Malnutrition & Protein-Energy Malnutrition (PEM) - Complete Notes

a) Definition of Malnutrition & Classification of PEM

Definition of Malnutrition

• Robbins & Kumar Basic Pathology, p. 289

Classification of PEM

WHO/Wellcome Classification

IAP (Indian Academy of Pediatrics) Classification

WHO Anthropometric Classification (Z-score based)

• Underweight - weight-for-age Z-score < -2SD (composite measure)
• Stunting - height-for-age Z-score < -2SD (chronic/past malnutrition)
• Wasting - weight-for-height Z-score < -2SD (acute/current malnutrition)

• Park's Textbook of Preventive and Social Medicine, p. 736

b) Causes & Clinical Features of Severe Forms of Malnutrition

MARASMUS

• Severe generalized wasting of muscle and subcutaneous fat
• Body weight typically <60% of expected for age
• No edema - distinguishes from kwashiorkor
• Extremities emaciated; head appears disproportionately large ("old man's face" / "monkey facies")
• Skin loose, wrinkled - "baggy pants" appearance
• Serum albumin normal or only slightly reduced
• Anemia and multi-vitamin deficiency features
• Immune deficiency (especially T-cell mediated) - concurrent infections common
• Growth retardation, mental apathy, irritability
• Arm circumference < 12.5 cm indicates severe malnutrition

KWASHIORKOR

MARASMIC-KWASHIORKOR

Common Causes of PEM (General)

1. Poverty - inadequate food availability; most common root cause in India
2. Ignorance - lack of knowledge about infant feeding, weaning practices, nutritional needs
3. Faulty feeding practices - early weaning, delayed introduction of complementary foods, inadequate breastfeeding
4. Infections - diarrhea, measles, respiratory infections (create a malnutrition-infection cycle)
5. Large family size - food shared among many children
6. Birth spacing - closely spaced pregnancies, displacement of older child from breast
7. Low birth weight - starts life already malnourished
8. Maternal malnutrition - inadequate nutrition during pregnancy
9. Food taboos and cultural beliefs - restriction of certain foods for children
10. Secondary causes - chronic diarrhea, protein-losing enteropathies, nephrotic syndrome, burns, malabsorption

• Robbins & Kumar Basic Pathology, p. 289-291; Park's Textbook of Preventive and Social Medicine, p. 736-737

c) Preventive Measures to Reduce PEM in India

(a) Health Promotion

1. Measures for pregnant and lactating women - nutritional education, iron-folate supplementation, distribution of protein-caloric supplements through the ICDS (Integrated Child Development Services) and National Health Mission
2. Promotion of breastfeeding - exclusive breastfeeding for first 6 months; colostrum should not be discarded; breast milk is the ideal food for infants
3. Development of low-cost weaning foods - indigenous weaning foods using cereals + pulses (e.g., amylase-rich foods); timely introduction at 6 months; frequent feeding
4. Measures to improve family diet - promotion of balanced diet using locally available foods; kitchen gardens
5. Nutrition education - correct feeding practices through health workers, ANMs (Auxiliary Nurse Midwives), anganwadi workers; POSHAN Abhiyaan (National Nutrition Mission)
6. Home economics - better food preservation, cooking practices that retain nutrients
7. Family planning and birth spacing - limiting family size, spacing births at least 2-3 years apart reduces competition for food and maternal resources
8. Improving family environment - safe water, sanitation, reducing infection burden

(b) Specific Protection

1. Diet must contain protein- and energy-rich foods - milk, eggs, pulses, fresh fruits and vegetables; protein-calorie supplements
2. Immunization - prevents infections (measles, diarrheal diseases) that precipitate and aggravate PEM; under Universal Immunization Programme (UIP)
3. Food fortification - fortification of commonly consumed foods; e.g., iodized salt, vitamin A in dalda (vanaspati), iron-fortified wheat flour (double-fortified salt)

(c) Early Diagnosis and Treatment

1. Periodic growth surveillance - maintenance of Road-to-Health (growth) charts at anganwadi centres; monthly weight monitoring through ICDS
2. Early diagnosis of growth faltering - detection before severe malnutrition develops
3. Arm circumference measurement - <12.5 cm indicates severe malnutrition; easy to measure in field
4. Early diagnosis and treatment of infections and diarrhea - ORS, zinc supplementation, antibiotic use
5. Rehydration programmes - Oral Rehydration Therapy (ORT) for diarrheal dehydration
6. Supplementary feeding during epidemics/emergencies
7. Deworming - mass deworming programmes; helminth infestation worsens nutritional status

