A lucid presentation on Nutritional importance of protein for medical , dental , pharmacology and biotechnology students to facilitate self-learning.

1. Nutritional importance of Proteins
Dr. Rohini C Sane

2. Nutritional importance of Proteins
• Protein: 10-15% of total energy source
• form the fundamental basis of cell structure and its function (building
blocks for body tissue).
• Protein are source of essential amino acids.
• if enough carbohydrate present in diet , no utilisation of amino acids
for yielding energy(Protein sparing effect of carbohydrate).
• in starvation ,amino acids may act as the major energy sources .
• are involved in maintenance of osmotic pressure ,clotting of
blood ,muscle contraction etc.
• 1985/WHO/FAO safe levels protein intake for adults = 0.75-0.8 g/kg/day

3. Functions of proteins
• Fundamental basis of cell structure and functions : e.g Keratin from hair ,nails and
collagen from bone. Protein form building blocks for body tissue.
• Synthesis of catalytic proteins i.e.enzymes e.g. Hexokinase ,Pepsin
• Synthesis of several hormonal proteins and hormone receptors : Insulin , Growth
hormones
• Synthesis of defence proteins : immunoglobulins
• Synthesis of contractile proteins : Actin , Myosin involved in muscle contraction
• Synthesis of transport carriers: Haemoglobin, serum albumin
• Synthesis of genetic proteins: nucleoproteins
• Maintenance of osmotic pressure
• Clotting of blood : e.g. Prothrombin , Fibrinogen
• Major supplier of energy( but no storage form): 15% of total energy
• During starvation : amino acid derived from structural proteins are the major supplier of
energy.

4. Non essential amino acids
• Non essential (dispensable) amino acids :
1. Alanine
2. Asparagine
3. Aspartic acid
4. Cysteine
5. Glutamic acid
6. Glutamine
7. Glycine
8. Proline
9. Serine
10. Tyrosine
Alanine ,Aspartate and Glutamate are truly dispensable ,as they
can be synthesised from pyruvate, oxaloacetate and alpha
ketoglutarate respectively . These precursors are generally available
in plenty.
Cysteine and Tyrosine can be synthesised when Methionine and
Phenylalanine (respectively) are available.

5. Essential amino acids
1. Arginine
2. Valine
3. Histidine
4. Isoleucine
5. Leucine
6. Lysine
7. Methionine
8. Phenylalanine
9. Tryptophan
10.Threonine
AVHILLMPTT
Human body is incapable of synthesising 9 of the 20 amino
acids required for protein biosynthesis .
These amino acids must be supplied in the diet and are termed
essential amino acids.
Nutritional importance of proteins is based on the content of
essential amino acids .

6. Semi-essential amino acids
1. Histidine
2. Arginine
synthesised by adults not by growing children.
}

7. Daily dietary requirement of essential amino acids
Essential amino acids
mg/kg body
weight /day
(requirement)
for adult
mg/kg/day
(requirement)
for infants
(3-4 months)
mg/kg/day
(requirement)
for children(2yrs)
Phenylalanine 16 125 69
Leucine 16 161 73
Lysine 12 103 64
Valine 14 93 38
Isoleucine 12 70 31
Threonine 8 87 37
Methionine 10 58 27
Tryptophan 3 17 12.5
Histidine 28
Cysteine can spare (partly) Methionine.
Tyrosine can spare (partly) Phenylalanine.

8. Recommended protein allowances
Group
Recommended protein allowance
(g/ kg body weight /day)
Infants 2.4
Children(up to 10yr) 1.75
Adolescent boys 1.6
Adolescent girl 1.4
Adult(men/women) 0.8
Pregnancy 2.5
Lactation 2.5

9. Nitrogen balance
Dr. Rohini C Sane

10. Nitrogen balance
• Nitrogen balance: is a state in which the total daily loss of nitrogen from the body
equal the daily nitrogen intake(utilisation of nitrogen = loss of nitrogen).
• Dietary protein is an exclusive source of nitrogen to human body. In protein,16%
is nitrogen content.
• Daily Intake of Nitrogen in normal adult : is 10-15 g chiefly as dietary protein.
1g of nitrogen is derived from 6 g of protein.
• Excretion of Nitrogen occurs through following routes:
1.Urine account for excretion of 90-95 % of nitrogen as urea constituting 80-85%
and smaller amounts as urates ,ammonia and creatinine.
2.in faeces in form of :
undigested and unabsorbed nitrogenous dietary material
end products of nitrogenous /proteins metabolism from shed intestinal cell by
digestive enzymes.
intestinal bacterial nitrogen.
3. Sweat
4. Saliva
5. Desquamated skin
6. Hair and nails
• Nitrogen equilibrium in normal healthy adult: I = U+F+S
Daily nitrogen dietary intake (I) = nitrogen loss[U (urine)+ S(sweat)+F (faeces)]

