Protein Energy Malnutrition (PEM)

• Nutrition related health problems

Developing countries
Macronutrients : Protein-Energy (Calorie) Malnutrition (PEM/PCM)

Micronutrients: Iron, iodine and vitamin A (and of course Zn) are the
nutrients most lacking and cause several disorders

Developed countries and countries in transition

None Communicable Chronic Diseases/NCD/ : Hypertension, CVDs,
Stroke, Diabetes (None insulin dependent), Obesity, Dental carries,
Carcinomas, Osteoporosis, etc
Factors -Changes in life style (sedentary, stress) and
- feeding pattern ↑ fat intake, ↑ sugar intake, ↑ energy intake, ↓fibers
 PEM ……
• Other terms of PEM are
• Multi-deficiency syndrome
• Failure to thrive

• The term PEM/PCM/PED has been used to describe

– A range of disorders primarily characterized by growth failure or
retardation in children
 PEM ……
• Growth deficit is catalogued based on Clinical forms as
– Marasmus
• Retarded growth with wasting of subcutaneous fat
• Chronic onset

– Kwashiorkor
• Growth failure with wasting of muscles and preservation of
subcutaneous fat and
• pitting type edema
• Acute onset

– Mixed: Marasmus-Kwashiorkor (MK)

• Edema of kwashiorkor with wasting of marasmus
Differences Between the two Forms PEMs
Dermatosis
 Milder to moderate forms of PEM
• Wasting :thinness, assessed by using weight for height
(W/H)measurement.
• Stunting: linear growth retardation, assessed by using height for age
(H/A)measurement
• Underweight : A result of wasting and/or stunting , assess using
(W/A) measurement.
Classification of moderate and severe malnutrition
Malnutrition
Classification of PEM Moderate Severe

Symmetric edema No Yes

(bilateral pitting (edematous malnutrition or
edema) kwashiorkor)
Weight for Height
• SD Score • –2 to – 3 • < -3 severe wasting
• % Median • 70 to 79 • < 70 or marasmus

Length (Height) for age

• SD Score • –2 to – 3 • < -3 severe stunting
• % Median • 85 to 89 • < 85
• 1. All nutritional health children have weight of 16
kg and height of 107 Cm with 1.5kg standard
difference in wide population. Tamru is young child
visits pediatrics clinic. He has height of the
population and weight 11 kg).
• A. What is your anthropometric assessment tool for
Tamru?
• B. Determine Tamru’s nutritional status with Z-SD
and percentile median
 ASSESSMENT OF PEM
• Nutritional Assessment
– A measurement is the extent to which the individual’s physiologic
need for nutrients is being met

– Is an interpretation of commonly used methods (anthropometric,

biochemical, clinical, dietary and ecological ) data to tell the
nutritional status of a person or group of people

- It defines nutritional status by using various assessment methods

(ABCDEFGHs)
A-Anthropometric Assesses nutritional status of all population group by
determining the prevalence of under weight and height, thinness, over
wt

B-Biochemical assesses micronutrient deficiency

e.g. Iron , vit-A ..
C- Clinical Assesses manifestation of disorder

D- Dietary survey determined adequacy of food and nutrient intakes of

households and all population

E-Ecology determined socioeconomic and demographic characteristic of

household and individual
1. Anthropometry
• Measurement of physical dimension and gross composition of human
body

 Anthropometric assessment is done for two purposes

• For measurements of growth
• For measurements of body composition

1.1 Anthropometric measurements of growth

Head circumference,
Length,
Height,
Weight
Measurement of head circumference (HC)

Need a flexible, non stretchable tape

- Subject stand with left side facing; arms relaxed

-Tape should rest at occipital protuberance and supraorbital ridge at same

level on each side of head;
Weight measurement
Weight can be measured with a :
-Hanging spring scale (< 2 years children)
-Beam balance (> 2 years)
-Portable electronic scale
- Calibration needed after every measurement
- Remove or make allowance for clothing
-Wait until the subject calm or remove the cause of anxiety
Measurement of recumbent length
Note: Toes are pointing upwards
Knees must be straight.
If subject restless, then only left leg used to measure the Ht

Measured in children:
• Younger than 24 months
• Less than 85cm long if age is not known
• Who are too ill to stand

Correct measurement of length requires that:

