---

Protein Energy Malnutrition (PEM) - Park's Textbook of Preventive and Social Medicine

Definition

• Low birth weight (if the mother is malnourished)
• Poor growth in children
• High level of mortality in children between 12 and 24 months
• Estimated to be an underlying cause in 30% of deaths among children under age 5

Park's Textbook of Preventive and Social Medicine

---

Magnitude of the Problem

• 27% of children in low-income countries have low height-for-age (stunting)
• 17% have low weight-for-height
• In India (NFHS 2015-16): 35.7% children under 5 are underweight; 7.5% have moderate-to-severe wasting; 38.4% have moderate-to-severe stunting
• Globally (2018): >21.9% of children under 5 were stunted; 7.3% had wasting
• 45% of children who died before age 5 had malnutrition as an underlying factor
• 80% of newborn mortality occurs in low birth weight babies

---

Forms of PEM

1. Kwashiorkor

• Severe form of undernutrition developing in individuals on diets with a low protein/energy ratio
• Cause: Inadequate protein intake, low concentration of essential amino acids
• Clinical features:
  • Oedema
  • Wasting
  • Liver enlargement (hepatomegaly)
  • Hypoalbuminaemia
  • Steatosis
  • Possible depigmentation of skin and hair

2. Marasmus

• Caused by inadequate intake of both protein and energy
• A form of severe cachexia with weight loss due to wasting in infancy and childhood
• Clinical features:
  • Severe wasting
  • Little or no oedema (key difference from kwashiorkor)
  • Minimal subcutaneous fat
  • Severe muscle wasting
  • Non-normal serum albumin levels

---

Severe Acute Malnutrition (SAM)

• Weight-for-height/length Z-score below -3SD of the median WHO Child Growth Standards
• Mid-upper arm circumference (MUAC) <115 mm
• Presence of nutritional oedema

---

Early Detection of PEM

1. Growth Charts

• First indicator: underweight for age
• Growth charts can be maintained even by field health workers
• Indicate at a glance whether the child is gaining or losing weight

2. Arm Circumference (MUAC)

• Reliable estimation of the body's muscle mass
• Cannot be used before 1 year of age
• Between ages 1-5 years, it hardly varies

---

Ecology of Malnutrition (Jelliffe, 1966)

1. Conditioning Influences

• Infectious diseases (diarrhoea, intestinal parasites, measles, whooping cough, malaria, TB) are the important conditioning factors
• Vicious circle: infection --> malnutrition --> more severe infection
• Small children may suffer from infection for almost half of their first 3 years of life

2. Cultural Influences

• Food habits, customs, beliefs, traditions - deeply entrenched aspects of culture
• Many customs apply most to vulnerable groups (infants, toddlers, expectant/lactating women)
• Example: Papaya avoided during pregnancy due to belief it causes abortion

3. Socio-economic Factors

• Malnutrition is largely the by-product of poverty, ignorance, insufficient education
• Large family size, lack of knowledge of nutritive value, inadequate sanitation
• Rapid population growth makes the problem worse
• "Causes of malnutrition are built into the very nature of society"

4. Food Production

• Average Indian has 0.6 hectare vs. 5.8 hectare per head in developed countries
• Per capita arable land: only 0.3 hectare for an average Indian
• Yields per hectare are ~1/4 of those in industrialized countries
• Scarcity of food is true at the family level but not globally - it is a problem of uneven distribution
• "There will be very little malnutrition in India today if all the food available can be equitably distributed"

5. Health and Other Services

1. Nutritional surveillance - continuous monitoring; identify groups via clinical examination and simple body measurements
2. Nutritional rehabilitation - immediate measures; children with severe PEM + complications may need hospital care; less severe cases managed domiciliary or in nutrition rehabilitation centres (NRCs)
3. Nutrition supplementation - target groups are mothers and children; supplementary feeding as a stop-gap measure
4. Health education - "About 50% of nutritional problems can be solved by appropriate educational action"

---

Prevention of PEM (FAO/WHO Expert Committee on Nutrition, 8th Report)

(a) Health Promotion

1. Measures directed to pregnant and lactating women (education, distribution of supplements)
2. Promotion of breast-feeding
3. Development of low-cost weaning foods; child should eat more food at frequent intervals
4. Measures to improve family diet
5. Nutrition education - promotion of correct feeding practices
6. Home economics
7. Family planning and spacing of births
8. Improving family environment

(b) Specific Protection

1. Child's diet must contain protein and energy-rich foods (milk, eggs, fresh fruits if possible)
2. Immunization
3. Food fortification

(c) Early Diagnosis and Treatment

1. Periodic surveillance
2. Early diagnosis of any lag in growth
3. Early diagnosis and treatment of infections and diarrhoea
4. Development of programmes for early rehydration of children with diarrhoea
5. Development of supplementary feeding programmes during epidemics
6. Deworming of heavily infested children

(d) Rehabilitation

1. Nutritional rehabilitation services
2. Hospital treatment
3. Follow-up care

---

Malnutrition - Broader Context (Park's Definition)

Five Principal Nutritional Deficiency Diseases (Globally):

1. Wasting
2. Stunting
3. Xerophthalmia
4. Nutritional anaemias
5. Endemic goitre

---

Effects of Malnutrition on the Community

• Kwashiorkor, marasmus, vitamin and mineral deficiency diseases

• High morbidity and mortality among young children (nearly 50% of total deaths in developing countries occur in children under 5; <5% in developed countries)
• Retarded physical and mental growth and development (may be permanent)
• Lowered vitality - reduced productivity and life expectancy
• Malnutrition predisposes to infection; infection predisposes to malnutrition - vicious cycle
• High maternal mortality, stillbirth, and low birth weight

---

Nutritional Indicators for Surveillance

---