Clinical Cases of Nutrition

Case Scenario 1:

A 4-year-old child from a poor socioeconomic background presents with frequent infections, lethargy, edema, protruded abdomen, and moon face. On examination, the child is found to have edema and is diagnosed with protein-energy malnutrition (PEM).

1. a) Identify the type of PEM in this child.
   b) List the investigations needed to confirm the diagnosis.
   c) Differentiate between the two main types of PEM.

Answer:

1. a) Type of PEM:
   The child is suffering from Kwashiorkor, indicated by edema, moon face, lethargy, and frequent infections.
2. b) Investigations:

• Serum albumin (↓ in Kwashiorkor)
• Serum total protein
• Complete blood count (to check for anemia and infections)
• Electrolytes & renal function tests
• Anthropometric measurements (weight-for-height, weight-for-age, MUAC)

1. c) Differences between Marasmus and Kwashiorkor:

Feature	Marasmus	Kwashiorkor
Cause	Total calorie deficiency	Protein deficiency (adequate calories)
Age	Usually < 1 year	1–3 years
Edema	Absent	Present
Muscle wasting	Severe	Mild (masked by edema)
Fat stores	Depleted	Present
Serum albumin	Normal or mildly ↓	Markedly ↓
Mental status	Alert & irritable	Lethargic & apathetic

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Case Scenario 2:

A 9-month-old male infant is brought to the pediatric clinic with complaints of poor growth, lethargy, and reduced activity. His weight gain has been minimal for age.

1. a) What is the most likely diagnosis?
   b) Mention any two clinical features of this condition.
   c) Explain the biochemical basis of this disorder.

Answer:

1. a) Diagnosis:
   Marasmus — a form of protein-energy malnutrition (PEM) due to severe calorie deficiency.
2. b) Clinical Features:

• Severe wasting of muscle and subcutaneous fat, making the child look emaciated.
• Failure to gain weight, growth retardation, and increased susceptibility to infections.

1. c) Biochemical Basis:

• In marasmus, total energy (calorie) intake is grossly deficient, leading the body to use its own fat and muscle stores for energy.
• Muscle proteins are broken down for gluconeogenesis to maintain blood glucose.
• Adipose tissue is mobilized, depleting fat stores (lipolysis).
• Since protein intake is relatively preserved compared to Kwashiorkor, serum albumin is usually normal or only mildly reduced, and edema is absent.

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Case Scenario 3:

A 3-year-old child is brought to the pediatric clinic with complaints of a swollen abdomen, patchy depigmented skin, generalized edema, and sparse, light-colored hair. Parents report a recent dietary change due to financial constraints. On examination, the child is apathetic, has reduced muscle mass, palpable liver, and laboratory tests show hypoalbuminemia.

1. a) What is the most probable diagnosis?
   b) What is the cause of edema in this child?
   c) Describe the biochemical changes in the two main types of protein-energy malnutrition (PEM).

Answer:

1. a) Probable Diagnosis:
   Kwashiorkor, a type of PEM characterized by protein deficiency with adequate or nearly adequate calories.
2. b) Cause of Edema:

• Severe hypoalbuminemia due to insufficient dietary protein reduces plasma oncotic pressure, leading to fluid leakage into interstitial tissues (edema).
• Also contributed by increased capillary permeability and sodium/water retention.

1. c) Biochemical Manifestations in PEM:

Parameter	Marasmus	Kwashiorkor
Energy intake	↓↓↓ (severe calorie deficit)	↓ (mainly protein deficit)
Protein intake	↓ (moderate)	↓↓↓ (severe)
Serum albumin	Normal or mildly ↓	Markedly ↓
Fat stores	Depleted	Present (masked by edema)
Muscle protein	Severe wasting	Mild-to-moderate wasting
Gluconeogenesis	Increased (muscle breakdown)	Increased
Liver	Normal	Fatty liver (impaired lipoprotein synthesis)
Immune function	Depressed	Depressed (more infections)

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Case Scenario 4:

A 41-year-old woman visits her physician with complaints of progressive weight gain despite dieting and exercising. She leads a sedentary lifestyle and consumes high-calorie processed food. Examination reveals a BMI of 35 kg/m², with central obesity and increased waist circumference.

1. a) How is obesity categorized based on BMI?
   b) Explain the role of leptin in obesity.
   c) Explain the role of thermogenin in energy metabolism.

