Dr. Kavanaugh, Nutrition 302
31 March 2011
“Wasting Away: Protein-energy Malnutrition”
Heart-breaking photos of starving children in foreign countries are familiar to most when
watching television. It is common for children on these commercials to be seen with pot bellies,
edema, and altered hair texture. In most cases, they are portrayed with miserable expressions on
their faces. These characteristics are not from starvation alone, but from a certain deficiency that
wastes away its victims. Protein Energy Malnutrition (PEM) is the classification of the
deficiency in protein intake, most often seen in developing countries. The term Protein-energy
Malnutrition is used to encompass a gamut of protein deficiencies, from kwashiorkor to acute
marasmus (1). Many complications are seen with severe protein-energy malnutrition and those
affected normally present many of the same symptoms (2). There are three forms of clinical
protein-energy malnutrition: marasmus, kwashiorkor, and marasmus kwashiorkor, a mix of the
two forms (2). The deficiency is not only characterized by the lack of animal protein, but a
deficiency in “vegetable proteins, minerals and in vitamins” (3). Protein deficiency can be
treated if the right nutrients are provided. If not provided, however, the effects can be fatal. A
study conducted by Jorge Gonza´lez-Barranco, M.D., and Juan M Rı´os-Torres states, “Early
malnutrition has been significantly associated with chronic diseases later in life. The finding of
metabolic abnormalities in individuals with malnutrition in fetal life and early in postnatal life
may have important public health implications in developing countries” (4). Studies by many
doctors along with the World Health Organization (WHO) are being conducted in order to
combat a condition easily preventable but highly threatening to its victims.
The classification of PEM is attributed to the many scientists who studied the deficiency.
Williams first classified protein-energy malnutrition as simply kwashiorkor during her studies
(1). In her first published article in 1933, Williams describes kwashiorkor as detailed as it is
written about in the present day, and she first uses the name kwashiorkor in her second paper (1).
Through studies by Brock and Trowell, it was eventually realized that kwashiorkor occurs
worldwide and in many tropical climates. Williams came to the realization that kwashiorkor is
omnipresent and has probably always been with us, revealing itself wherever there is destitution,
scarcity, and insufficient infant feeding (1). It was discovered to be not only prevalent in young
children, but also in adolescents (1). It was then discovered that there were many different
symptoms of protein deficiency, not all looking like kwashiorkor. Kwashiorkor was then
differentiated and regarded as separate from pellagra, and the concept of protein deficiency
became firmly recognized in the 1950s (1). “Thus the causal name ‘protein malnutrition’ was
born and seemed ready to supersede the name kwashiorkor which Williams herself described as
‘cacophonous’ (1). With the discovery of marasmus, it was exposed that these deficiencies were
not only the cause of a lack of protein, but also of energy. This is why the encompassing name
of protein-energy deficiency (PEM) was finally chosen (1).
Although seen in some impoverished areas of America, the majority of PEM cases are
observed in developing nations around the world. When trying to combat Protein Energy
Malnutrition, it is crucial to know who is affected. Severe PEM is most commonly seen in
children. In a case study conducted in Iran regarding children’s body-types, “the prevalence of
stunted children under the age of 5 years is still relatively high, nearing 20%. For children under
the age of 6 years, 5.2% are wasted and 5% are stunted, reflecting malnutrition over the past
years” (5). According to the WHO, “protein-energy deficiency is classified by the degree of
children underweight compared to average (western) children of the same age, and the presence
or absence of edema” (2). The reason PEM is prevalent in children is due to the fact that the
“protein requirement per calorie is higher in infants than in children and adolescents and higher
in children and adolescents that in adults” (3). PEM is prevalent within the first five years of life
because cow’s milk, which is normally the most standard resource of protein in children during
the post-weaning stage, is not accessible in areas such as the tropics of Africa. According to
Brock, “its absence is probably among the important causes of the prevalence of the syndrome”
(3). PEM is prevalent in children living in the countries of India, Jamaica, Haiti, Uganda,
Turkey, Sudan, and Lesotho, to name a few (1). A more specific form of PEM, kwashiorkor, has
been found to be specifically prevalent in the Kikuyu, Wakamba, and the Belgian Congo in
Since children are the most prevalent group affected by PEM, causation needs to be
discussed more in-depth. It is obvious PEM is caused by a lack of protein and caloric source,
more importantly the causes can be traced back to climate, war, and cultural circumstances.
There are three factors, according to Waterlow, that operate at the level of the individual child.
These include lack of food, infection and psychosocial deprivation (1). In Waterlow’s
hierarchical model of the causes of PEM, Level I encompasses inequality, drought, and war.