11. Positive and Negative Nitrogen balance
• Nitrogen balance : is determined by measurement of dietary nitrogen
intake(chiefly by proteins) and daily nitrogen loss / excretion (mostly
undigested protein in faces , urea ,ammonia in urine).
• 16% weight contribution of Nitrogen in proteins.
• Nitrogen equilibrium in normal healthy adult: I= U+F+S
Daily nitrogen dietary intake (I) = nitrogen loss[U (urine)+ S(sweat)+F (faeces)]
• Positive nitrogen balance is state in which Nitrogen intake higher than
Nitrogen loss/excretion . Some amount of Nitrogen retained in body causing
increase in the body protein and weight gain.
• Negative nitrogen balance is a state in which Nitrogen loss /output/excretion
is higher than Nitrogen intake / input . Some amount of Nitrogen is lost
depleting the body protein and loss of body weight .
Prolonged nitrogen loss leads to death.e.g. Kwashiorkor, Marasmus .
Fudge factor (3g) is nitrogen lost in faces ,sweat and nails etc.

12. Causes of Negative nitrogen balance
• inadequate dietary intake of protein and energy intake (Kwashiorkor and marasmus)
• deficiency of even a single essential amino acid
• Decreased amino acid absorption :
A. after surgery
B. intestinal disease
C. inherited transport defects
• decreased protein digestion(chronic pancreatic disease)
• serious illness
• increased breakdown /catabolism /destruction of tissue protein (loss of nitrogen
from body): starvation, infections , severe trauma and endocrine hyperactivity
(Cushing’s syndrome and Thyrotoxicosis).
• Prolonged nitrogen balance may even lead to death.
In negative nitrogen balance, the body adapts itself and
increases the breakdown of tissue proteins causing loss
of nitrogen from the body.

13. Conditions associated with protein loss
• during menstruation
• following burns
• nephrotic syndrome
• protein -losing gastro-enteropathies as in malignancies
• haemorrhage

14. Overview of nitrogen balance
Body proteins
Anabolism Catabolism
Dietary proteins amino acids pool Urinary of N2 (U)as Urea,Creatinine
faeces (F) skin (S)
Nitrogen input(I)
Nitrogen balance : Nitrogen input = Nitrogen output
Positive Nitrogen balance : Nitrogen input/intake > Nitrogen output/Excretion/loss
Negative Nitrogen balance : Nitrogen output/Excretion/loss > Nitrogen input (intake) or
Nitrogen input (intake)< Nitrogen output (Excretion)
Nitrogen output

15. Conditions associated with Positive Nitrogen balance
Positive Nitrogen balance : is a state in which the nitrogen intake is
higher than nitrogen output/ loss / excretion .
Some amount of nitrogen is retained in the body during positive
nitrogen balance ,causing a net increase in the body proteins.
Conditions associated with Positive Nitrogen balance:
1. During Growth
2. Pregnancy
3. Convalescence(recovery after serious illness)
4. Excess secretion of anabolic hormones such as androgens,
estrogens and growth hormone.

16. Maintenance of Nitrogen balance
• To maintain the Nitrogen Balance , following conditions regarding
nitrogen intake to be satisfied :
1. Obligatory nitrogen loss: 3.5 g nitrogen /day for 65 kg person
(urine ,fecal and cutaneous loss=22g protein).
2. Requirement for protein turnover: the minimum daily protein
requirements to compensate for above two categories 0.75- 0.8 g/kg
body weight of good quality protein.
3. Protein requirement for growth : applicable for infants ,children,
adolescents ,pregnancy , lactation and convalescence.
4. Protein requirement decreases as growth stops.
5. For 5kg body weight gain( i.e. 1kg protein added to the body ),160
g of nitrogen has to be retained.

