (TNF) increased and what is the impact on metabolism and protein synthesis (albumin,
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