(d) Rehabilitation

1. Nutritional Rehabilitation Services (NRS) - NRC (Nutritional Rehabilitation Centres) established in district hospitals; 14-day facility-based care using F-75/F-100 therapeutic feeds (WHO protocol)
2. Hospital treatment - management of SAM with complications
3. Follow-up care - regular follow-up after discharge; Community-Based Management of Acute Malnutrition (CMAM) using Ready-to-Use Therapeutic Food (RUTF)

India-Specific Programmes

• Park's Textbook of Preventive and Social Medicine, p. 737

d) Prevention & Social Measures Against Malnutrition at Family & Community Level

AT THE FAMILY LEVEL

• Ensure adequate intake of protein-rich foods (legumes, pulses, milk, eggs, meat/fish) at every meal
• Practice appropriate complementary feeding from 6 months; do not delay introduction of semisolid foods
• Feed children more frequently - small meals 5-6 times/day rather than 2-3 large meals
• Avoid giving only starchy staple foods; ensure dietary diversity (cereals + pulses + vegetables + fruits)
• Do not restrict food during illness (a common harmful practice); feed more during convalescence

• Initiate breastfeeding within 1 hour of birth; give colostrum
• Practice exclusive breastfeeding for 6 months
• Continue breastfeeding up to 2 years with complementary foods
• Use locally available weaning foods - khichdi (rice + dal), ragi, sathu maavu

• Adequate nutrition during pregnancy and lactation - extra 300-500 kcal/day
• Regular antenatal care attendance, iron-folate supplementation
• Treat anemia before and during pregnancy

• Space births at least 3 years apart
• Limit family size to ensure each child receives adequate nutrition and care

• Safe drinking water and proper sanitation reduce diarrheal diseases
• Hand washing before feeding children
• Proper food storage to prevent contamination

• Kitchen gardens (vegetable and fruit cultivation) to improve food security
• Poultry, dairy, backyard farming at household level

AT THE COMMUNITY LEVEL

• Community-based nutrition counselling by ANMs, ASHA workers, and anganwadi workers
• Dispelling food taboos and myths (e.g., eggs/fish not for children)
• Teaching mothers about growth monitoring and recognition of malnutrition signs
• Audio-visual campaigns, street plays (nukkad natak), radio messages

• Monthly weighing at anganwadi centres; plotting on growth charts
• Community-level identification of faltering children
• Grading of malnutrition (colour-coded growth charts - green/yellow/red zones)
• Village Health Nutrition Days (VHND)

• Anganwadi supplementary nutrition (ICDS) - take-home rations or hot cooked meals
• Mid-Day Meal Scheme in schools
• Therapeutic feeding at NRCs for SAM children

• Full immunization under UIP protects against measles, diarrhea, whooping cough - all of which precipitate PEM
• Polio, DPT, BCG, Hepatitis B, Rotavirus vaccine

• Mass deworming (National Deworming Day - 10 February; Albendazole 400 mg)
• ORT corners at sub-centres for management of diarrhea
• Zinc supplementation during diarrhea (20 mg/day for 14 days in children >6 months)

• Public Distribution System (PDS) - subsidized food grains
• National Food Security Act 2013 ensures entitlement to food
• Community grain banks (especially in tribal areas)
• Self-Help Groups (SHGs) for women - income and awareness

• Poverty alleviation programmes - MGNREGS, PM-KISAN
• Education of women - educated mothers make better nutritional choices
• Empowerment of women - women who control household income spend more on food and health
• Reduction of gender discrimination - girl child given equal food as boys

• Swachh Bharat Mission - construction of toilets, open defecation free villages
• Safe drinking water supply (Jal Jeevan Mission)
• Reduces diarrheal disease burden, breaking the malnutrition-infection cycle

• Convergence of Health, ICDS (Women and Child Development), Education, Agriculture, and Rural Development departments
• POSHAN Abhiyaan (National Nutrition Mission, 2018) coordinates all nutrition interventions with district-level targets

• Training of ASHAs, ANMs, anganwadi workers in growth monitoring, nutrition counselling, SAM identification, ORS preparation, and referral
• Capacity building in community management of acute malnutrition (CMAM)

Summary Table: Prevention at Different Levels

• Park's Textbook of Preventive and Social Medicine, p. 736-737
• Robbins & Kumar Basic Pathology, p. 288-291

Malnutrition & PEM - SPM Exam Answer (Park's Textbook)

a) Definition of Malnutrition & Classification of PEM

Definition of Malnutrition

1. Undernutrition - condition resulting from insufficient food eaten over an extended period; in extreme cases called starvation
2. Overnutrition - pathological state from consumption of excessive quantity of food over extended period (e.g., obesity, diabetes, cardiovascular disease in western societies)
3. Imbalance - pathological state from disproportion among essential nutrients, with or without absolute deficiency of any nutrient
4. Specific deficiency - pathological state from a relative or absolute lack of an individual nutrient (e.g., scurvy, rickets)