These lead to Level II, which is a poverty and social disadvantage (1). Level III includes
disadvantages such as lack of food, infections and neglect (1). Infections and neglect lead to
Level IV, which is anorexia (1). Finally, the lack of food from Level III and anorexia from
Level IV directly lead to malnutrition (1). Brock summarizes the main causes in his book. He
states “there is almost a complete lack of animal protein in the diet of young children as soon as
the supply of breast milk gives out.” There is also a lack of vegetable protein. He also states,
“dietary errors due to poverty and ignorance are a causative factor” (3). Areas such as central
and tropical Africa lack livestock for animal protein, contributing to the causation of PEM in its
Protein-energy malnutrition not only has many different causes, but also has several
severe symptoms. Retardation is a symptom due to the lack of nutrients supplemented to the
brain. Another body system affected by PEM is the muscular system. “Marasmic infants muscle
mass was 30 percent of normal, while the body weight was 50 percent of normal. It is evident
that muscle bore the lion’s share of tissue loss” (1). According to Waterlow, two different kinds
of changes in chemical composition occur. These include changes in fat tissue and lean tissue
and the other is in terms of water, protein, fat and minerals (1). A third symptom of PEM is
dehydration. “The child with PEM nearly always suffers from diarrhea and vomiting, which
results in some degree of dehydration….In severe dehydration, the child is limp, lethargic, or
unconscious, with sunken eyes, dry tongue, and weak or absent radial (wrist) pulses” (2). Urine
flow is often scarce or unobserved (2). Dyspigmentation in skin and hair color is common in
victims of PEM, and show lightening of the hair and skin in victims (3). Edema associated with
hypoalbuminaemia is prevalent. Most children with specific protein deficiency, kwashiorkor,
have abdominal swelling that is characterized by a potbelly (3). Pathological changes in the liver
including fatty infiltration, necrosis, and fibrosis are known to occur (3). If PEM goes
undiagnosed or is improperly diagnosed, a heavy mortality rate is associated (3). Dermatosis can
occur, and is sometimes referred to as elephant skin, found mostly on the knees and back (3).
Gastrointestinal disorders are common, including anorexia, digestive upset, diarrhea, and mild
steatorrhoea (3). There are many emotional and behavioral symptoms that are associated with
PEM. These include peevishness, fussiness, miserable facial expressions, and mental apathy (3).
Mild normocytic or macrocytic anemia can occur and is associated with parasitic infestation (3) .
There is a decrease in enzymatic activity caused by atrophy or the acini of the pancreas (3). If
these symptoms are left untreated, the outcome is fatal (3).
There are three main types of Protein-energy deficiencies. These include kwashiorkor,
marasmus, and marasmic kwashiorkor, or a mix between the two (2). “The leading signs of a
diagnosis of marasmus are those of starvation: an “old man’s face”, and emaciated body that is
“only skin and bones”, accompanied by irritability and fretfulness” (2). Children with marasmus
do not express edema and generally appear to be starving. Those with kwashiorkor look quite
different. The leading symptoms are edema and apathy but also express discoloration of the hair
and “flaky paint” dermatitis (2). The child does not appear emaciated like in victims of
marasmus. According to Dr. Barbara Underwood, “Today, kwashiorkor is much less prevalent
globally and in India, yet stunting and underweight remain prominent reflectors of
persistent moderately severe undernutrition” (6). In the mixed form, marasmic kwashiorkor,
marasmus with edema is more common than kwashiorkor in its pure form (3).
Protein-energy malnutrition is a dangerous condition with serious consequences if not
treated properly. There are, in fact, many ways in which PEM can be treated, no matter what
kind of protein deficiency the person has. The WHO states “when a child with PEM is seen for
the first time, a history of his recent physical condition should be taken, and a physical
examination should be made” (2). Because dehydration is the most serious factor of PEM, it has
first priority for treatment (2). Other steps to take with high priority include “restoration of diet
and prevention or cure of infection, severe anemia, hypoglycemia, and vitamin A deficiency”
(2). First, a history of the patient should be noted such as their “previous intake of food and
fluids, duration and frequency of vomiting and diarrhea, presence of fever, difficulty in
breathing, urine flow and when urine was last passed, and mental apathy and loss of appetite”
(2). Then the child should be examined for dehydration, infection, weight, and temperature (2).
Investigations of hemoglobin levels, urine, chest, and blood are conducted next (2). The child
should be assessed to see if there are any signs of dehydration. Most with PEM “nearly always
suffer from diarrhea and vomiting, which results in dehydration (2). Following this exam, the
patient’s appearance, radial pulse, examination of the eyes and fontanelle, urine flow, and skin
elasticity should be noted (2). “In kwashiorkor, dehydration can occur in the presence of edema.
The skin at the side of the neck and over the abdomen is a useful site to test for elasticity” (2).