17. Factors affecting Nitrogen balance
promote Positive nitrogen balance
negative nitrogen balance
1. Growth: active growth Positive nitrogen balance e.g. 5 kg weight gain 1 kg protein are
added to the body 160 g nitrogen has to be retained .
2. Hormones:
Growth Hormone
Insulin
Androgens
Corticosteroids : cause negative nitrogen balance.
3. Pregnancy :Positive nitrogen balance( due to the growth of foetus)
4. Convalescence : after surgery Positive nitrogen balance(due to active regeneration of
tissues)
5. Acute illness : surgery
Trauma
Burns
6. Chronic illness : Malignancy , uncontrolled Diabetes Mellitus,other debilitating diseases
(Cachexia) negative nitrogen balance
7. Protein Deficiency( Kwashiorkor/Marasmus ) and deficiency of even single amino acid
negative nitrogen balance

18. Assessment of Nutritional Values(Nutritional
indices) of proteins
Dr. Rohini C Sane

19. Dietary sources of proteins
Protein content(as a dietary source) of animal protein >vegetable protein
Dietary source of protein Protein content(% of weight)
Cereals 6-12
Meat 18-25
Egg
10-14
Milk 3-4
Leafy vegetables 1-2

20. Dietary requirement of proteins
Dietary requirement of proteins depend on:
1. Nutritive value
2. Caloric intake
3. Physiological status (growth,pregnancy ,lactation)
The quantity of dietary protein alone is not sufficient to evaluate the nutritional
importance of proteins.
category
Dietary requirement of proteins(g protein /kg body
weight /day)
Adult 0.8-1.0
growing Children/
pregnant /lactating
women
1.6-2

21. Protein quality
• Protein quality : refers to the content of the essential amino
acids present in the diet.
• Proteins that lack any of the essential amino acids have less
biological value .
• Quality of protein depends upon :
A. the content and proportion of amino acids.
B. content of essential amino acids
C. easy digestibility
D. efficacy of absorption

22. Classification of proteins based on quality of Dietary protein
First class proteins : which include animal proteins that
contain all essential amino acids in correct
proportions .The animal proteins are superior in their
nutritive value compared to the proteins of vegetable
origin.
Second class proteins: which include vegetable proteins
that lack some essential amino acids .e.g. cereal proteins
are poor in Lysine, Methionine and Tryptophan. They are
less digestible .

23. Nutritional values (Nutritional indices) of proteins
• Whipple(Nobel prize 1934) introduced plasmapheresis as a means to
assess nutritional value of proteins.
Plasma of animal taken out of the body of animal.
Plasma albumin removed from the animal body.
The plasma was introduced back in animal body.
Mice fed with the test protein.
The time for restoration of original level of plasma albumin noted to
qualify the protein given to animal.
Modern way to assess nutritional value of protein:
Mice fed with the test protein . Since protein is the only source of
nitrogen to animal .Weight gain in the animal is noted.

24. Indices for Assessment of protein quality
• Indices for assessment of Nutritional value (protein quality) :
1. Biological value(BV)
2. Net protein utilisation(NPU)
3. Protein efficiency ratio(PER)
4. Chemical score
5. Amino acid score

25. Biological value(BV) of Dietary protein
Biological value(BV) : is defined as the percentage of
absorbed nitrogen retained by the body i.e.it is the ratio
between the amount of nitrogen retained and nitrogen
absorbed during a specific interval.
Application of Biological value : BV gives an estimate of
digestibility of protein , through percentage of nitrogen
absorbed from the diet.
Biological value = x100
Nitrogen retained
Nitrogen absorbed

26. I I I II I I I
Assessment of Biological value of Dietary protein
weaning albino rat protein-free
diet
10days
nitrogen content of diet, urine
& faeces analysed before
intake of the protein diet.
I I I I
10% protein diet
nitrogen content of diet, urine
& faeces analysed after intake
of the protein diet.

27. Biological value (BV)of Dietary protein
BV= percentage of absorbed Nitrogen retained in human body/albino rat
N2 retained
N2 absorbed
[N2 absorbed -N2 lost in metabolism]
N2 absorbed
In-[(Fn-Fc)]-(Un-Uc)]
In-(Fn-Fc)
In = N2 ingested(100 mg)
Fn= N2 in faeces (on intake of protein diet)
Fc= N2 in faeces (on intake of protein-free diet)
Un= N2 in urine (on intake of protein diet)
Uc= N2 in urine (on intake of protein-free diet)
BV=
BV=
BV=
x100
x100
x100

28. Inherent drawback of Biological value in evaluation of Dietary protein
• Biological Value(BV) cannot take account the nitrogen that might be lost
during the digestion process.
Example of Erroneous nature of Biological value of protein:
N2 ingested (on intake of protein diet)=100mg
N2 retained= 8 mg
N2 absorbed= 10 mg
BV= 8/10 X100 =80
This is figure is erroneous,since the major part of the protein (90 mg)
didn’t enter the body at all for utilisation.

