الفهرس 
Acknowledgement
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Abstract
Nutrition plays a crucial role in both the prevention and treatment of disease. Both overnutrition and undernutrition can lead to negative health outcomes. For example, overnutrition from excess intake of calories and fat can result in weight gain, elevated blood lipids, and risk of hypertension, diabetes, and some cancers. Undernutrition, in which dietary intake is less than the body’s requirement, can result in impaired wound healing, poor response to medical treatment, and loss of functional capacity. (Kathleen et al., 2009)
Several definitions of malnutrition have been put forward as well as ways to assess malnutrition/nutritional state. Malnutrition was defined since almost 15 years in the advanced ESPEN (European society for clinical nutrition and metabolism) courses as ‘‘a state resulting from lack of uptake or intake of nutrition leading to altered body composition (decreased fat free mass but specifically body cell mass) and diminished function’’. (Lochs et al., 2006)
Malnutrition occurs because of decreased intake, increased losses, or unmet increased needs for energy or any nutrient. Patients have decreased intake for a number of medical and psychosocial reasons. Nutrient losses can occur from malabsorptive disease or drug interactions. Hypermetabolism during physiological stress, or increased energy needs because of growth, development, and physical activity can cause increased nutritional needs that must be met or malnutrition will develop.
Often the general term malnutrition is synonymous with the specific term protein-calorie malnutrition. (Kathleen et al., 2009)
Malnutrition has adverse consequences such as poor wound healing, risk of decubitus ulcer development, decreased muscle mass (including respiratory and heart) with subsequent loss of strength and functional decline, diminished immunocompetence, and altered pharmacokinetics. (Covinsky, 2002)
There are two conventional categories of malnutrition: kwashiorkor and marasmus.
The term kwashiorkor was first used to describe what was thought to be a form of malnutrition observed in young children from underdeveloped areas of the world. Health care experts associated early weaning from human milk to a protein-deficient oral diet, consisting mainly of grain-based foods, with kwashiorkor. Children presented with hypoalbuminemia; edema of the extremities, lower back, and face; fatty liver; and anorexia. (Golden et al., 2000)
The clinical syndrome of kwashiorkor is best described as a state of dysmetabolism due to the misuse of protein by the body as an energy substrate instead of as a building block (seres and resurrection, 2003). Kwashiorkor has been theoretically ascribed to diet composed almost exclusively of carbohydrate, causing high insulin levels, which diminish the rate of protein and fat oxidation. The relative absence of protein in the diet leads to inadequate amounts and altered ratios of amino acid substrate for protein synthesis. Hypoalbuminemia causes a reduction in colloid oncotic pressure in the vascular space and subsequent extravascular fluid accumulation, which presents as edema and ascites. (Patricia et al, 2004)
In contrast, marasmus is caused by long-term inadequate intake of all macronutrients. Clinical characteristics are weight loss, muscle wasting, but no edema. During short-term starvation, homeostatic mechanisms maintain glucose supply to glucose-requiring tissues by utilizing muscle derived amino acid substrate for gluconeogenesis. Continuous muscle protein catabolism for gluconeogenic substrate can cause death. The process is abated by increased utilization of fatty acids for oxidative substrate and from oxidation of ketones derived from fatty acid oxidation. In this manner, muscle protein is “spared.” Protein catabolism continues, albeit at a slow rate, to provide obligatory glucose requirements. Death from marasmus is usually caused by loss of respiratory muscle function and subsequent respiratory failure. In the case of marasmus, serum hepatic protein levels are not affected by inadequate nutrient intake in that synthesis of hepatic proteins is maintained until very late in the process. (Kurita et al., 2002)
Nutrition assessment:
The cornerstone of all nutritional care is based on the foundation of well done nutrition assessment. Nutritional assessment serves several goals. The most important of these is to identify patients at nutritional risk early, particularly those with systemic disease, to prevent the development of a state of nutritional depletion or excess, both of which will adversely affect prognosis. The nutritional screening and evaluation process should identify those patients who may benefit from nutritional interventions, including those at higher risk for responding poorly to, or developing complications from, medical or surgical interventions. (ASPEN, 2002)
No one parameter or single piece of data should be used as an indicator of nutrition status. Data gathered during the physical exam and laboratory assays together with subjective data from the focused interview provide a comprehensive set of information on which to base a nutritional assessment. A nutrition assessment based on limited data has limited clinical value since many parameters used in a nutrition assessment can be influenced by nonnutritional factors. (Kathleen et al., 2009).