• Park's Textbook of Preventive & Social Medicine, p. 748

Classification of PEM

1. Wellcome Classification (Most widely used in SPM exams)

2. IAP (Indian Academy of Pediatrics) Grading

3. WHO Z-score Classification (Anthropometric)

• Weight-for-height Z-score below -3 SD, OR
• Mid-upper arm circumference (MUAC) < 115 mm, OR
• Presence of nutritional oedema

• Park's Textbook of Preventive & Social Medicine, p. 736-737

b) Causes & Clinical Features of Severe Malnutrition (Kwashiorkor & Marasmus)

KWASHIORKOR

Causes:

1. Inadequate protein intake with relatively adequate calorie intake (low protein/energy ratio diet)
2. Low concentration of essential amino acids in the diet
3. Early abrupt weaning - displaced child fed on starchy gruels, diluted cereal porridges
4. Infections - diarrhoea, measles, whooping cough precipitate/aggravate kwashiorkor
5. Poverty and food insecurity
6. Food taboos - restricting protein-rich foods (eggs, meat, fish) for children
7. Ignorance of proper feeding practices

Clinical Features of Kwashiorkor:

MARASMUS

Causes:

1. Total calorie and protein deficiency - starvation
2. Early or abrupt cessation of breastfeeding without adequate replacement
3. Repeated infections - diarrhoea, respiratory infections in infancy
4. Poverty - inability to purchase adequate food
5. Large family size - competition for food
6. Maternal malnutrition - low birth weight, inadequate breast milk
7. Ignorance of proper infant feeding

Clinical Features of Marasmus:

Malnutrition-Infection Cycle

c) Preventive Measures to Reduce PEM in India

(a) Health Promotion

1. Measures directed to pregnant and lactating women - nutrition education, distribution of protein-calorie supplements; iron-folic acid supplementation; treatment of anaemia
2. Promotion of breastfeeding - initiate within 1 hour of birth; give colostrum; exclusive breastfeeding for first 6 months; continue up to 2 years with complementary feeds
3. Development of low-cost weaning foods - timely introduction at 6 months; child should be made to eat more food at frequent intervals; use locally available foods (khichdi, ragi, sattu)
4. Measures to improve family diet - promote dietary diversity with locally available foods; kitchen gardens; encourage consumption of pulses, green leafy vegetables, fruits
5. Nutrition education - promotion of correct feeding practices through health workers, ASHA, ANM, anganwadi workers; counter misleading commercial advertising for baby foods
6. Home economics - better food preservation; cooking practices that retain nutrients; hygienic food preparation
7. Family planning and spacing of births - limiting family size; spacing births at least 2-3 years apart reduces competition for food and maternal nutritional resources
8. Family environment - improve the overall family environment including safe water, sanitation, housing

(b) Specific Protection

1. Diet must contain protein- and energy-rich foods - milk, eggs, pulses, fresh fruits and vegetables; protein-calorie supplements through ICDS
2. Immunization - full immunization under Universal Immunization Programme (UIP) prevents infections (measles, diarrhoea, pertussis) that precipitate PEM
3. Food fortification - addition of nutrients to commonly consumed foods: vitamin A in vanaspati/dalda; iodised salt; iron-fortified flour (double-fortified salt)

(c) Early Diagnosis and Treatment

1. Periodic nutritional surveillance - continuous monitoring of nutritional status in the community
2. Growth monitoring - maintenance of growth charts (Road-to-Health cards) at anganwadi centres; monthly weighing; early diagnosis of any lag in growth
3. Arm circumference measurement - MUAC: >13.5 cm = satisfactory; 12.5-13.5 cm = mild/moderate malnutrition; <12.5 cm = severe malnutrition
4. Early diagnosis and treatment of infections and diarrhoea - ORS, zinc supplementation, antibiotic use when appropriate
5. Rehydration programmes - Oral Rehydration Therapy (ORT) for diarrhoeal dehydration
6. Supplementary feeding during epidemics/outbreaks
7. Deworming of heavily infested children - National Deworming Day; Albendazole 400 mg

(d) Rehabilitation

1. Nutritional rehabilitation services - Nutrition Rehabilitation Centres (NRCs) for inpatient management of SAM with complications; F-75 and F-100 WHO therapeutic feeds
2. Hospital treatment - for complicated SAM (oedema, infections, hypoglycaemia, hypothermia)
3. Community-Based Management of Acute Malnutrition (CMAM) - using Ready-to-Use Therapeutic Food (RUTF) for uncomplicated SAM
4. Follow-up care - regular follow-up after discharge to prevent relapse

