The Reverse Paradigm Underlying Pathology Revealed by Detection of Abnormal Nutrition

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In clinical medicine, a type of 'reversal of roles' often occurs. Rather than primarily recognizing the presentation of the underlying pathology, recognition of an abnormal nutritional status without a suitable dietary cause leads to the diagnosis of the underlying disorder before any specific (pathogno-monic) sign or symptom has yet occurred. For instance, the Prader-Willi syndrome of pathological obesity would initially present as common obesity. Similarly, in hypercorticosteroidism (Cushing's syndrome), abnormal fat deposition and weight gain can be the changes that lead to the recognition of the underlying pituitary or adrenal dysfunction.

Classically, in type 2 diabetes, unexplained weight loss is a presenting complaint when polyuria is mild or absent. Moreover, with common forms of childhood gastrointestinal disorders, such as celiac sprue or Crohn's disease, arrested linear growth is often the first clue that something is clinically awry. It provokes the diagnostic inquiry that leads to the recognition of the bowel lesions. In milder presentations of cystic fibrosis, a similar growth failure occurring in infancy, can indicate an underlying pathological disorder.

In fact, the entire roster of conditions listed in Table 1 and Table 2, as well as others of a similar nature, are subject to being diagnosed as the result

Table 3 Three-level diagnostic principles related to secondary malnutrition

Assessment of dietary and nutrient intake: A quantitative and qualitative evaluation of usual dietary intake by a nutritionally trained practitioner or clinical dietician serves to exclude the possibility that the situation is not primary (low intake) in nature and suggests the secondary basis of the nutritional problem. Caveat: In certain situations, a combination of reduced intakes and nutritional stress at absorption, retention, or utilization may coexist.

Assessment of nutritional status: This includes the measures of anthropometry and body composition, hematological status, biological indices, and functional indicators, as well as clinical (physical) evaluation.

Diagnosis of underlying cause(s) of secondary nutritional imbalance: It is important, where possible, to identify the underlying entitie(s) that are causing the nutritional problem, to enable (where possible) a direct remedial approach to the cause of malnutrition and to orient management based on any pathophysiological knowledge about the underlying disease.

of a secondary change in nutritional status. The practical message is that the nutritional specialist, physician, or nonphysician may be the first person to whom the secondarily malnourished patient is referred and the acumen of recognising a secondary causation will guide the case to an appropriate clinical diagnostic program to uncover (and hopefully address and remedy) the underlying medical or surgical problems. Overarching guideline principles for uncovering secondary malnutrition states are provided in Table 3.

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