29. Biological value (BV)of Dietary protein
BV= Nitrogen Retained / Nitrogen absorbed in body x 100(within special
interval)
Casein from milk
Gliadin from wheat
Zein from corn
Days
weightingofmice
Casein : complete protein
Gliadin : deficient in Lysine
Zein : deficient in Lysine and Tryptophan

30. Biological value (BV)of a Dietary protein
Amount protein ingested /consumed by a rat in a day:127 mg
Amount nitrogen recovered from feces : 4 mg
Amount of nitrogen recovered /excreted in urine: 24 mg
Amount of nitrogen absorbed :127-4 =123 mg
Amount nitrogen retained : 123-24= 99mg
Biological value (BV) = 99/123 X 100 =81%
BV does not account for any allowances for nitrogen losses during digestion.
Good proteins will cause weight gain.
Amount nitrogen ingested /consumed : 100 mg
Amount of nitrogen absorbed : 5 mg
Amount nitrogen retained : 4.5 mg
BV = 4.5 /5 X100 =90%
Biological value (BV) of Protein B is better than Protein A.
Protein A
Protein B

31. Net Protein utilisation(NPU)of Dietary protein
NPU is a better index than Biological Value to denote nutritional quality and
availability of protein .It accounts for Nutritional value and digestibility of proteins.
The experimental procedure for NPU is similar to that of BV.
N2 Retained by the body
N2 ingested (Intake)by the body
In calculating protein quality, 100g of protein is assumed to be equivalent to be
6.25g of Nitrogen.
NPU of the protein of Indian diets = 50-60 %
NPU of “A” protein= 99/127x100=78%( if NPU is high, protein requirement is low).
NPU of “ B” protein= 4.5/100x100=4.5%( if NPU is low, protein requirement is high).
Application of NPU: gives more complete expression (both absorption and
retention )of protein than amino acid score.
X100NPU =

32. Protein efficiency Ratio(PER)for Dietary protein
Protein efficiency Ratio(PER) represents the body weight gain (g) of a
rat per gram of protein intake(ingested) with 10% test protein solution.
or
gain in body weight (g)
protein ingested (g)
21 days old weaning albino mice is injected with 10% solution of test
protein diet. Gain in body g weight is noted for a period of 4 weeks.
e.g.
Dietary source of protein Protein efficiency ratio(PER)
Rice 2.2
Milk 3.0
Egg 4.5
Protein efficiency Ratio(PER)=

33. Net Dietary protein value(NDPV) of Dietary protein
(NDPV)=intake of nitrogen x 6.25 x NPU(Net protein utilisation)
Application of NDPV: to assess quantity and quality of proteins
in the diet.

34. • Chemical score : is based on the chemical analysis of protein for
composition of essential amino acids which is then compared with
a reference protein (usually egg protein). It is mg of amino acid per
gram of protein.
• Chemical score is defined as the ratio between the quantity of the
most limiting essential amino acid in the test protein to the quantity of
same amino acid in the egg protein .It is expressed as percentage.
• e.g.Chemical score of egg protein for any one of the essential amino
acids=100 and the rest of the proteins are compared.
mg of limiting amino acid /g test protein
Chemical score of dietary protein
Chemical score= x100
mg of the same amino acid /g egg protein

35. Chemical and amino acid score of the protein
Chemical score: It is an analysis for composition of essential amino
acids of the protein . It indicates mg of essential amino acid content
per gm of protein.
mg of the limiting amino acid /1g of test protein
mg of the same limiting amino acid / 1g of reference(egg)protein
Amino acid score =
mg of amino acid /1g of test protein
mg of amino acid / 1g of reference protein
Limiting amino acids and supplementation: Limiting amino acids
limit weight gain when protein supplied to an animal.
x100
x100
Chemical score=

36. Nutritive value of food proteins
Source of
protein
Biological
value
(BV)
Net protein
utilisation
(NPU)
Protein
efficiency
ratio
(PER)
Chemical
score
Limiting amino
acid(s)
Egg 90 91 4.5 100 Nil
Milk 84 75 3.0 65 Cysteine ,Methionine
Meat 80 76 2.8 70 Cysteine ,Methionine
Fish 85 70 3.0 60 Tryptophan
Rice 68 60 2.2 60 Lysine, Threonine
Wheat 58 47 1.7 42 Lysine, Threonine
Bengal
gram
58 47 1.7 45 Cysteine,Methionine
Ground nut 54 45 1.7 44
Lysine,Threonine,
Cysteine ,Methionine
Soybean 65 54 2.0 57 Cysteine ,Methionine
Gelatin 0 0 Tryptophan
Zein 0 0 Tryptophan,Lysine

