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MALNUTRITION AND PROTEIN-ENERGY MALNUTRITION (PEM)

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PART A: DEFINITION OF MALNUTRITION AND CLASSIFICATION OF PEM

Definition of Malnutrition

"Malnutrition is a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients."

• Park's Textbook of Preventive and Social Medicine

Forms of Malnutrition

┌──────────────────────────────────────────────────────────────────────┐
│                         MALNUTRITION                                 │
├─────────────────┬────────────────┬───────────────┬───────────────────┤
│  UNDERNUTRITION │  OVERNUTRITION │   IMBALANCE   │ SPECIFIC          │
│                 │                │               │ DEFICIENCY        │
│ Insufficient    │ Excessive food │ Disproportion │ Lack of a single  │
│ food over       │ over extended  │ among         │ individual        │
│ extended period │ period         │ nutrients     │ nutrient          │
│ (extreme =      │ (Obesity,      │ (with/without │ (Vit A, Iron,     │
│ starvation)     │ Diabetes,      │ absolute      │ Iodine            │
│                 │ Atheroma)      │ deficiency)   │ deficiency etc.)  │
└─────────────────┴────────────────┴───────────────┴───────────────────┘

Classification of Protein-Energy Malnutrition (PEM)

1. Classification by Clinical Type

┌────────────────────────────────────────────────────────────────────────────┐
│                    PROTEIN-ENERGY MALNUTRITION (PEM)                       │
│                                                                            │
│        ┌──────────────────┐         ┌──────────────────┐                  │
│        │    MARASMUS       │ ←Mixed→ │   KWASHIORKOR    │                  │
│        │  (Energy deficit) │         │ (Protein deficit)│                  │
│        └──────────────────┘         └──────────────────┘                  │
│              ↓                             ↓                               │
│   Both protein + calorie      Protein deprivation >                        │
│   severely deficient          energy reduction                             │
│   Weight <60% of normal       Weight 60-80% (masked                        │
│   No edema                    by edema)                                    │
└────────────────────────────────────────────────────────────────────────────┘

2. Classification by Severity (Gomez Classification - Weight for Age)

3. WHO/UNICEF Classification (Acute vs Chronic)

4. MUAC (Mid-Upper Arm Circumference) Classification

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PART B: CAUSES AND CLINICAL FEATURES OF SEVERE MALNUTRITION

Causes of Severe Malnutrition (Ecology)

                    CAUSES OF PEM / MALNUTRITION
                              │
         ┌────────────────────┼─────────────────────┐
         ▼                    ▼                     ▼
  CONDITIONING          CULTURAL               SOCIO-ECONOMIC
  INFLUENCES            INFLUENCES              FACTORS
  • Diarrhoea           • Food habits,          • Poverty
  • Intestinal           customs, taboos        • Ignorance
    parasites           • Food fads              • Unemployment
  • Measles             • Religious beliefs      • Large family size
  • Whooping cough      • Cooking practices      • Poor education
  • Malaria             • Purdah/gender          • Rapid population
  • Tuberculosis          discrimination           growth
  • Infection-                                   • Inadequate
    malnutrition                                   sanitation
    vicious cycle
         │
         ▼
  FOOD PRODUCTION
  • Low per capita
    arable land
    (0.3 ha in India)
  • Low crop yields
  • Uneven food
    distribution
         │
         ▼
  INADEQUATE
  HEALTH SERVICES
  • Poor surveillance
  • Lack of nutrition
    rehabilitation
  • Inadequate MCH care

• Poverty - homeless, aged, children of the poor
• Acute and chronic illnesses - increased metabolic demands (cancer, AIDS)
• Chronic alcohol use - poor diet + defective absorption
• Ignorance - failure to recognize increased nutritional needs of infants, adolescents, pregnant women
• Self-imposed dietary restriction - anorexia nervosa, bulimia
• Gastrointestinal diseases - malabsorption syndromes, chronic diarrhea
• Premature weaning - replacing breast milk with carbohydrate-only diets
• Close birth intervals - nutritional depletion of mother and child

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Clinical Features of Severe Forms of Malnutrition

A. MARASMUS

Marasmus develops when the diet is severely lacking in both calories and protein. A child is considered to have marasmus when weight falls to 60% of normal for sex, height, and age.