• Child is relaxed with no shoes on
• Child lies parallel to the long axis of the board
• Crown of the head is against the fixed board
• Movable board is brought up against the heels
Standing height
Measured in children over 24 months of age(85-110 cm tall)
-The child stands barefoot wearing little clothing
- Child faces forward with legs straight
-Head, shoulder blades ,buttocks and heels contact the vertical board
- Movable headboard is gently lowered;
• Anthropometric indices are derived from combination of two or more
raw measurements

Conditioning factors:
• Age , birth weight, birth length, gestational age, sex, parental stature,
and feeding mode during infancy, maturation in adolescence,
• pre pregnancy weight , maternal height, parity and pregnancy.
1.2 - Anthropometric assessment of body composition
• It is based on a model in which the body consists of two chemically
distinct compartments
• Fat and
• Fat free mass ( skeletal muscle, non-skeletal muscle, and soft lean
tissue and the skeleton)
 Assessment of body fat
• It is the most variable component of the body which varies with
age ,sex and weight

Measured By:
A. Skin fold thickness
B. Waist-to-hip circumference ratio
 A-Skin fold thickness
• Provides an estimate of the size of subcutaneous fat depot
• Assumptions:
- Thickness to the subcutaneous adipose tissue reflects a constant
proportion of the total body fat

- The selected skin fold sites are representative

• Biceps and Triceps (mid point of the arm),
• Sub-scapular ( left arm and shoulder relaxed )
• Supra-iliac (above iliac crest at mid axillary line and
• Mid-axillary (on the mid axillary line at the level of xyphoid process)

* measured by precision skin fold thickness calipers

skin fold thickness calipers Biceps skin fold measurement

B- Waist to hip circumference ratio

• Used to distinguish lower trunk ( hip and buttocks) and fatness in

upper trunk (waist and abdomen)
Waist to hip circumference ratio
It is the circumference of the waist measured mid-way between the
lowest rib cage and anterior superior illiac spine and

divided by the circumference of the hip measured at the level of the

greater trocanter of the fumer.

If the ratio is > 1 in male, and > 0.87 in female there is high risk of
coronary heart disease.
1.3-Index
Combination of two measurements
-Height for age
Low HA is stunting (Chronic malnutrition)

-Weight for age

Low WA is underweight

-Weight height ratios (Benn’s Index)

Low WH is wasting ( acute malnutrition)

-Body Mass Index (BMI) = Weight (kg)/(Height in meters)2

Best for measuring adult nutritional status
18.5 – 24.9 kg/m2: Normal
• Calculation of indices
1. Percentiles / %/
• Weight for age (W/A) = Child Weight X 100
Wt of the reference child of the same age

Weight for height (W/H) = Child weight X100

wt of the reference child of the same height

• Height for age (H/A) = Child Height X 100

Ht of the reference child of the same age
• Expressing anthropometric measurements in Z-score
- Z scores (SDs)= -1 to -2 mild,
< -2 to -3 moderate,
= < -3 sever
• Z-scores = Individual’s value – median value of reference population
Standard deviation value of reference population

• < -2 Z Height for Age = > Stunted

• < -2 Z Weight for Height = >Wasted
• < -2 Z Weight for Age = >Underweight
• Ht for age Z- score = Observed height – Median reference* height
Reference SD in height

• Wt for age Z- score = Observed weight – Median reference* wt

Reference SD in weight

• Wt for Ht Z- score = Observed weight – Median reference* wt

Reference SD in weight

• *Median value of reference children of same age & sex

• **Median weight of reference children of same height & sex

• Identifying PEM in children and adults

– Under five children

I-Gomez classification (weight-for-age)
II-Well come classification (weight-for-age)
III-Water low classification (height-for-age)

– Adults
• In adults, PEM is called Chronic Energy Deficiency (CED)
• It is characterized by weight loss and lack of energy

•  NCHS = National center for health statistics, USA.

I. Gomez classification : Employs weight for age

% of NCHS reference Level of malnutrition

>= 90 Normal

75 - 89 Mild (Grade I)

60 – 74 Moderate (Grade II)

< 60 Severe (Grade III)

– Disadvantage of Gomez Classification

• Edema is ignored and yet it contributes to weight
• Age is difficult to know accurately in developing countries
(where illiteracy is common)
II. Welcome classification :Employs weight-for-age
In clinical setups in order to clearly distinguish the different clinical
forms (Marasmus, Kwashiorkor or mixed)
Level of malnutrition

