Protein Energy Malnutrition
(PEM)
Mustapha Umar Imam, MBBS, PhD
Medical Biochemistry, Usmanu Danfodiyo
University, Sokoto
Learning objectives
• Overview on Proteins/CHO
• Significance of PEM
• Types of PEM
• Causes of PEM
• Biochemical changes in PEM
• Prevention and treatment
Macro v. micro nutrients
• Macro-nutrients
–Protein (amino acids)
–Energy (carbohydrates)
–Fat (fatty acids)
• Micro-nutrients
–Water soluble vitamins
–Fat soluble vitamins
–Minerals
Macro-nutrients
• CHO
–Energy needed for all bodily function
• Protein
–Necessary for structural development & others
• Fat
–Used for energy, structure and others
What is Protein?
Protein: an energy-yielding nutrient composed of
carbon, hydrogen, oxygen, and nitrogen.
•Differs from carbohydrates and fats because of
the presence of nitrogen.
•The body has at least 30,000 types of protein,
each with a different job.
•The building blocks of all protein molecules are
amino acids.
Protein
• The quality of a protein is determined by its ability to provide the 9
essential amino acids.
• Proteins from animal sources (eggs, dairy, meat, poultry, and fish)
and one vegetable protein (soy) are all considered high-quality
because they contain all of the essential amino acids in the
necessary proportions.
Complete protein
• contain an adequate proportion of all the essential
amino acids in a diet.
• Proteins from animal sources (meat, poultry, milk,
and fish)
Incomplete protein
• lack one or more essential amino acids or
contain them in inadequate proportions
necessary for human metabolism.
• Proteins from plant sources (wheat, corn,
rice, and beans) have a lower quality (except
soy protein)
Complementary proteins
Incomplete proteins from different plant
sources may be combined in such a way that
the result is equivalent in nutritional value to
animal protein.
Ile, Leu Lys Met Trp
Legumes x x
Cereals x x
Combined
Uses of proteins
Food proteins
Digestion
Amino acid mixture
Glycogen
New proteins Lipids
(re-synthesis)
Biologically
Active Fluid balance Energy
Compounds Acid-base regulation (May provide up to
Hormones: insulin, 10-15% of body’s
serotonin and melatonin energy need. )
Carbohydrates
• Energy
• Store energy
• build macromolecules
• Fat and protein sparing
Abnormal nutrition
Abnormal nutrition
• Malnutrition is having the inappropriate level of a
micro- or macro- nutrient;
• Malnutrition can be under-nutrition or over-
nutrition;
• In Nigeria and most developing world,
malnutrition is associated with under-nutrition;
• Malnutrition contributes to over 50% of deaths in
children in the world.
Malnutrition is implicated
in >50% of deaths of <5
children (5 million/yr)
• Malnutrition due to inadequate intakes of
protein/energy is called protein energy
malnutrition.
• Why is PEM common in children?
PEM
• High nutrient requirement.
Growth - Rapid from birth till six months
Fat - Rapid increase in the 1st 6 months
Water - Higher body water> older children
• Dependence on adults for food
Growth Curves (0-3 years)
Length/
Height
Weight
Age
• What are some of the causes?
Causes of PEM
Child malnutrition
death and disability
Inadequate Disease
Diet
Insufficient Poor water/ sanitation Inadequate
access to food/ inadequate health maternal and
Breast milk services child care
Types of PEM
Kwashiorkor
Marasmus
Marasmic Kwashiorkor
Definition : ( WHO)
Marasmus- Weight less than 60% of expected
weight, no oedema.
Kwashiorkor- Weight between 60-80% of
expected weight + oedema
Can you tell the type of PEM?
Kwashiorkor
• Cecilly Williams, a British nurse, introduced
the word Kwashiorkor in 1933. The word is
taken from the Ga language in Ghana &
used to describe the sickness of weaning.
Kwashiorkor
• Occurs after weaning
• Kwashiorkor more likely in areas where
cassava, yam, plantain, rice and maize are
the main staples
• Increased carbohydrate intake with
decreased protein intake eventually leads
to edema (swelling)
Marasmus
• The term marasmus is derived from the Greek
marasmos, which means wasting.
• Marasmus involves inadequate intake of protein and
calories and is characterized by weight loss (skin and
bone)
• Marasmus is an extreme case of starvation
Main differences
Kwashiorkor Marasmus
Swelling (moon face) no swelling
Low protein intake Low protein + carbs
Abnormal adaptation Normal adaptation (like starvation)
This should be easy
Specific biochemical changes in PEM
• Gluconeogenesis,
• Ketogenesis + protein sparing
• Hypoglycemia
• Fats: ↓cholesterol, triglycerides
• Blood: ↓ Hb (anemia), Dehydration, protein
(+enzymes), albumin, transferrin, Urea
• Fluid and electrolytes: ↓K, ↓mg, ↓Na
• Hormonal: ↓thyroid, ↓insulin, ↓leptin,
↑cortisol, ↑growth hormone, ↑ glucagon
• Nervous system: ↓brain size
• Bone: wasting
• Immune system: infections
• Micronutrients: reduced, especially Vit. A, Vit.
K, Zn, Cu, Fe
Reversing and preventing PEM
1. Restore body water
2. Treat infections and anemia.
3. Give adequate nutrition + supplements (vit A etc).
4. Others: keep warm, education (Breast Feeding), social
and psychological intervention
Take home message
• Malnutrition can mean over-nutrition (obesity) or
under-nutrition (PEM)
• There are different types of PEM
• Kwash: low protein intake (body swelling/moon
face)
• Marasmus: Low energy (+protein) intake (skin and
bone)
• PEM is preventable and treatable
Interesting cases that show PEM is reversible
Before
After
Before
After
Brain shrunken Brain tissue regenerated
Even internal organs like the brain improve significantly after
PEM is treated. Above is an example of a child's brain with PEM
before (left) and after (right) treatment.
Long term effects of malnutrition
Increased offsprings’ risk of:
obesity
diabetes
hypertension & CVD
chronic lung disease
cancers
cognitive and mental disorders
death
Q&A
Sample questions
A pregnant mother brings her 1 year old child
to the hospital and complains that he does not
eat well, and has been passing watery stools.
The Child has been crying since arriving at the
doctor’s office and upon examination the
doctor found the child to have a large
abdomen, and swollen legs. Which of these is
true of the child’s condition?
A.His abdominal swelling is caused by
edema.....True
B.Abnormal metabolic adaptation favoring
carbohydrate and fat metabolisms is partly
responsible for his conditiont..true
C.The excessive crying is due to abnormal
biochemical reactions in the brain..true
D.The child’s weight is expected to be between
60-80% of normal for his age. True
E.There is more glycolysis happening in this
child than gluconeogenesis.false