• Robbins, Cotran & Kumar Pathologic Basis of Disease

• Adaptive response: catabolism of somatic protein (muscle) provides amino acids for energy
• Visceral protein compartment is spared (survival priority)
• Leptin production is low → hypothalamic-pituitary-adrenal axis activation → high cortisol → lipolysis
• Subcutaneous fat mobilized as fuel

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B. KWASHIORKOR

Kwashiorkor occurs when protein deprivation is relatively greater than the reduction in total calories.

• Robbins, Cotran & Kumar

• Marked protein deprivation → reduced synthesis of visceral proteins
• Hypoalbuminemia → reduced oncotic pressure → generalized edema
• Reduced lipoprotein synthesis → fat accumulates in liver (fatty liver)
• Relative sparing of muscle and subcutaneous fat (energy intake relatively maintained)

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C. MARASMIC-KWASHIORKOR (Mixed Form)

Comparison Table: Marasmus vs. Kwashiorkor

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Indicators of Malnutrition

• Presence of edema (bilateral pitting)
• Skin changes ("flaky paint" dermatosis)
• Hair changes (flag sign, depigmentation)
• Hepatomegaly
• Signs of vitamin deficiency (Bitot's spots, rickets, angular stomatitis, etc.)
• Growth faltering on growth chart

• 24-hour dietary recall
• Food frequency questionnaire
• Diet history
• Food balance sheets (national level)

• Under-5 mortality rate
• Infant mortality rate
• Low birth weight rate
• Prevalence of stunting, wasting, underweight (from NFHS data)
• First indicator of PEM = underweight-for-age (monitored by growth chart)

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PART C: PREVENTIVE MEASURES TO REDUCE PEM IN INDIA

"There is no simple solution to the problem of PEM. Many types of actions are necessary."

• Park's Textbook (adapted from 8th FAO/WHO Expert Committee on Nutrition)

Prevention Framework (Levels of Prevention)

┌──────────────────────────────────────────────────────────────────┐
│            PREVENTION OF PEM - A Four-Level Approach             │
├──────────────────┬───────────────────────────────────────────────┤
│ (a) Health       │ (b) Specific     │ (c) Early       │ (d) Re- │
│ Promotion        │ Protection       │ Diagnosis &     │ habili- │
│                  │                  │ Treatment       │ tation  │
└──────────────────┴───────────────────────────────────────────────┘

(a) Health Promotion

1. Measures for pregnant and lactating women - education, distribution of nutritional supplements
2. Promotion of breast-feeding - exclusive breastfeeding for the first 6 months of life
3. Development of low-cost weaning foods - child should eat more food at frequent intervals during the weaning period (6 months to 2 years)
4. Measures to improve family diet - balanced diet with locally available foods
5. Nutrition education - promotion of correct feeding practices; health education can solve ~50% of nutritional problems
6. Home economics - planning nutritionally adequate diets within family budget
7. Family planning and spacing of births - prevents maternal depletion; recommended birth spacing of >2 years
8. Improving family environment - clean water, sanitation, hygiene

(b) Specific Protection

1. Protein and energy-rich diet - milk, eggs, fresh fruits, dal, leafy vegetables
2. Immunization - prevents infections that trigger PEM; BCG, OPV, DPT, measles vaccine (prevents post-measles PEM)
3. Food fortification - iodized salt (goitre), iron-fortified foods (anemia), vitamin A in oil/vanaspati

(c) Early Diagnosis and Treatment

1. Periodic nutritional surveillance - growth monitoring using growth charts (Road to Health card)
2. Early diagnosis of growth lag - weight-for-age monitoring; detection of growth faltering
3. Early diagnosis and treatment of infections and diarrhoea - ORS, antibiotics
4. Rehydration programmes - early rehydration in children with diarrhea
5. Supplementary feeding programmes during epidemics
6. Deworming - heavily infested children (albendazole 6-monthly)

(d) Rehabilitation

1. Nutritional Rehabilitation Services (NRS) - Nutrition Rehabilitation Centres (NRC) for SAM children
2. Hospital treatment - for severe cases with complications
3. Follow-up care - community follow-up after discharge to prevent relapse

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PART D: PREVENTIVE AND SOCIAL MEASURES AT FAMILY AND COMMUNITY LEVEL

"Since malnutrition is the outcome of several factors, the problem can be solved only by taking action simultaneously at various levels - family, community, national and international levels."

