Protein Energy Malnutrition (PEM)

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. 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

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

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

8. MARASMUS - Biochemical Mechanism

9. Moderate form Severe form

10. Kwashiorkor - Biochemical Mechanism

11. EDEMA Skin Lesions Pale Hair Moon Face

12. 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

13. 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

14. 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

15. 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.

16. 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.

17. 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.

18. 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.

19. 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).