%NCHS Edema No Edema

60 - 79 Kwashiorkor Undernourished

< 60 Mixed Marasmus

– Disadvantage
• Doesn’t differentiate acute from chronic malnutrition
III. Water low classification
– Weight-for-height and height-for-age are used together in a two
by two table
– In field (community) set ups, the water low setup is used to
distinguish the acute and chronic forms of malnutrition

Water low Weight for height

classification
>= 80% < 80%

Height for >= 90% Normal Wasted

age
< 90% Stunted Wasted and
stunted
• 1.4 –MUAC/ maid upper arm circumference /
– Useful in the diagnosis of PEM
– MUAC for age can differentiate normal children from those with
PEM as reliably as weight for age
– Has been used for screening for PEM in emergencies such as
famines and refugee crises
– In emergency situations, the measurement of weight or height may
not be feasible and ages of children are often uncertain
– A single cutoff of 12.5 cm (12 in Ethiopia) has sometimes been
used in the past for children <5 year as a proxy for low weight for
height (wasting)
. > 13.5cm = normal ;
. 12.5 -13.5cm = at risk;
. < 12.5 cm = marasmic
• 1.5- BMI
• Identify chronic energy deficiency (CED) in adults
– the three degrees of CED are parallel to the Gomez classification
of PEM in children

• Grades of CED BMI

–0 (Normal) 18.5 – 25 kg/m2
– I (Mild underweight) 18.4 – 17.0 kg/m2
– II (Moderate underweight) 16.9 – 16.0 kg/m2
– III (severe underweight) < 16.0 kg/m2

• A pregnant women with BMI less than 16 kg/m2 will have

– Low birth weight in 50% of the cases
– Decreased work capacity
– Poor resistance of infection
2-Biomarkers
– Measurement of either total amount of the nutrient in the body or
the concentration in a particular storage site (organ) in the body or
in the body fluids
– Advantages
• Objective and not subject to the biases of self report
– Disadvantage
– Depend upon issues like practicality and cost
Considerations include
• Ability to access easily the body compartments for measurement
(e.g. blood, urine, adipose tissue)

• Procedures to collect, process and store samples

• Resources and technology needed for laboratory analysis
Example -Serum Iron, Leukocyte ascorbic acid, Hair zinc
3-Clinical methods
- Used to detect deviations from the normal state of nutrition just by
observing and interpreting clinical signs and symptoms of deficiency
or excess

– Signs : observations made by qualified examiner

– Symptoms : Manifestations reported by the patient

– Diagnosis of a nutritional deficiency should not exclusively on

clinical methods
– Because the signs and symptoms are often nonspecific
and only develop during the advanced stages of
nutritional depletion (poor specific and sensitive)
• 4- Dietary methods
• The method used for measuring food intake at
• National
• Household
• Individual level
– Of two types
• Methods to assess current intake
– Weighed food record : Gold standard
• Methods to assess past intake
– 24 hours dietary recall
– Repeated 24 hours recall
– Estimated food records
– Dietary history
– Food frequency questionnaire
• Types of food intake measurement
• Indirect measurement of food intake: make use of information on the
availability of food at national, regional, or household levels to
estimate food intakes,
• rather than using information obtained directly from individuals who
consume the food.

• Direct measures of food intake:

• Information on food intake can be obtained directly from consumers
in a number of different ways.
• Why studying food people eat?/propose /

Public Health: to evaluate the adequacy and safety of the food that
people eat at national or community level
• and to identify the need for or to evaluate nutrition-based intervention
programs.

Clinical: to assist with the prevention, diagnosis, and treatment of diet-

related conditions.

Research: to study the interrelationships between food intake and

physiological function
or disease conditions under controlled conditions or in field conditions.
5-Ecological methods
– Collection of information on a variety of other factors known to
influence the nutritional status
• Socioeconomic and demographic data
– Household composition
– Education
– Literacy
– Ethnicity
– Religion
– income,
– Employment
– Material resources
– Water supply and household sanitation
– Access to health and agricultural services
 MANAGEMENT OF PEM

• Therapeutic Feeding Program (TFP) for the management of SAM

• Integrates the management of Severe Acute Malnutrition (SAM) into
hospitals, health facilities and medical universities
• SAM management includes two approaches

I-Acute stabilization phase

Therapeutic Feeding unit (In patient care) for children with SAM and
complications
The main focus is treatment of infections and other complications
such as dehydration, hypothermia, hypoglycemia& other electrolyte
imbalances (see protocol from the MOH)
 OTP – First Contact, Appetite test

Uncomplicated
• Phase 1. Patients without an adequate appetite and/or a
major medical complication are initially
• admitted to an in-patient facility for Phase 1 treatment.