Following these tests and examinations, patients should be put on a nutrient/energy dense
feeding schedule that is followed regularly (2). Studies are now being conducted that are
attempting to enhance foods nutritionally in other countries. An example of this is a study
conducted by Dr. Ingo Potrykus, who developed protein-rich rice for developing countries. They
called this the “golden rice project,” and it was designed to help countries improve nutrient
content in their basic foods using GMO technology (7). Fortified blended foods (FBF) are
another important method that scientists are testing and using in developing countries to provide
a source of protein for the people (8). Klein states, “Fortified blended foods (FBFs) with high
protein and micronutrient content, such as corn-soy milk (CSM) and wheat-soy blend (WSB),
were developed in 1967 as part of a strategy from the United States to improve child nutrition”
(8). The study found “positive effects on weight gain and recovery from moderate acute
malnutrition… in populations receiving FBFs as food-aid supplements” (8). With the use of
technology and medical treatment, PEM can be combated and overcome.
Protein-energy malnutrition can be prevented, and many are working to see that it is
prevented in other countries. The use of enhanced foods such as “Golden Rice” is important in
fighting PEM (7). Global hunger is a major problem throughout the world today, and is a major
reason why PEM exists (9). Finding the solution for chronic hunger is a priority because this
would lead to the prevention of PEM and many other problems. Sibrian states, “Hunger can be
measured using three major indicators: 1) the prevalence of undernourishment (food
deprivation); 2) the prevalence of critical food poverty (income deprivation); and 3) the
prevalence of underweight in children (child undernutrition) (9). Solving the solution to these
indicators will help in the prevention of PEM in the developing world. Another step in the
prevention of PEM is clean water. According to Alive Canadian Journal of Health and Nutrition,
“WHO estimates that half the people in the developing world have one or more water-borne
diseases. One of the most serious is roundworm infection, which can cause serious anemia,
gastrointestinal problems, malnutrition, and heart disease when contaminated drinking water is
consumed” (10). The lack of clean water contributes to infections that cause malnutrition that
leads to protein-energy malnutrition. Groups, such as the WHO, are working to prevent PEM by
starting with the importance of clean water in developing nations (10).
Organizations such as WHO are working to prevent protein energy malnutrition in young
children by providing clean water and fortified foods. However, without clean water and proper
nutrition, the chances of having the proper amount of protein are slim. The harmful effects of
protein deficiencies such as marasmus and kwashiorkor inhibit young infants and children from
ever reaching late adulthood (1). As technologies advance worldwide, the possibilities are
endless in how proper nutrition can be provided for the developing world. PEM leads to serious
problems, but with the help of the global community, this deficiency can be improved in the
1. Waterlow, J.C. Protein energy malnutrition. 2nd ed. London, England: Edward Arnold;
2. World Health Organization. Treatment and management of severe protein-energy
malnutrition. Geneva: World Health Organization; 1981.
3. Brock, J.F. Kwashiorkor in Africa. Geneva: World Health Organization; 1952.
4. González-Barranco J, Ríos-Torres J. Early malnutrition and metabolic abnormalities later
in life. Nutrition Reviews [serial online]. July 2, 2004;62(7):134-139. Available from: Alt
HealthWatch, Ipswich, MA. Accessed March 23, 2011.
5. Atinmo T, Mirmiran P, Oyewole O, Belahsen R, Serra-Majem L. Breaking the
poverty/malnutrition cycle in Africa and the Middle East. Nutrition Reviews [serial
online]. May 2, 2009; 67:S40-S46. Available from: Alt HealthWatch, Ipswich, MA.
Accessed March 23, 2011.
6. Underwood B. Health and nutrition in women, infants, and children: overview of the
global situation and the Asian enigma. Nutrition Reviews [serial online]. May 2,
2002;60(5):S7. Available from: Alt HealthWatch, Ipswich, MA. Accessed March 23,
7. Potrykus I. Nutritionally enhanced rice to combat malnutrition disorders of the poor.
Nutrition Reviews [serial online]. June 15, 2003; 61(6):s101. Available from: Alt
HealthWatch, Ipswich, MA. Accessed March 23, 2011.
8. Pérez-Expósito A, Klein B. Impact of fortified blended food aid products on nutritional
status of infants and young children in developing countries. Nutrition Reviews [serial
online]. December 2009; 67(12):706-718. Available from: Alt HealthWatch, Ipswich,
MA. Accessed March 23, 2011.
9. Sibrián R. Indicators for monitoring hunger at global and subnational levels. Nutrition
Reviews [serial online]. May 2, 2009; 67:S17-S20. Available from: Alt HealthWatch,
Ipswich, MA. Accessed March 23, 2011.
10. Water woes. Alive: Canadian Journal of Health & Nutrition [serial online]. October
2005;(276): 14. Available from: Alt HealthWatch, Ipswich, MA. Accessed March 23,