Protein energy malnutrition (PEM) or Protein Malnutrition is a problem that can effect a few after weight loss surgery (WLS) and Duodenal Switch (DS). In our previous blog post on protein  we discussed  the types of essential and non-essential Amino Acids and  possible sources. We also discussed  how to choose the best bioavailable protein and to vary protein sources to achieve adequate protein levels.  There are cases even with adequate protein intake that can result in PEM due to inadequate protein absorption. The early signs of low protein may be low energy, muscle weakness, moodiness, inability to sleep well, joint pain, changes in hair and nails and carb craving. It is imperative after WLS that you maintain your protein levels throughout your lifetime. The minimum protein intake is 80-100 grams per day after WLS.  There is no leeway where protein is concerned.  It is important in almost ever function in the body.

There are two types of protein energy malnutrition,  Kwashiorkor and Marasmus:

Kwashiorkor is a lack of protein intake with adequate or slightly lower caloric intake.  It’s symptoms are edema (swelling in legs, ankles, feet) enlarged abdomen, irritability, anorexia, hair discoloration and loss, muscle weakness, changes in psychomotor function, mental lethargy, ulcerations, brittle nails, rash or discoloration of the skin, bradycardia (slow heart rate), non-tender parotid enlargement, enlarged liver with fatty infiltrates that are similar to alcohol liver disease.  The edema is caused by osmotic imbalance in the intestinal system causing swelling of the gut.  Protein, primarily albumin is responsible for the colloidal pressure within the circulatory and tissue systems.  The lack of protein within the circulatory systems cause fluids to “leak” into tissues causing edema. Gastro-intestinal symptoms can include nausea, vomiting, dehydration, diarrhea and increases in appetite.  People who have pathological bacteria or parasites and/or after WLS diarrhea can precipitate lower levels of protein. If left untreated can lead to protein malnutrition.

Marasmus is characterized by a lack of protein and caloric intake.  The symptoms are an emaciated appearance with edema. There is no liver changes as in Kwashiorkor.  This is a starvation mode and can be difficult to treat and can progress to a point of no return.

Catabolysis is the bodies response to lack of protein and or nutrition.  This biologic process breaks down muscle and fat to maintain bodily functions. Catabolysis is the body’s last resort to keep it alive.  It is a starving body eating itself to keep vital organs alive.

Laboratory Studies are needed to determine the level of malnutrition and treatment routes.  These studies include:

• Lipids
• CBC (complete blood count)
• CMP (comprehensive metabolic panel) includes liver and kidney function tests, Calcium and electrolytes
• Albumin   Normal is greater than 3.5 gdL (transports nutrients such as calcium, zinc and Vitamin B6)
• Prealbumin (transthyretin) transports retinol (Vitamin A)
• Total protein  Normal is greater than 6.3 gdL
• Iron tests such as serum iron, TIBC, and ferritin

• Vitamins and trace minerals such as B12 and folate, vitamin A, vitamin D, vitamin K, B vitamins, calcium, and magnesium
• Ova and Parasite stool testing

Protein is an extremely important nutrient within our bodies and is considered the workhorse in cells and organs.  They are responsible for catalysts, messenger duties, structural, immunoprotectors, transporters, buffers, fluid balancers and many other roles. Protein has a hand in synthesizing other proteins, regulates protein turnover, enzyme activity, neurotransmission, gene transcription, transport of other nutrients, messenger and signals for growth hormone and insulin, structure, storage for other nutrients and immunity.

The muscular system is the most obvious structural protein in our bodies, 40% of the total body protein, as is hair, fingernails and cells. Our organs also require protein in order to function appropriately. However, protein’s role in red blood cell formation, size and health is extremely important.  If you don’t have adequate protein levels your body can not make red blood cells. Transferrin is a protein that carries iron to receptors.  Ferritin is an intercellular protein that stores iron until it is needed. Glycine is a protein for heme synthesis. B12 is also transported via a protein for red blood cell production. Protein is also important in blood clotting and plasma.

Cardiovascular health is also reliant on protein for structure and function. Also, proteins can have a protective effect at the mitochondrial level.

Kidney function relies on protein to regulate the acid base balance and ammonia disposal. The kidneys are also the site of amino acid production.

Protein is also important in bone health as a carrier for Vitamin K and calcium binding, tissue repair, healing and growth. Proteoglycans play a role in extracellular structures such as skin, bone, and cartilage. Also related to the skeletal system are glycoproteins, which also aid in building connective tissue, collagen, elastin and bone matrix.

Central Nervous system relies on proteins for neurotransmission, hormone production and other functions.  Protein deficients can lead to neurologic problems such as altered behavior and mental function among other manifestations. The neuorpeptides have actions on transmission functions, mood and behavior. They can also effect a wide range of functions such as blood pressure, body temperature, pain sensation, and learning ability.

Immonoproteins are the group of proteins that provide immune protection such as immunoglobulins and antibodies.

Protein also have storage roles for copper, iron and zinc called metalloproteins. Copper and zinc are considered neurotransmitters, important for iron metabolism, and connective tissue formation in heart, blood vessels and skeletal.

There are situation where your protein needs will increase. In cases of wounds, burns, surgery, stress, sepsis or other illnesses, protein requirements increase. Also age, pregnancy, lactating and increased exercise increases protein needs.

Protein Energy Malnutrition is protein deficit that can and should be avoided after WLS.  PEM, if left untreated, can lead to organ failure and death. Protein is crucial in almost every function of the body and without adequate levels there will be symptoms and side effects. Please take care to maintain your protein levels throughout your life.  We have discussed several of protein’s function, however, there are many more.