Evolution of Nutritional Management of Acute Malnutrition

The treatment of severe malnutrition hasbeen dominated by concepts of itsetiology. Recently these concepts havechanged dramatically. Instead of administering abundant protein and energy and treating the complications as one would do in a normal child, the pathophysiological changes and detailed studies of the metabolism of individual nutrients have been used to formulate diets and guidelines for the management of severe malnutri-tion and its complications. This has resulted in a dramatic fall in case fatality rates. It should be emphasized that nearly all physiological, biochemi-cal and immunological systems in the body are changed in the malnourished individual. This is brought about by a mixture of reductive adaptation to the inadequate intake, nutritional imbalance and deficiency of specific nutrients and to the resulting effects of infection and other environmental stresses that cannot be adequately resisted because of the physiological and immunological changes. HISTORICAL PERSPECTIVE Malnutrition has been recognized for millennia as being due to a shortage of food. Ancel Keys lists many of the famines recorded in history(1) which disappeared when the normal diet of the population returned. Kwashiorkor as a separate entity was recognized early in Latin America and called “multi-deficiency syndrome”(2) and in Europe as “flour dystrophy”(3). Later it was described from Africa by Cecile Williams in the English literature(4-6), given the name kwashiorkor, and recorded as responding to milk. After a brief argument whether this was a form of pellagra(7) most experts accepted that the cause was protein deficiency(8-11), a view that has persisted(12) particularly among those who invested their life’s work investigating protein metabolis