Nutritional Disorders , Protein Energy Malnutrition (PEM) - Kwashiorkor, Marasmus

1. Protein Energy Malnutrition
(PEM)
Neha Sheth
Tutor
Dept. of Biochemistry
Parul Institute of Medical Sciences & Research

2. Protein Energy Malnutrition
(PEM/PCM)
Introduction
• Most widespread nutritional problem in Undeveloped and developing
countries.
• Predominantly affecting children.
• Prevalence rate varies 20-50% in different areas.
Depending on:
Socioeconomic status
Level of education and awareness.

3. Protein Energy Malnutrition
Marasmus Kwashiorkor
• Greek Word “To Waste”
• Results from severe
deficiency of both
i) Dietary Energy
ii) Protein
• Severe Muscle Wasting
• Means- “Sickness of First child
gets, when second child is born”
• Ga Tribe of Ghana
• Marginal energy but insufficient
Protein
• Edema

4. Marasmus Kwashiorkor

5. PEM
Causes
Improper/
inadequate
food intake
Food
faddism
Deficient
supply of
food / poor
dietary
habit
Emotional
factors
Metabolic
abnormalities
Diseases /
inadequate
absorption
of food

6. CLINICAL INDICATIONS FOR
EVALUATION OF MALNUTRITION
• Weight-for-Age (Underweight)
• Height-for-Age (Stunting)
• Weight-for-Height (Wasting)
• Head circumference
• Comparative measurement of mid-arm circumference and skin
fold thickness

7. A classification by WHO is based on body weight as a percentage of
standard body weight.

8. Muscle wasted; Prominent
ribs are seen
Bilateral edema in feets
and lower legs

9. MARASMUS- Biochemical Mechanism
Inadequate calories intake (Deficient)
Causes: Decrease insulin levels and Increase cortisol
in Plasma
Results: Protein breakdown & release of amino acids
from muscles (cause severe muscle wasting)
Amino acids are available to liver to synthesize –
ALBUMIN ( So, NO EDEMA)

10. Moderate form Severe form

11. Kwashiorkor- Biochemical Mechanism
Deficiency of Proteins
(Protein : Energy ratio decreases)
Causes: Increase insulin levels and Decrease
cortisol in Plasma
Increases Uptake of amino acids, by muscle
diverting them from liver
Decreases albumin synthesis (< 2 g/dl) [ leads EDEMA]
Also decreases synthesis of LIPOPROTEINS – [FATTY LIVER]
Free radicals are generated - [ SKIN LESIONS]

12. EDEMA
Skin Lesions
Pale HairMoon Face

13. Comparison between salient features
Marasmus Kwashiorkor
Age of
onset
Below 1 year One to 5 year
Deficiency of Calories Protein
Cause
Early weaning and repeated
infection
Starchy diet after weaning,
precipitated by an acute infection
Growth retardation Marked Present
Attitude Irritable and fretful Lethargic and apathetic
Appearance Shrunken with skin and bones
only. Dehydrated
Looks plump due to edema on face
and lower limbs

14. Marasmus Kwashiorkor
Appetite Normal Anorexia
Skin Dry and atrophic ‘Crazy pavement dermatitis’ due to
pealing, cracking and denudation
Hair No characteristic change Sparse, soft and thin hair; curls may
be lost
Associated
features
Other nutritional
deficiencies;
Watery diarrhea Muscles are
weak and atrophic
Angular stomatitis and cheilosis are
common; Watery diarrhea Muscles
undergo wasting
Serum
albumin
2 to 3 g/dL < 2 g/dL
Serum
cortisol
Increased Decreased

15. Biochemical Alterations in PEM
i. Hypoalbuminemia: Albumin values less than 2 g/dl is a biochemical
marker in cases of kwashiorkor. [EDEMA]
In marasmus, this may not be so low.
ii. IgG increases due to associated infections.
iii. Fatty liver is seen in some cases of kwashiorkor, but not in
marasmus.
Fatty liver is due to decreased lipoprotein synthesis.
iv. Glucose tolerance is often normal, but hypoglycaemia may be seen
in marasmic children.
v. Hypokalemia and dehydration may be seen when there is diarrhea.
vi. Hypomagnesemia is a usual finding

16. Management for Protein Energy Malnutrition
• Optimal response is observed with diets providing
150-200 kcal/kg body weight and 3-4 g of protein/kg
body weight.
• A mixture of three parts of vegetable proteins (Bengal
gram or peanuts) and one part of milk protein is found
to be very effective.
• It is monitored by disappearance of edema, rise in
serum albumin level and gain in weight.

17. Sequelae of Protein Calorie Malnutrition
• Severe malnutrition in early life can lead to permanent and
irreversible physical and functional deficits.
• Severe persistent malnutrition may have deleterious effects
on the intellectual capacity in later life.
• There may not be any sequelae where the moderate and mild
forms are corrected in time.

18. Cachexia due to Diseases
• Patients with advanced cancer, AIDS (HIV infection),
tuberculosis, etc. are seen as undernourished; this is called
cachexia.
• This is similar to marasmus, but the loss of body protein is
more than that seen in simple malnutrition.
Cachexia is explained by the following facts:
1. Chronic infections and cancer will induce production of
inflammatory cytokines; this leads to breakdown of protein by
ubiquitin or proteasome pathway. This increases the energy
expenditure. BMR is considerably increased.

19. Cytokines also stimulate uncouplers such as thermogenin,
leading to increased oxidation and thermogenesis without
trapping energy.
3. Futile cycling of lipids occurs, as the hormone sensitive
lipase is activated by proteoglycans secreted by tumors. So,
free fatty acids are liberated from adipose tissue. These are
utilized for triacylglycerol synthesis in liver; this is a process
that needs high expenditure of energy. This fat is again
reaching adipose tissue through VLDL, thus completing the
futile cycle.

20. 4. Most of the tumors preferentially use anaerobic glycolysis,
the end result being lactic acid. This lactate enters the
gluconeogenesis pathway in liver, which is an energy
consuming reaction (requiring 6 ATPs for each glucose unit).