Protein-Energy Malnutrition: Kwashiorkor vs Marasmus

• Protein-energy malnutrition (PEM) ranges in severity from mild to severe.
• Mild to moderate forms are generally subclinical and detectable via anthropometric measurements.
• Severe forms manifest as clinical conditions: marasmus, kwashiorkor, and marasmic kwashiorkor.

Learning Objectives

• Define protein energy malnutrition.
• Distinguish between kwashiorkor and marasmus.
• Describe the features of Kwashiorkor, Marasmus and Marasmic kwashiorkor.
• Calculate protein requirements.

Assessing Subclinical PEM

• Anthropometry (measurements of physical growth) is used.
• Measurements include: Weight, Height, weight and height.
• Z-Scores (WAZ; HAZ; WHZ) and BMI are calculated using weight and height.
• Head circumference is measured.
• Mid-upper arm circumference (MUAC) is measured.
• Waist-to-Hip ratio is assessed.

Clinical Malnutrition: Kwashiorkor

• First described in Ghana in the 1930s by Cicely Williams.
• It is the disease an old baby gets when a new baby is born, associated with abrupt weaning.
• More linked to poor diet quality than quantity of diet.
• Outward signs include swollen feet/legs/hands, extended stomach, irritability, apathy, sparse hair, poor appetite, and high mortality risk.
• Other symptoms involve decreased muscle mass, swollen belly (oedema and lipid build-up around the liver).
• Changes in skin pigment and hair occur.
• Increased infections and increased severity of normally mild infections, diarrhoea.
• Apathy, lethargy, irritability.
• Death results from secondary infection, not starvation.

Marasmus

• Involves severe wasting (emaciation) due to inadequate food intake.
• It may be associated with prolonged breastfeeding without adequate complementary feeding (dilute and unhygienic) or famine situations.
• Results in a wrinkled 'old man' appearance.
• Typically occurs in children under 2 years of age.
• Patients are usually ravenously hungry.
• Energy intake is insufficient, forcing the body to draw on its energy stores.
• Liver glycogen stores are depleted within hours.
• Skeletal muscle protein is broken down via gluconeogenesis to maintain blood glucose levels, which are vital for the brains energy.
• When prolonged, fatty acids are oxidized to ketone bodies as fuel for the brain and other organs.

Marasmic-Kwashiorkor

• A combination of both marasmus and kwashiorkor.
• Features severe wasting plus oedema.

Causes of Severe Undernutrition

• Chronic, severely low energy and protein intake.
• Exclusive breastfeeding for too long.
• Dilution of formula.
• Unclean/non-nutritious complementary foods (CF) of low energy and micronutrient density.
• Infections e.g. measles, diarrhea, others.
• Exposure to Xenobiotics (aflatoxins).

Recommended Intakes of Protein

• 0 to 0.5 years: 1.52 g/kg/day
• 0.5 to 1 year: 1.20 g/kg/day
• 1 to 3 years: 1.05 g/kg/day
• 4 to 8 years: 0.95 g/kg/day
• 9 to 13 years: = 0.95 g/kg/day
• 14 to 18 years: 0.85 g/kg/day
• 19 to 30 years: 0.80 g/kg/day
• 31 to 50 years: 0.80 g/kg/day

• 50 years: 0.80 g/kg/day

How to Calculate Protein Requirement

• Determine your ideal healthy weight based on your height.
• Convert weight from pounds to kilograms by dividing pounds by 2.2.
• Multiply weight in kilograms by 0.8 to calculate your RDA in grams per day.

Example Calculation

• A person with a healthy body weight of 150 lb needs the following protein RDA/day:
• 150 lb. / 2.2 lb. = 68.2 kg
• 68 kg x 0.8 g/kg = 54.5 g protein