• Park's Textbook of Preventive and Social Medicine

Flowchart: Levels of Action Against Malnutrition

PREVENTING MALNUTRITION IN INDIA
             │
    ┌────────┼───────────┬──────────────┐
    ▼        ▼           ▼              ▼
FAMILY   COMMUNITY   NATIONAL    INTERNATIONAL
LEVEL    LEVEL       LEVEL       LEVEL

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ACTION AT THE FAMILY LEVEL

1. Nutrition Education for Housewives and Husbands
   • Selection of right kinds of local foods
   • Planning nutritionally adequate diets within purchasing power limits
   • Food expenditure = 50-70% of family budgets; education is a good investment
2. Correction of Harmful Food Practices
   • Identify and correct food taboos (e.g., avoiding papaya/leafy vegetables during pregnancy)
   • Counter misleading commercial advertising on baby foods
   • Correct faulty cooking practices (avoid discarding rice water, prolonged boiling, excessive peeling)
3. Promotion of Breast-feeding
   • Exclusive breastfeeding for 6 months
   • Continued breastfeeding up to 2 years
   • Correct weaning practices with locally available foods
4. Attention to Vulnerable Groups
   • Nutritional needs of expectant and nursing mothers
   • Adequate complementary feeding for children 6 months to 2 years
   • Small, frequent meals for young children
5. Kitchen Garden and Poultry
   • Shortage of protective foods can be met by planning a kitchen garden
   • Keeping poultry for eggs and protein
   • Growing fruits and vegetables at home
6. MCH + Family Planning Integration
   • Mother and Child Health services, family planning (birth spacing), and immunization as a "package"
   • Community health workers (ANM, ASHA) to impart nutrition education at family level

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ACTION AT THE COMMUNITY LEVEL

• (a) Extent, distribution and types of nutritional deficiencies
• (b) Population groups at risk
• (c) Dietary and non-dietary contributing factors

          ICDS Programme (Integrated Child Development Services)
                              │
              ┌───────────────┼───────────────┐
              ▼               ▼               ▼
   Supplementary        Immunization     Health Check-ups
   Nutrition            (BCG, OPV,       (Growth monitoring,
   (hot cooked meal)    DPT, Measles)    Referral)
              │
              ▼
   Health and Nutrition Education
   for Mothers
              │
              ▼
   Non-Formal Pre-School Education
   for Children
   (Target: Children <6 yrs; Pregnant/Lactating Women;
    Women 15-44 yrs in identified Anganwadi areas)

1. Increasing availability of foods in quantity and quality
2. Ensuring access to food for those at risk - income support, food subsidies
3. Health education on nutrition, hygiene, infant feeding
4. Improvement of water supply and sanitation - prevents infection-malnutrition cycle
5. Control of infectious diseases - immunization, vector control
6. Broad socio-economic development of the entire community

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ACTION AT THE NATIONAL LEVEL (for completeness)

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Summary Flowchart: Comprehensive Strategy Against PEM in India

                        PEM IN INDIA
                             │
            ┌────────────────┼────────────────┐
            ▼                ▼                ▼
     IMMEDIATE          MEDIUM TERM      LONG TERM
     MEASURES           MEASURES         MEASURES
     
 • Hospital care       • ICDS            • Rural development
 • NRC (SAM           • Midday meals    • Agricultural
   management)        • Vitamin A         production
 • ORS for              prophylaxis     • Population
   diarrhea           • IFA tablets       stabilization
 • Deworming          • Fortification   • Poverty alleviation
 • Immunization       • Growth          • Female education
                        monitoring      • Safe water &
                      • Nutrition         sanitation
                        education

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KEY NATIONAL PROGRAMMES RELEVANT TO PEM PREVENTION IN INDIA

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