India-Specific National Programmes

• Park's Textbook of Preventive & Social Medicine, p. 737

d) Prevention & Social Measures Against Malnutrition at Family & Community Level

ACTION AT THE FAMILY LEVEL

• The housewife is the "manager" of food consumption in the family; in some families, the husband also determines what foods reach the table
• Both husband and wife must be educated on selection of right local foods and planning of nutritionally adequate diets within their purchasing power
• Harmful food taboos and dietary prejudices can be identified and corrected (e.g., avoiding eggs/fish for children, food restrictions in pregnancy)
• Since food expenditure amounts to 50-70% of family budgets, nutrition education programmes are a good investment

• Promote breastfeeding - initiation within 1 hour of birth, exclusive breastfeeding for 6 months
• Timely introduction of complementary foods - from 6 months; frequent small feeds; dietary diversity
• Counter misleading commercial advertising regarding baby foods
• Attention to nutritional needs of expectant and nursing mothers in the family

• Kitchen garden - planning a kitchen garden to grow vegetables, fruits
• Backyard poultry - to meet shortage of protective foods (eggs, meat)
• Adequate nutrition can be obtained in most countries with a combination of locally available and acceptable foods

• Other related activities at the family level include the "package" of mother and child health, family planning and immunization services
• The community health workers and multipurpose workers are key people to impart nutrition education to families in their areas

• Spacing of births - reduces maternal nutritional depletion and competition for food among children
• Limiting family size - ensures adequate per-capita food availability

ACTION AT THE COMMUNITY LEVEL

• (a) Analysis of the extent, distribution and types of nutritional deficiencies
• (b) Identification of population groups at risk
• (c) Assessment of dietary and non-dietary factors contributing to malnutrition (through diet and nutrition surveys in representative samples)

• ICDS supplementary nutrition - take-home rations or hot cooked meals at anganwadis for children 6 months to 6 years and pregnant/lactating women
• Mid-Day Meal Scheme - school meals to reduce hunger and improve attendance
• These are regarded as stop-gap/palliative measures for rehabilitation of malnourished children - permanent solution requires more fundamental approaches

• Promotes production of various types of protective foods by the community for the community
• Kitchen gardens, fisheries, poultry, dairy at community level

• Delivers a basic minimum package: supplementary nutrition + immunization + health check-ups + health and nutrition education for mothers + non-formal education for pre-schoolers
• Target groups: children up to 6 years, pregnant and lactating women, other women 15-44 years

• "Continuous monitoring of factors/conditions which indicate, relate to, or impinge on nutritional status of individuals or groups of people" (WHO, 1976)
• Clinical examination + body measurements at health centres; surveys in villages
• Village Health Nutrition Days (VHND) - monthly weighing, growth monitoring

• Children with severe PEM and complications: hospital/NRC-based care
• Less severely affected: managed on domiciliary basis or in special Nutrition Rehabilitation Centres linked with health centres

• Full immunization under UIP protects against infections that precipitate PEM
• Children need immunization against: tuberculosis, diphtheria, whooping cough, tetanus, hepatitis B, Hib, Japanese encephalitis (endemic states), measles, and polio

• ORT corners at sub-centres; zinc supplementation during diarrhoea
• Mass deworming programmes (National Deworming Day)
• Improvement of water supply and environmental sanitation

• "About 50% of nutritional problems can be solved by appropriate educational action" - Park's SPM
• Community-level nutrition counselling by ASHA, ANM, anganwadi workers
• Audio-visual campaigns; behaviour change communication (BCC)
• Teaching mothers to recognise growth faltering and signs of malnutrition

• Safe drinking water supply (Jal Jeevan Mission)
• Improved sanitation - Swachh Bharat Mission - open defecation free villages
• Reduction of infection burden through WASH interventions

• "A broad socio-economic development of the entire community is called for" - Park's SPM
• Poverty alleviation, women's empowerment, education of women
• Women's education is one of the most powerful predictors of child nutritional status

ACTION AT THE NATIONAL LEVEL (Brief Overview)

1. Rural development - raise living standards and purchasing power, especially in rural India (72% of population)
2. Increasing agricultural production - modern farming, irrigation, better seeds and fertilisers; food distribution system
3. Stabilisation of population - population policy linked to food and nutrition policy
4. Food distribution - Public Distribution System (PDS), National Food Security Act 2013
5. Nutrition policy - National Nutrition Policy; POSHAN Abhiyaan with district-level targets

Key Points for Exam

Ecology of malnutrition (Jelliffe, 1966) - five conditioning factors:

1. Conditioning influences (infections)
2. Cultural influences (food habits, taboos, religion, food fads, cooking practices)
3. Socio-economic factors (poverty, purchasing power)
4. Food production (agriculture, availability)
5. Health and other services (nutritional surveillance, rehabilitation, supplementation, health education)

"Malnutrition is a man-made disease. It is a disease of human societies. It begins quite commonly in the womb and ends in the grave." - Jelliffe; Park's SPM p. 748