This document presents information on Protein Energy Malnutrition (PEM). It begins with defining malnutrition and the different forms of undernutrition, including PEM. It then discusses the three main forms of PEM: Marasmus caused by calorie deficiency, Kwashiorkor caused by protein deficiency, and Marasmic Kwashiorkor having features of both. Risk factors, diagnosis, management, and prevention strategies for PEM are also outlined. The document concludes with discussing government programs in Nepal aimed at preventing malnutrition, such as the Multi-Sector Nutrition Plan and Integrated Management of Acute Malnutrition.

1. Presentation on
Protein Energy Malnutrition
(PEM)
Nabin bisht
PSM

2. Table of Content
• Concept of malnutrition
• Concept of PEM
• Forms of PEM (Marasmus,Kwashiorkor,marasmic-kwashiorkor)
• Risk factor
• Diagnosis
• Management
• Prevention

3. Malnutrition
• Malnutrition refers to deficiencies, excesses or imbalances in
a person’s intake of energy and/or nutrients.
• The term malnutrition covers 2 broad groups of conditions.
One is ‘undernutrition’—which includes stunting (low
height for age), wasting (low weight for height), underweight
(low weight for age) and micronutrient deficiencies. The
other is overweight, obesity and diet-related non-
communicable diseases (such as heart disease, stroke,
diabetes, and cancer)

4. Malnutrition Framework
Malnutrition
Over-Malnutrition
Under-Malnutrition
Wasting Micronutrient Deficiency
Stunting Underweight
e.g. Over-weight, Obesity
SAM MAM
• Marasmus
• Kashiworker
• Marasmickwashiorkor
e.g. Iron def., Iodiene

5. Global Prevalence
• 1.9 billion adults are overweight or obese, while 462 million are
underweight.
• Globally in 2020,
• 149 million children under 5 were estimated to be stunted .
• 45 million were estimated to be wasted
• 38.9 million were overweight or obese.
• Around 45% of deaths among children under 5 years of age are linked
to undernutrition. These mostly occur in low- and middle-income
countries.

6. National Prevalence

7. Prevalence of Malnutrition (Province)
NDHS 2022
province 1
Madhesh
Province
Bagmati
Province
Gandaki
Province
Lumbini
Province
Karnali
Province
Sudurpashchim
Province
National
Stunted 20 29.3 17.6 19.7 25.1 35.8 28.4 25
Wasted 3.8 10.1 4.5 4 16.2 3.8 5.1 8
Underweight 13 26.8 10.5 18.1 23.3 17.7 13.9 19
20
29.3
17.6
19.7
25.1
35.8
28.4
25
3.8
10.1
4.5 4
16.2
3.8
5.1
8
13
26.8
10.5
18.1
23.3
17.7
13.9
19
0
5
10
15
20
25
30
35
40

8. PROTEIN ENERGY
MALNUTRITION

9. PROTEIN ENERGY MALNUTRITION
• It is the Deficit condition of Protein or Energy(carbs+ Fat)
or combination of Both .
• Protein–energy malnutrition (PEM), sometimes
called protein-energy undernutrition (PEU), is a form
of malnutrition that is defined as a range of conditions
arising from co-incident lack of dietary protein and/or
energy (calories) in varying proportions. The condition
has mild, moderate, and severe degrees.

10. INTRODUCTION
• It is a one of the major public health problem of developing
countries including Nepal.
• PEM denotes a range of pathological conditions arising out of
immediate lack of protein and energy in varying proportions,
most frequently seen in infants and young children usually
associated with infections.
• It occurs in three clinical forms Marasmus and Kwashiorkor or
marasmic-kwashiorkor.

11. INTRODUCTION
• The main cause of PEM is “food gap” i.e. due to an
inadequate intake of food both quality and quantity.
• Infections especially chronic diarrhea, ARI,
measles, and intestinal worms which increase the
requirements for calorie, protein and other nutrients
while decreasing the absorption and utilization
causes PEM.