37. Certain proteins are deficient in one or more essential amino acids.If this
particular protein is fed to a young rat as the only source of protein, it
fails to grow.
Limiting amino acid is that which limits the weight gain when a protein is
supplied to an animal.
Source of protein Limiting amino acids
Protein
supplementation
Rice Lysine ,Threonine Pulse proteins
Wheat Lysine ,Threonine Pulse proteins
Gelatin Tryptophan Milk proteins
Zein Tryptophan,Lysine Meat proteins
Tapioca Phenylalanine ,Tyrosine Fish proteins
Bengal Gram Cysteine, Methionine Cereals
Limiting amino acids in proteins

38. Limiting amino acid is that which limits the weight gain when a protein is
supplied to an animal.
Zein+ Tryptophan
Method to identify the limiting amino acid
Zein + Tryptophan+ Lysine
weightofanimal
Days
Zein
Zein+Lysine
The effect of mutual supplementation in proteins is best observed with
the same meal for at least on the same day.

39. Cereals alone
Zein alone
Two second class proteins when combined produce the effect of first class protein
Cereals+Pulses
weightofanimal
Days
Pulses alone
Lactalbumin alone
Days
weightofanimal
Lactalbumin + Zein
The nutritive value of protein of a particular food can be enhanced by
appropriate combination with other food items.

40. Common names of Pulses
Pulses Common name
Bengal gram channa
Black gram Udad
Green gram Moong
Red gram Arhar
Horse gram Kulthi

41. Mutual supplementation of proteins:1
• Mutual supplementation : the phenomenon to overcome the deficiency
of certain essential amino acids in one food by being supplemented
from others(a mixed diet).
• An indian diet with cereals (wheat ,rice)is taken along pulses(dal).
Ratio of pulses :cereals =1:5
• Limitation of Lysine and Threonine in cereal proteins is overcome by
their supplementation from dal proteins.
• Limitation of sulphur-containing amino acids in Bengal gram is
compensated by the cereals which are rich in them.
• Due to the consumption of mixed diets ,dietary deficiency of essential
amino acids is the most uncommon.
• It ensures the supply adequate quantities of essential amino acids to
the people subsisting on pure vegetarian diets.

42. Mutual supplementation of Proteins:2
Deficient in amino acid Rich in amino acid
Pulses Methionine Lysine
Cereals Lysine Methionine
Therefore combination of pulses + cereals (Chapati +dal) cancel each other’s
deficiencies become equivalent to First class protein.
Supplementation of First class proteins Weight gain
Dietary protein limiting / deficient in amino acids
Rice /wheat Lysine /Threonine
Bengal gram Methionine/Cysteine (sulphur containing amino acids )
For supply of adequate quantities of essential amino acids, Mixed diet for
pure vegetarians is recommended.
Mixed diet= Cereals ( Rice /Wheat deficient in Lysine & Threonine but
rich in Methionine and cysteine)+Dal(deficient in Methionine and
Cysteine).
Dietary deficiency of essential amino acids is most uncommon .

43. Dietary requirement and sources of proteins
• Dietary requirement of proteins are dependent on its :
1. Nutritive value
2. calorie intake
3. physiological states ( growth ,pregnancy and lactation)
• Dietary sources of proteins:
Dietary source Weight contribution by Protein (%)
Cereals 6-12
Meat 18-25
Pulses 18-22
Egg 10-14
Milk 3-4
Leafy vegetables 1-2
The animal proteins are superior than vegetable proteins as the dietary sources.

44. Protein energy malnutrition
Dr. Rohini C Sane

45. Protein Energy Malnutrition(PEM)
Protein energy malnutrition(PEM)/ Protein calorie
malnutrition(PCM):
• occurs under conditions where the diet is inadequate to
meet the needs of the body for protein /energy or both.
• It mainly affects infants and pre-school children.
• Mild PEM is seen in elderly subjects ,during pregnancy
and lactation.

