Introduction

Malnutrition in some form exists in all parts of the world, including both developed and developing countries. Malnutrition refers to an imbalance in a person’s intake of energy and/or nutrients. This imbalance can either be an excess or a deficiency of protein and energy. Malnutrition can be classified into undernutrition (wasting, stunting, and underweight), overnutrition (overweight and obesity), diet-related non-communicable diseases, and micronutrient-related malnutrition (vitamins or minerals).¹ In 2022, 390 million adults were underweight. 

Kwashiorkor is a form of undernutrition with a deficiency of protein and energy, commonly known as protein-energy malnutrition (PEM). Kwashiorkor is commonly seen in children, but has also been found in adults. Kwashiorkor in adults is usually not reported, and there is not a lot of documentation on this not-so-common but important condition.^1,2,3 Hence, the purpose of this article is to identify the causes of kwashiorkor in adults and the modes of presentation of kwashiorkor in adults.

Causes of kwashiorkor in adults

Kwashiorkor in adults, just like in children, is a state of protein energy undernutrition. It can be caused by:⁴

• Reduced dietary intake
• Malabsorption
• Increased loss of nutrients or an imbalance in nutrient requirements
• Energy expenditure

Reduced dietary intake

Reduced dietary intake is a common cause of kwashiorkor in adults. It could be due to changes in cytokines, glucocorticoids, insulin, and insulin-like growth factors, which lead to a reduction in appetite sensation. When appetite sensation or the sensation of having food is reduced, the act of eating decreases, leading to less consumption of healthy and balanced meals. 

Reduced dietary intake is also common in patients admitted to the hospital for a long period. This is attributed to the inability of hospitals and/or caregivers to provide regular, nutritious meals.⁴ This paucity of regular nutritious meals could be due to the nature of the illness, warranting a loss of appetite or the difficulty in providing nutritious, healthy meals in a hospital setting.

Dieting/Starving/Fad dieting

Fad diets are popular because of their quick and dramatic ability to produce significant weight loss results among individuals trying to lose weight. Adults who engage in fad dieting tend to starve themselves to lose weight, thereby predisposing them to the consumption of poor and unhealthy diets. Unfortunately, starving or consuming fad diets is a temporary solution to weight loss and not sustainable, as the weight adds back on after the individual stops consuming the fad diet or cannot keep up with starvation.^4,5

Dietary preferences and habits

Predominantly vegetarian diets have been found to be linked to kwashiorkor in adults. Vegetarian diets are diets lacking in animal products or seafood. Consuming diets high in carbohydrates, such as rice with little or no protein, over a long period of time, has also been implicated in kwashiorkor.²

Alcoholism

Adults who consume alcohol in large quantities and frequently over a long period of time are usually found to prefer consuming alcohol instead of eating healthy foods or other fluids such as fruit juices or water. This behaviour over long periods of time leads to poor nutrient intake.⁶ Kwashiorkor due to alcoholism can also be found in the elderly.³ 

Malabsorption

Malabsorption of nutrients and protein is another cause of kwashiorkor. Malabsorption can be found in patients with intestinal failure and in patients who have had abdominal surgical procedures. Kwashiorkor has been reported in cases following bariatric surgery and/or short-gut syndrome. Bariatric surgery is a procedure that is used to alter the stomach and intestines in an obese person, which leads to weight loss.^4,8,9 

A complication of bariatric surgery is malabsorption, which leads to or worsens vitamin and mineral deficiency.⁸ Alcohol also leads to micronutrient deficiency by negatively affecting the digestion, absorption, and metabolism of nutrients.⁷

Increased loss of nutrients or an imbalance in nutrient requirements

The nutritional requirements and metabolism in conditions such as enterocutaneous fistulae or burns are different from the normal and are usually high with associated specific nutrient loss.⁴

Energy expenditure

Kwashiorkor is associated with conditions such as long-standing infections, chronic inflammatory conditions, hyperthyroidism, trauma, and burns. These conditions lead to an increase in the metabolic demands of the patient, leading to protein-energy undernutrition.^4,5

Other medical conditions that can lead to protein energy malnutrition and kwashiorkor include:^10,11

• Anorexia
• Depression
• Cancer that is undetected/undiagnosed
• Undergoing treatment for cancer (cancer cachexia)
• Critically ill patients being managed in intensive care units or those hospitalised for a long period
• Cushing’s syndrome, chronic adrenal insufficiency, long period of steroid use, uncontrolled diabetes mellitus, and hypogonadism 

Presentation of kwashiorkor in adults

Kwashiorkor in adults is associated with high rates of illness and, in some cases, death. Kwashiorkor in adults does not typically present the same way as kwashiorkor manifests in children. This condition in adults is characterised by low energy levels, reduced productivity, decreased work capacity, and the inability to earn a living and economic capability.^12,3,14 

Pointers to kwashiorkor include:

• Irritability
• Weakness
• Easy fatigability
• Apathy and low work capacity

In some instances, kwashiorkor in adults may present with the classic presentation seen in children. Symptoms in this case include:

• “Moon face” appearance
• Muscle shrinking
• Fat wasting
• Cachexia
• Dry skin
• Thin, inelastic, and cold skin
• Peeling of the skin
• Dry hair
• Hair loss
• Scalp thinning 
• Oedema of the legs (peripheral oedema)
• Jaundice
• Petechiae (tiny spots of bleeding under the skin)
• Ascites

Other severe presentations include:^2,8,15

• Amenorrhoea in people assigned female at birth
• Gonadal atrophy and loss of libido in both sexes
• Impaired cognition
• Low blood pressure, low pulse rate
• Hypothermia
• Death in rare cases

Signs of kwashiorkor in adults

Clinically, kwashiorkor can be diagnosed using anthropometric measurements, including body mass index (BMI), waist circumference, waist-to-height ratio, mid-arm circumference, calf circumference, hip circumference, and triceps skinfold thickness. In Kwashiorkor, all the parameters are low.¹⁶ Kwashiorkor can also be assessed using gait speed and grip strength, assistance with walking, ability to get up from a chair, climb a flight of stairs, and frequency of falls.²

Management

Management of kwashiorkor involves screening, followed by a proper evaluation, replacement of the identified deficit, and supplementation of protein and energy as appropriate. Strict monitoring is required in patients to correct the deficit and prevent over-supplementation and its complications. 

Health care workers must work with patients to create customised nutritional support plans. Factors taken into consideration in the development of personalised plans include, but are not limited to, the resources available to the patient to procure food, the ability to cook, and the physical and mental state of the patient. The management requires a multidisciplinary approach.

Summary

Kwashiorkor in adults is an uncommon but serious form of protein and energy malnutrition. It can be caused by reduced dietary intake, malabsorption, increased nutrient losses, altered nutritional requirements, and increased energy expenditure. Early identification of signs and symptoms and proper management are important in prompt treatment to prevent death in severe cases.