13. Causes of Malnutrition

14. Types/Forms of PEM
1. Marasmus (deficiency in calorie intake)
2. Kwashiorkor (protein deficiency malnutrition)
3. Marasmic kwashiorkor (marked protein deficiency and
marked calorie insufficiency signs present, sometimes
referred to as the most severe form of malnutrition)

15. Classification of PEM (FAO/WHO)
FORMS of PEM Body weight by
AGE
OEDE
MA
MARASMUS <60% -
KWASHIWORKOR 60-80% +
MARASMIC
KWASHIKOR
<60% +

16. 1.MARASMUS (सुक
े नास)
• Marasmus is a form of severe Acute
malnutrition characterized by energy
deficiency.
• It can occur in anyone who has severe
energy deficiency, but it usually occurs in
children.
• It is a form of severe cachexia(wasting) with
weight loss as a result of wasting in infancy
and childhood. The main symptoms of
marasmus are severe wasting, with little or
no oedema, minimal subcutaneous fat,
severe muscle wasting.

17. 2. KWASHIORKOR (फ
ु क
े नास)
• Kwashiorkor is a severe form of
undernutrition ,the main cause of this
form of malnutrition is inadequate
protein intake and low concentration of
essential amino acids.
• It develop in individuals on diets with a
low protein/energy ratio.
• The main symptoms of Kwashiorkor are
oedema, wasting, liver enlargement,
hypoalbuminaemia, steatosis and the
possible depigmentation of skin and hair.

18. 3.MARASMIC KWASHIORKOR (सुक
े नास सहितको
फ
ु क
े नास)
• It is the combination of both marasmus and
kwashiorkor.
• Mixed type of under-nutrition with oedema, gross
wasting, and mild liver enlargement.

19. DIFFERENCE BETWEEN MARASMUS AND KWASHIORKOR
Features Marasmus Kwashiorkor
Age Usually below 1 1 to 5 year
Cause Calories Protein
Weight/height <60 %(Gomez‘) 60-80 %
Face Old man Moon
Abdomen shrunken Distended
Muscle wasting Obvious Sometimes hidden by edema
Fat wasting Severe loss of
subcutaneous fat
Fat often retain but not firm
Oedema* None Present in lower legs and usually
face and lower limbs

20. Features Marasmus Kwashiorkor
Appetite Usually good Poor
Mental changes Sometimes quite and
apathetic
Irritable, moaning, apathetic
Diarrhea Often (current and past) Often (current and past)
Skin changes Dry Diffuse pigmentation,
sometimes ‘flaky paint
dermatitis’
Hair changes Seldom silky, easily pulled out
Serum albumin Normal or slightly
decreased
Low (<3g/dl of blood)
Hepatic
enlargement
None Sometimes, due to
accumulation of fat

21. Risk factors:-
• Age- 6 to 18 months child is growing fast, food commonly given is
not adequate
• Sex - Girls (many cultures boys valued more)
• Many children
• Short interval between births
• Failure or stoppage of breast feeding
• Delay in introducing additional food
• Infectious diseases, especially -repeated diarrhoea,pneumonia or
measles
• Low birth weight
• twins

22. Diagnosis

23. Treatment of Severe Acute Malnutrition
1. Treat/prevent hypoglycemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte imbalance
5. Treat/prevent infection/ Deworming
6. Correct micronutrient deficiencies
7. Initiate Refeeding
8. Facilitate catch-up growth
9. Provide sensory stimulation and emotional support
10.Prepare for follow-up after recovery
Source: WHO guideline for the management of severe acute malnutrition

24. Prevention of malnutrition

25. the 8th FAO/WHO Expert Committee on Nutrition
for the prevention of PEM in the community :
(a) Health promotion :
1. Measures directed to pregnant and lactating women (education, distribution of
supplements);
2. Promotion of breast-feeding;
3 . Development of low cost weaning foods : the child should be made to eat more
food at frequent intervals;
4. Measures to improve family diet;
5. Nutrition education -Promotion of correct feeding practices;
6. Home economics;
7. Family planning and spacing of births; and
8. Family environment.