46. Protein Energy Malnutrition(PEM)
• PEM is the common Nutritional problem of the developing countries.
• its prevalence is from 20-50% in different areas depending on
socioeconomic status,level of education and awareness.
• Marasmus: which results from a continuous severe deficiency of
both energy and proteins (primary calorie inadequacy ,secondary
protein deficiency).
• Kwashiorkor : isolated deficiency of proteins(sickness of elder /
deposed child when next child/baby is born)
• Marasmus = deficiency of protein + energy
• Kwashiorkor = deficiency of protein

47. Causes of Protein energy malnutrition(PEM)
• Inadequate of food
• inadequate protein intake
• malabsorption
• increased metabolic demands in disease conditions
• increased nutrient losses
• infections
• maternal malnutrition

48. Nutritional disorders of protein
Most common disorders in developing countries:
• Protein energy malnutrition: PEM
• Protein calorie malnutrition : PCM

49. Classification of PEM
Criteria Mild PEM Moderate PEM Severe PEM
weight loss <10% >10% and <20% >20%
weight for height
(normal 90-110)
80-89 70-79 <70%
height for age
(normal 95-105)
90-94 85-89 <85
changes in body
functions
no disruption of
physiological
functions
impairment in
biological
functions
severe impairment
of physiological
functions
morbidity not increased increased very high
Severe PEM is seen in kwashiorkor and marasmus.

50. Types of Protein Energy Malnutrition(PEM)
The major difference between marasmus and kwashiorkor is the adaptation to
PEM.
The adaptive response of marasmus to PEM is better than that shown by
kwashiorkor. The difference is due to higher glucocorticoid levels in marasmus.
Types of PEM
% Body Weight
Compared to
Standard Weight
Edema
deficiency in weight for
height
Kwashiorkor 80-00 + +
Marasmic Kwashiorkor <60 + ++
Marasmus <60 Nil ++
Nutritional dwarfism <60 Nil Nil
Underweight child 80-60 Nil Nil

51. Prevalence of Kwashiorkor
• Kwashiorkor: literally means “the sickness of the elder
(deposed) child gets i.e. a disease the child gets when the next
child is born”.
• Kwashiorkor: a term was introduced by Cicely Williams(1933) to a
nutritional disease affecting Ga tribe of Gold Coast of modern
Ghana in Africa.
A. is prevalent in less developed areas of tropical America, India,
Central and South Africa.
B. occurs in pre-school children who are fed a diet rich in
carbohydrates but poor in proteins .
C. is precipitated by outbreaks of malaria ,measles and
gastroenteritis.

52. Clinical manifestations of Kwashiorkor:1
• Stunted growth: the weight of the child is 60-80% of the
expected weight for the age.
• Failure to thrive.
• Oedema due to low plasma albumin(< 2g / dL against normal
3-4.5 g/dL)and Potassium . Plasma sodium is high.
• Oedema in kwashiorkor:
A. is soft ,pitting and painless.
B. occurs in the lower limbs / legs and hands.
• is associated with protruding abdomen and full ,well -rounded
face( moon face).

53. Clinical manifestations of Kwashiorkor:2
• Skin lesions include erythema, dryness,hyperkeratosis desquamation ,
hyperpigmentation of the buttocks, back of thighs & axillae.
• Hair :sparse ,soft, dry ,thin and brittle
• Gastrointestinal symptoms : loss of appetite ,vomiting , diarrhoea,
steatorrhea ,hepatomegaly and fatty liver
• Anaemia due to iron and folate deficiency
• Vitamin A deficiency leading to xeropthalmia and keratomalacia
• Riboflavin deficiency presenting as glossitis and angular stomatitis
• Mental changes : Apathy and general unhappiness
• Diarrhoea(Vitamin K+
deficiency) , respiratory and skin infections can
eventually result in death.

54. Biochemical findings of Kwashiorkor:1
Proteins in Kwashiorkor:
A. Depletion of visceral protein due low amino acid supply
B. decreased synthesis of hepatic albumin
C. decreased synthesis of immunoglobulins resulting in low immunological
response of the child to infection
D. decreased synthesis of plasma retinol binding protein(RBP)
E. low plasma albumin levels (0.2 - 2.2 g/dL) have the following consequences:
1. decreased intravascular oncotic pressure
2. entry of water into the extravascular space , fluid accumulation in extravascular
tissues resulting in oedema
3. decreased cardiac output and GFR
4. retention of sodium and water

55. Biochemical findings of Kwashiorkor:2
• Lipids in Kwashiorkor :
1. decreased total cholesterol
2. increased hepatic fatty acid synthesis and hepatomegaly
3. decreased synthesis of very low density lipoproteins((VLDL) resulting in fatty liver
4. decreased activities lipase and cholinesterase
• Carbohydrates in Kwashiorkor:
A. Low fasting blood glucose
B. decreased activities amylase
• Electrocytes and water in Kwashiorkor:
• Hypokalemia due to diarrhoea
• low plasma Magnesium
• Water retention due to low plasma albumin
Plasma glucocorticoids
lower than in marasmus.

