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Dev Ram Sunuwar, M.Sc. Nutrition and
A pathological state resulting from relative or absolute
deficiency of one or more essential nutrients
Comprises four forms:
The world health organization (WHO) defines Malnutrition as –
“The cellular imbalance between the supply of nutrients and
energy and the body’s demand for them to ensure growth,
maintenance, and specific functions."
On a global
are five main
“ A range of pathological
conditions arising from
simultaneous deficiency of
“proteins & energy” and
commonly associated with
• PEM is the single most important
cause of childhood morbidity and
• Severe form of PEM is found in
about 5% children below the age
of 5 yrs .
•About 50-60% have mild to
Protein Energy Malnutrition
The term protein energy malnutrition
has been adopted by WHO in 1976.
Highly prevalent in developing countries
among <5 children; severe forms 1-10% &
All children with PEM have one or more
The term marasmus is derived from the Greek word “marasmos”, which means
“withering or wasting away”. Marasmus involves inadequate intake of protein
and calories and is characterized by emaciation.
The term kwashiorkor is taken from the Ga language of Ghana and means "the
sickness of the weaning." Williams first used the term in 1933, and it refers to an
inadequate protein intake with reasonable caloric (energy) intake. Edema is
characteristic of kwashiorkor but is absent in marasmus.
Children may present with a mixed picture of marasmus and kwashiorkor, and
children may present with milder forms of malnutrition. For this reason, Jelliffe
suggested the term protein-calorie (energy) malnutrition to include both
Protein Energy Malnutrition (PEM) or Protein Calorie Malnutrition (PCM ) is the
name given to various degrees of nutritional disorders caused by inadequate
quantities of protein and energy in the diet. This is one of the most widespread
deficiency disease in India and Nepal
Classification of PEM (FAO/WHO)
Body weight as
Oedema Deficit in weight
Kwashiorkor 60 – 80 + +
< 60 + ++
Marasmus < 60 0 ++
< 60 0 Minimal
60 – 80 0 +
The most common cause of malnutrition is poverty.
PEM is primarily due to two factors:
• An inadequate intake of food both in quantity and quality
• Infections like – Diarrhoea, Respiratory Infections, Measles,
Intestinal worm infestation
• These infections increase requirements for calories, proteins
and other nutrients, while decreasing their absorption and
ETIOLOGY / CAUSES OF PROTEIN ENERGY
Malnutrition is a serious problem in Nepal, as in
other countries of South Asia, and is a major threat
to the health of infants, adolescent girls and
pregnant & lactating mothers.
National studies over the last 50 years show
malnutrition rates in children under 5 years of age
persist at rates around 50%.
Malnutrition in Nepal
Poor hygiene and poor environmental conditions
Poor maternal health and nutritional status
Poor maternal nutrition during Pregnancy
Failure of Lactation
Premature termination of breast feeding
Social and cultural feedingpractices
Low birth weight
Mal-absorption states like- Short bowel syndrome (small intestineinsuﬃciency)
The other main factors causing PEM
Protein and calorie
Common in infants
3 years of age.
Onset is more
months of age.
Onset is more
The term marasmus is derived from the Greek marasmos,
which means wasting.
Marasmus involves inadequate intake of protein and
calories and is characterized by emaciation.
Marasmus represents the end result of starvation where
both proteins and calories are deficient.
Marasmus represents an adaptive response to starvation.
In Marasmus the body utilizes all fat stores before using
Seen most commonly in the first year of life due
to lack of breast feeding and the use of dilute
Poverty or famine and diarrhoea are the usual
Ignorance & poor maternal nutrition are also
EPIDEMIOLOGY & ETIOLOGY
Kwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of
life following abrupt weaning
Kwashiorkor is not only dietary in origin. Infective,psycho-socical, and cultural
factors are also operative.
Kwashiorkor is an example of lack of physiological adaptation to
unbalanced deficiency where the body utilized proteins and conserves S/C
One theory says Kwashiorkor is a result of liver insult with
hypoproteinemia and oedema.
Food toxins like aflatoxins have been suggested as precipitating factors.
“Prevention of PEM is the fight against poverty and
It must be appreciated that there is no single shot solution to
the treatment or prevention of PEM.
It is a complex problem involving each of the social,
economic, educational, political, administrative, medical and
An integrated effort involving all these and also awareness
and a positive attitude towards the condition might help to
Prevention and control of PEM