Answer:

1. a) Classification of obesity based on BMI (WHO criteria for adults):

BMI (kg/m²)	Category
< 18.5	Underweight
18.5–24.9	Normal weight
25–29.9	Overweight
30–34.9	Obesity Class I
35–39.9	Obesity Class II
≥ 40	Obesity Class III (Morbid obesity)

For this patient, BMI = 35, indicating Obesity Class II.

1. b) Role of leptin:

• Leptin is a hormone produced by adipose tissue.
• It signals the hypothalamus about the body’s energy stores.
• High fat stores → ↑ leptin → ↓ appetite and ↑ energy expenditure.
• In obesity, although leptin levels are high, there may be leptin resistance, reducing its effectiveness.

 

1. c) Role of thermogenin (UCP-1):

• Thermogenin is an uncoupling protein (UCP-1) found in the inner mitochondrial membrane of brown adipose tissue.
• It dissipates the proton gradient as heat rather than producing ATP → non-shivering thermogenesis.
• Helps regulate body temperature and energy expenditure.
• In humans, especially important in neonates and may contribute to energy balance in adults.

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Case Scenario 5:

A 45-year-old woman presents with bloating, irregular bowel movements, and discomfort during defecation. She consumes a diet high in processed foods and low in fruits, vegetables, and whole grains. She wishes to know about dietary measures to improve her bowel habits.

a) What are the beneficial effects of dietary fiber in preventing and managing digestive symptoms?
b) What are the possible adverse effects of excessive dietary fiber intake?

Answer:

1. a) Beneficial effects of dietary fiber:

• Improves bowel movements: Fiber increases stool bulk and water content, making stools softer and easier to pass, thus relieving constipation.
• Prevents diverticulosis: By promoting regular bowel movements and reducing colonic pressure.
• Reduces risk of colorectal cancer: Fiber reduces transit time and dilutes potential carcinogens in the colon.
• Helps in weight management: Provides a feeling of fullness, reducing overall calorie intake.
• Lowers cholesterol: Soluble fiber binds bile acids and reduces cholesterol absorption.
• Improves blood sugar control: Slows glucose absorption, beneficial in diabetes.

1. b) Adverse effects of excessive dietary fiber:

• Bloating and flatulence: Fermentation of fiber by gut bacteria produces gas.
• Abdominal discomfort or cramps: Especially if fiber intake is suddenly increased.
• Interference with nutrient absorption: Excess fiber may bind minerals like calcium, iron, and zinc, reducing their absorption.
• Diarrhea: In some individuals, very high fiber can cause loose stools.

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Case Scenario 6:

A 25-year-old pregnant woman from a low-income community visits the clinic with complaints of fatigue, pallor, and breathlessness on exertion. On examination, she is pale, her BMI is 18 kg/m², and her hemoglobin is 8 g/dL. Dietary history reveals she consumes mostly cereals and tea, with little intake of fruits, vegetables, and animal products.

a) Identify the type of malnutrition and its possible cause in this patient.
b) Describe the role of iron and vitamin C in nutrition and their deficiency manifestations.
c) Suggest dietary advice to improve her nutritional status.

Answer:

1. a) Type of malnutrition & cause:

• The patient has iron-deficiency anemia, a form of micronutrient malnutrition.
• Likely causes: increased demand during pregnancy, low intake of iron-rich foods, high phytate (cereal) and tannin (tea) intake inhibiting iron absorption, and undernutrition (BMI < 18.5).

1. b) Role and deficiency:

• Iron:
  • Role: Component of hemoglobin, myoglobin, and enzymes; essential for oxygen transport and cellular metabolism.
  • Deficiency: Microcytic hypochromic anemia → fatigue, pallor, dyspnea, reduced immunity.
• Vitamin C:
  • Role: Enhances non-heme iron absorption, collagen synthesis, antioxidant.
  • Deficiency: Scurvy → bleeding gums, petechiae, poor wound healing.

1. c) Dietary advice:

• Include iron-rich foods: green leafy vegetables, legumes, jaggery, eggs, meat (if non-vegetarian).
• Consume vitamin C-rich fruits (citrus fruits, guava, amla) to enhance iron absorption.
• Avoid tea/coffee with meals (tannins inhibit iron absorption).
• Take adequate calories and proteins to improve BMI and meet pregnancy needs.