56. Management of Kwashiorkor
• Ingestion of protein-rich foods or the dietary
combination to provide about 3-4 g of protein /body kg
weight /day will control Kwashiorkor.
• The treatment of Kwashiorkor is monitored by :
1. measuring plasma albumin concentration
2. disappearance of oedema
3. gain in the body weight

57. Predisposing factors for Marasmus
• Marasmus (Greek “to waste”)is a PEM commonly seen weaned
infants , characterised by severe deficiency of both protein and
energy (primary calorie inadequacy and secondary protein
deficiency).
• Predisposing factors for Marasmus include:
A. rapid succession of pregnancies
B. early abrupt weaning
C. inadequate artificial feeding of infants with dilute milk or milk
products
D. recurring infections treated with starvation

58. Clinical manifestations of Marasmus
• Growth retardation : the weight of the child is less than 60% of the expected weight for
the age.
• Gross wasting: generalised muscular wasting(emaciation) with absence of
subcutaneous fat ,shrunken abdomen and atrophy of mucous membrane gives the
child a “skin and bones ”appearance.
• Absence or decreased concentration of plasma albumin and resulting in oedema.
• Skin : dry, thin and wrinkled with loss of elasticity.
• Hair : sparse , thin and dry with loss of sheen.
• Intolerance to food ,constipation ,diarrhoea and weakness.
• Bradycardia (decrease in heart rate),hypotension and hypothermia.
• Palpable lymph nodes.
• Mental retardation ,apathy , irritability and fretfulness.
• Death occurs due to acute gastroenteritis , dehydration ,respiratory infections and
systemic infections.

59. Biochemical findings of Marasmus
• Increased muscle protein breakdown leads to: muscle
wasting , released amino acids that are used for
gluconeogenesis and plasma protein biosynthesis.
• Plasma albumin : low(2.5 - 3g/dL)
• Visceral proteins : preserved.
• Fasting serum glucose level : Decreased(resulting in
weakness)
• plasma glucocorticoid level: high
• Haemoglobin: low(anaemia)

60. Marasmic Kwashiorkor
• Marasmic Kwashiorkor: is a condition in which clinical
features of both marasmus and kwashiorkor are seen.
• Characteristics of Marasmic Kwashiorkor:
1. oedema
2. weight of the child is less than 60% .
3. muscle wasting
4. reduced subcutaneous fat

61. Biochemical alterations in Protein Energy Malnutrition(PEM)
• Basal metabolic rate decreased
• Hypo albuminemia( Serum albumin<2gm/dl) Kwashiorkor
• Serum Retinol Binding Protein reduced
• Serum IgG increases (associated with infection)
• fatty liver (only in Kwashiorkor not in Marasmus)
• lipoprotein synthesis decreases ( as availability of VLDL decreases)
• Serum Free Fatty acids elevated
• GlucoseTolerance Test normal ( Hypoglycemia in Marasmus children)
• Hypokalemia
• Dehydration(because of diarrhoea)

62. Principles of management of PEM
• Compensation of fluid and electrolyte loss due to
diarrhoea and vomiting.
• Administration of antibiotics for infections.
• Blood transfusion if anaemia is severe.
• Administration of glucose for hypoglycaemia.
• Administration of Vitamin A.
• Improvement of nutrition by providing easily digestible
food with high protein ,high energy , supplementation of
vitamins and minerals.

63. Management of Protein Energy Malnutrition(PEM)
• Dietary supplementation: 150-200 kcal /kg body weight
• Protein supplementation: 3-4 g protein /kg body weight
• Malnourished child tolerates fat therefore fat may constitute major
source of diet upto 30%.
• Dietary supplementation is continued till disappearance of oedema ,
increase in serum albumin and gain in body weight.
vegetable proteins
Bengal gram / Peanuts
Milk protein

64. Sequelae of protein Calorie malnutrition
Severe Malnutrition in early life
1. permanent and irreversible physical and functional deficits
2. mental function and intellectual potential affected in later life
3. severe deleterious effect on the intellectual capacity in later life
There may not be any sequelae where the moderate and mild forms are
corrected in time.
Therefore Nationwide efforts needed to eradicate childhood malnutrition.