26. (b) Specific protection :
1. The child's diet must contain protein and energyrich foods.
Milk, eggs, fresh fruits should be given if possible;
2. Immunization; and
3. Food fortification.

27. (c) Early diagnosis and treatment:
l. Periodic surveillance;
2. Early diagnosis of any lag in growth;
3. Early diagnosis and treatment of infections and diarrhoea;
4. Development of programmes for early rehydration of children
with diarrhoea;
5. Development of supplementary feeding programmes
during epidemics
6. Deworming of heavily infested children.

28. (D) Rehabilitation :
1. Nutritional rehabilitation services;
2. Hospital treatment; and
3. Follow-up care.

29. Prevention at Individual level :
• Balance diet
• Diversity in food ( “Harek baar khana char” )
• Prohibition of Unhealthy diet
• Exclusive breastfeeding and complementary feeding
• Personal Hygiene and sanitation
• Nutritional assessment including growth monitoring
• Treatment of infectious disease Diarrhoea, malaria, measles etc.
• Immunization.
• Family planning

30. Prevention at family or/Household level:
• Maternal and child Nutrition (antenatal care ,postnatal care)
• Maternal and child Health care
• Home Food security
• Maternal education and empowerment

31. Prevention at community level:
• Community Awareness
• Community participation and Mobilization.
• Promotion of local endemic food
• Anthropometric assessment of the children such as:
(Height,Weight,MUAC )
• Early diagnosis, Screening and Hospitalization (NRH)

32. Prevention at National level:
• Multi sectorial Approach
• Nutritional intervention Policies, Programs (like IMAM)
• Mass Food fortifications
• Nutritional surveillance
• Socio economic status improvement
• Safe drinking water and sanitation.

33. Prevention at international level:
• Food & nutrition are global problems. International
cooperation in solving problems of malnutrition.
• Plays important role in mitigating the effect of acute
emergencies caused by floods & droughts.
• Multilateral coordination with organizations such as: WHO,
FAO, UNICEF, WORLD BANK, UNDP etc.

34. UNICEF Conceptual Framework on the Determinants of Maternal and
Child Nutrition, 2020. A framework for the prevention of malnutrition
in all its forms.

35. Government Of Nepal Strategies or Program
to prevent Malnutrition in Nepal
• Multi-sector Nutrition Plan II (2018-2022), Nepal
• IMAM (Community mobilization, Inpatient Therapeutic Care (ITC),
Outpatient Therapeutic Care (OTC) , Management of Moderate Acute
Malnutrition (MAM)
• Nutritional Intervention Program
• CB-IMNCI
• FCHV Screening
• MIYCN program
• IYCF program
• SUAHARA II 2016-2021 (42 District)

36. 1. MSNP (launched in September 2012)

37. 2.IMAM (Inegrated Management of Malnutrition)
• 2008 - Community Based Management of Acute Malnutrition
(CMAM) has been implemented by MoP with the help of UNICEF
since 2008 in 5 districts (Achham, Bardiya, Jajarkot, Kanchanpur and
Mugu).
The primary objectives of IMAM are:
• To reduce mortality and morbidity risks in children under five due to
acute malnutrition.

38. Components of IMAM
1) Community mobilization
2) Inpatient Therapeutic Care
(ITC),
3) Outpatient Therapeutic Care
(OTC)
4) Management of MAM.

39. 3. MIYCN (Maternal Infant and Young child Nutrition)
Maternal = Pregnant mother (270 days )
Infant = under 1 year (356 days
Young Children = 12- 23 months (365 days)
• The MIYCN campaign aims to promote new norms around feeding
practices among mothers and families, cultivate greater understanding
about good nutrition-related behaviour and improve nutrition
outcomes for children in the first 1000 days.

40. 5. Other Nutrition Intervention Program

42. Reference
• K. park textbook. 25th edition
• WHO Malnutrition Report
• IMAM program Nepal
• Annual Report
• NDHS 2022

43. THANK YOU