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Case Scenario 7:

A 30-year-old man working as a construction laborer complains of fatigue, weight loss, and frequent infections. On examination, he is underweight (BMI 17 kg/m²), has pale conjunctiva, and appears lethargic. His dietary history reveals he mainly eats polished rice, with very little vegetables, fruits, or protein sources.

a) Define a balanced diet and explain its importance.
b) What are the possible deficiencies in this patient’s diet?
c) Suggest dietary recommendations to improve his health.

Answer:

a) Definition and importance:

• A balanced diet is one that provides all the essential nutrients — carbohydrates, proteins, fats, vitamins, minerals, water, and fiber — in appropriate proportions to meet the daily requirements of an individual according to their age, sex, and activity level.
• Importance: Maintains health, supports growth and development, boosts immunity, prevents malnutrition and deficiency diseases.

1. b) Possible deficiencies:

• Protein-energy malnutrition (low proteins & calories).
• Iron deficiency → anemia (pale conjunctiva, fatigue).
• Vitamins (like B-complex, vitamin A) and minerals (like zinc) due to lack of fruits, vegetables, and variety.
• Fiber deficiency → possible digestive issues.

1. c) Dietary recommendations:

• Increase intake of pulses, legumes, eggs, and milk for protein.
• Include whole grains instead of polished rice for more fiber & micronutrients.
• Add fresh fruits and green leafy vegetables for vitamins & minerals.
• Ensure adequate calories and healthy fats to restore energy balance.
• Drink plenty of water and avoid excessive processed foods.

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Case Scenario 8:

A 20-year-old woman comes to the nutrition clinic for dietary advice. She is 12 weeks pregnant and wants to ensure proper growth of the baby. On examination, she is healthy, with normal BMI and no signs of malnutrition. Laboratory findings show increased plasma albumin and retention of nitrogen in the body.

1. a) Define nitrogen balance and explain what is meant by positive nitrogen balance.
   b) Mention two physiological conditions where positive nitrogen balance is observed and explain its significance.
   c) Suggest dietary components that help in maintaining positive nitrogen balance.

Answer:

1. a) Definition:

• Nitrogen balance is the difference between nitrogen intake (mainly from dietary proteins) and nitrogen loss (in urine, feces, sweat, etc.).
• Positive nitrogen balance occurs when nitrogen intake exceeds nitrogen loss — indicating net protein synthesis in the body.

1. b) Conditions & significance:

• Seen during:
  • Growth (infancy, childhood, adolescence)
  • Pregnancy & lactation
  • Recovery from illness or trauma
• Significance: Indicates tissue building, repair, and growth — essential for fetal development during pregnancy and for increasing maternal tissues.

1. c) Dietary components:

• High-quality (complete) proteins: eggs, milk, meat, pulses.
• Adequate energy (calories) to spare proteins for synthesis.
• Sufficient vitamins (like B-complex) and minerals (like zinc) that support protein metabolism.
• Balance of essential amino acids to meet anabolic needs.

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Case Scenario 9:

A 65-year-old man is admitted to the hospital after a serious road traffic accident with multiple fractures and burns. He has been bedridden for several weeks and has noticeable muscle wasting, poor wound healing, and generalized weakness. Laboratory investigations show decreased serum albumin and increased nitrogen loss in urine.

1. a) Define nitrogen balance and explain what is meant by negative nitrogen balance.
   b) Mention two conditions where negative nitrogen balance is observed and explain its significance.
   c) Suggest dietary and medical measures to minimize negative nitrogen balance in this patient.

Answer:

1. a) Definition:

• Nitrogen balance is the difference between nitrogen intake (from dietary protein) and nitrogen loss (in urine, feces, sweat, etc.).
• Negative nitrogen balance occurs when nitrogen loss exceeds nitrogen intake — indicating net protein breakdown.

1. b) Conditions & significance:

• Seen during:
  • Severe trauma, burns, surgery
  • Chronic infections or cancer
  • Starvation or inadequate protein intake
• Significance: Reflects muscle and tissue protein catabolism to meet energy and repair demands → leads to muscle wasting, impaired immunity, and delayed recovery.

1. c) Measures to minimize:

• Provide high-protein, high-calorie diet to meet increased demands and reduce protein breakdown.
• Supplement with essential amino acids and vitamins (like vitamin C and zinc) to promote healing.
• Early mobilization and physiotherapy to reduce muscle wasting.
• Treat underlying infections or complications promptly.