• The formula used during this phase (F75) promotes

recovery of normal metabolic function and nutrition-
electrolytic balance.

• Rapid weight gain at this stage is dangerous, that is why

F75 is formulated so that patients do not gain weight during
this stage.
- Transition Phase. A transition phase has been introduced for in-
patients because a sudden
• change to large amounts of diet, before physiological function is
restored, can be dangerous and lead to electrolyte disequilibrium.

• During this phase the patients start to gain weight as F100 or RUTF is
introduced.

• The quantity of F100 given is equal to the quantity of F75 given in

Phase 1 or an equivalent amount of RUTF.

• As this is resulting in a 30% increase in energy intake the weight gain

should be around 6 g/kg/day; this is less than the quantity given, and
rate of weight gain expected, in Phase 2.
 II-Rehabilitation phase
Required for

• On the restoration of the lost tissue and promotion of catch up growth

• Whenever patients have good appetite and no major medical
complication they go through
• Out-patient therapeutic program (OTP) indicated for children with
uncomplicated SAM and with good appetite
• In Phase 2 RUTF or F100 used in both in-patient and out-patient
settings) according to look-up tables.
 Inpatient Care

Phase II
Phase I Stabilization
Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.

Care Attend to complications (e.g. shock, hypoglycemia)

F-100 Therapeutic Milk

Feed F-75 Therapeutic Milk
(RUTF)

t
Quantity 135ml/kg/day atien 200ml/kg/day
Outp
Care

Time 1-7 Days, 3 to 4 Weeks

 Rehabilitation phase…….
• How much to give?
– The synthesis of new tissues requires protein and other nutrients.
– Synthesis also requires a considerable amount of energy.

• Aim is to provide all necessary nutrients so that none limits the

rate of recovery
• Normal rate of growth of children is such that they gain weight
of 1g/kg/day by
-taking 105 kcal/kg/day and
-0.78 g of protein/kg/day
• *: Stick to the current guidelines from the MOH
• Assess progress
– Patients should be weighed at least weekly, preferably daily and
the weights plotted

– Failure to maintain rapid catch-up may signal an undiagnosed

infection and/or inadequate intake

– Keeping a record of the child’s food intake helps to elucidate the

cause of poor weight gain

– Management of PEM see on table teaching aid of MOH

Prevention of PEM (options for intervention)
1. Dietary diversification
• Production of food stuffs at the back yard garden and
intensification of horticultural activities
2. Nutrition education
• Focuses on educating mothers/care givers and fathers on the
importance of having a balanced diet through diversification of
food
• On job training to DAs
• Inclusion of nutrition courses in curriculum
3. Economic approach
• Aims at improving the incomes of the target community as a
solution to their nutritional problems
• Different methods in this approach
– Food for work, food subsidy, income generating projects
4. Dietary modification
• Focuses on modifying the energy, protein and micronutrient content
of the complementary foods.
• In order to reduce dilution of the energy and protein contents of the
complementary foods and their level of contamination,
• These need to educate mothers and demonstrate to them the benefits
of sprouting (germination) and fermentation.
Fermentation
• Renders the food less contaminated probably because of the formation
of acid
Germination
Using sprouted (germinated) flour otherwise known as “power flour”
or amylase rich flour (ARF) makes the complementary food more
liquid but less dilute
5. Supplementation
– Could also be considered based on the local needs
 Public Health Consequences
• Undernutrition has a series of public health consequences that
diminish the individual quality of life and the prospects for social
progress

• Susceptibility to mortality (death)

• Undernutrition is associated with greater mortality rates from most
childhood diseases.
• Undernutrition accounts for 33-60% child deaths world wide

• Susceptibility to acute morbidity (disease)

- more likely to contract diarrheal, malarial and respiratory infections
and more likely to suffer from these illnesses for longer duration
• Decreased cognitive development
Specific nutrient deficiencies also impaired cognitive development
(e.g. iodine)
Decreased economic productivity
People of larger stature and musculature are more efficient and
accomplish more physical labor

Prompt and complete recovery from infectious diseases that is

promoted by adequate nutritional status increases economic
productivity

Susceptibility to chronic diseases in later life

There is early appearance and greater prevalence and severity of
obesity, hypertension, stroke and cardiac ischemia and diabetes in
people with low birth weight and nutritional problems in early life