65. Comparison of Marasmus and Kwashiorkor:1
Criteria Marasmus Kwashiorkor
Causes
breast fed infant of malnourished
mother,
Prolonged breast feeding with
inadequate supplementation of other
food,
fear of diarrhoea therefore less
feeding,
Artificial feeds inadequate & less
nutritive in proteins and calories,
Early weaning and repeated infections
Starchy diet after weaning and
precipitated by acute
infection.
seen in artificially fed children,
no milk, eggs and fed only
with gruel of cereals , grains .
Predisposing
factors
premature babies ,
malformation of mouth & nose with
inadequate feeding,
Local diseases
acute diarrhoea,
respiratory infection,
measles

66. Comparison of Marasmus and Kwashiorkor:2
Criteria Marasmus Kwashiorkor
Age of onset Weaned infant (< one year) pre -school children(1-5 years)
Deficiency Calorie + Protein(starvation) dietary Protein(insufficient intake)
Cause
Early weaning and repeated
infections
Starchy diet after weaning and
precipitated by acute infection
Growth retardation severe retardation mild retardation
Attitude irritable and freitful Lethargic and apathetic
Appearance
Old man’s face,shrunken skin
and bones(dehydrated),no
oedema,anaemic
Moon face,Look plump due to
oedema on face,hands and lower
limbs,Anaemic
Appetite Normal Anorexia
Skin
Dry and atrophic,poor wound
healing
Crazy pavement dermatitis due to
pealing ,cracking denudation
Hair No characteristic change
Spars,soft ,thin,discoloration,curls
may be lost .
Serum Albumin
2-3 g/dL(decreased along with
total proteins ), A:G ratio
maintained.
< 2g/dL( Hypo albuminaemia ) ,
alpha1, alpha2 globulins increased
serum cortisol increased Normal/decreased

67. Comparison of Marasmus and Kwashiorkor:3
Criteria Marasmus Kwashiorkor
Fasting blood
Glucose
decreased(hypoglycaemia,
decreased glucose tolerance)
decreased
Anemia
Haemoglobin and hematocrits
slightly reduced.
Mild to moderate type of anaemia
BMR subnormal may be low.
Plasma lipids not affected( lipid profile
normal)
serum cholesterol , Triglyceride,
phospholipids , Beta Lipoprotein
reduced.
Fatty liver not common may be seen due to decreased
lipoprotein synthesis , FFA elevated.
Associated
features
other nutritional
deficiencies ,vomiting , watery
diarrhoea (Hungry diarrhoea =
Dark green mucous stool),
Vitamin K deficiency, depleted
subcutaneous fat in
muscle ,Muscle weakness
(muscle wasting = emaciation)
and atrophic,abdomen
protruding,Hypomagnesemia
Metabolism of carbohydrates,
proteins and lipids disturbed. Early
manifestation:Apathy & anorexia
Angular stomatitis ,cheilosis , watery
diarrhoea(deficiency of K+ , vitamin K
deficiency), Muscle undergo
wasting ,crawling ,walking delayed.
Immunological response
low,abdomen shrunken

68. Comparison of Marasmus and Kwashiorkor:4
Criteria Marasmus Kwashiorkor
Management
supplementation of watery
gruel (of cereals)to adjuvant
the mother’s breast milk.
supplementation of protein rich
food(3-4 g /kg body weight/day) till
Serum protein and body weight is
normalised (oedema disappears) .

69. Recommended protein allowances
Group
Recommended protein allowance
(g/ kg body weight /day)
Infants 2.4
Children(up to 10yr) 1.75
Adolescent boys 1.6
Adolescent girl 1.4
Adult(men/women) 0.8
Pregnancy 2.5
Lactation 2.5

70. Cachexia due to chronic diseases
• Cachexia : undernourished patients e.g. patients with advanced cancer, AIDS(HIV
infection), tuberculosis etc. This is similar to marasmus, but the loss of body protein
(as a result of hyper metabolism )is more than that seen in simple malnutrition.
• Mechanism of Cachexia:
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 is considerably increased (thermogenesis).
2. Cytokines also stimulate uncouplers ,such as thermogenin , leading to increased
oxidation and thermogenesis without trapping energy.
• 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 utilised for triglyceride 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.
• Most of the tumors preferentially use anaerobic glycolysis with lactic acid as an end
product . This enters the gluconeogenesis in liver , which is energy consuming
reaction (requiring 6 ATPs for each glucose unit).

71. Thank You