National  
                                 Food &  
                                 Nutrition  Nutrition Fact Sheet 11 
                                 Centre 
                     Protein Energy Malnutrition 
                        Protein Energy Malnutrition (PEM) is a condition that refers to different levels of 
                           malnutrition caused by not having enough of the foods that would normally     
                                                     supply energy and protein to the body. 
                     Classification of PEM                                          Signs of kwashiorkor  
                                                                                    y Affects children 1– 3 years old 
                     These dietary deficiency disorders are mainly                  y Poor growth 
                     related to shortage of all nutrients or to protein             y Muscle wastage 
                     and energy deficiency. These include:                          y Apathetic looking 
                     y Underweight                                                  y Odema in face, hands and feet 
                     y Kwashiorkor                                                  y Swollen liver and abdomen 
                     y Marasmus                                                     y Hair changes colour and is more brittle 
                     y Marasmic Kwashiorkor                                          
                                                                                    Nutritional Treatment 
                     These disorders are prevalent amongst children in              Treatment  in  terms  of  nutritional  care  is  to       
                     poorer developing countries and usually common                 increase food intake of the child, gradually       
                     for infants from 6 months of age to 2 years of age.            especially high protein foods.  
                                                                                     
                     Although not common there are children been                    Foods high in protein are: 
                     admitted for Marasmus and Kwashiorkor in Fiji                  y Meat 
                     hospitals.                                                     y Fish 
                                                                                    y Milk & Cheese 
                     According to the World Health Organization,      y Eggs 
                     hunger and malnutrition are the gravest threats to             y Dhal 
                     the world’s public health.                                     y Pulses 
                                                                                     
                     Malnutrition is by far the biggest contributor to              Marasmus 
                     child mortality.                                                
                                                                                    This is an energy deficient condition. 
                     Underweight                                                     
                                                                                    Causes 
                     This is usually when the mothers do not have                   y Early weaning from breastmilk to other foods 
                     adequate nutritious meals  during  and  after                      and milk inadequate in nutritive value 
                     pregnancy resulting in low birth weight babies.                y Repeated diarrhoea 
                                                                                    y Tuberculosis and gut disease 
                     Underweight in children also  results  from         
                     hookworm infestation, poor complementary foods                 Signs of Marasmus 
                     and unbalanced meals. Complementary foods are                  y Affects children under 2 years old 
                     foods given to supplement breastmilk after baby is             y Child looks old and wrinkled 
                     6 months of age.                                               y Skin is dry and faces thin with sunken cheeks 
                                                                                        and large eyes, abdomen looks swollen 
                     If underweight is left untreated it can lead to                y Stunted growth 
                     severe malnutrition; leading to mortality.                     y Considerable weight loss 
                                                                                    y Muscle wasting - sagging skin on legs and   
                     Kwashiorkor                                                        buttocks  
                      
                     This condition is associated with severe lack of               y Diarrhoea  
                     protein foods.                                                 y Child is usually irritable and cries alot 
                                                                                    y Vitamin and mineral deficiencies 
                     Kwashiorkor is a African word translated as ‘the                
                     disease the older child gets when the new baby is              Nutritional Treatment 
                     born’.                                                         The nutritional treatment would be to increase  
                                                                                    energy (calories) in the diet. This is by adding oils 
                     Causes                                                         and fats such as ghee, butter, margarine or    
                     y Untimely introduction of complementary foods                 cooking oil to the child’s food before feeding while 
                     y Foods given to children are deficient in protein ;           maintaining a balanced diet. 
                        such as giving only cassava, yam, dalo, rice                 
                        and rice water, which have mainly starch.                    
                                                                                     
                                                                                     
                                                                                     
             Marasmic Kwashiorkor                                                              Statistics: Fiji 
                                                                                                
             This is a combination of both conditions and is the                               The following data is available from the National 
             most severe form of PEM.                                                          Nutrition Survey 2004. The figures listed below 
                                                                                               are for children under 5 years old. 
             Child with this condition is very underweight       
             usually <60% of normal for that age.                                              Underweight (measuring weight for age) 
                                                                                                 Male   Female 
             Treatment for this condition is a combination of                                  Indian  17.5%  14.1% 
             high protein and high energy (calories) foods in                                  Fijian  4.2%  3.5% 
             the diet.                                                                          
                                                                                               Stunting (impaired height gain: measured by 
             Complementary foods are foods and liquids that                                    height for age) 
             are provided to the child along with breast milk                                    Male   Female  
             after 6 months of age.  These foods and drinks are                                Indian  5.3%  3.9% 
             meant  to  supplement  breast  milk,  providing        Fijian  4.3%  3.5%  
             additional nutrients to the infant. Complementary                                  
             foods  introduce the baby to the typical family diet.                             Wasting (is a measure for acute undernutrition in 
             These complementary foods should be prepared                                      extremely undernourished people: measured by 
             from locally available foods. Some complementary                                  weight for height) 
             foods that can be introduced to infants are:                                        Male   Female 
                                                                                               Indian  7.1%  6.8% 
             y Strained fruit juice or mashed fruits, including                                Fijian  1.6%  4.8% 
                  pawpaw, banana, mango and orange.                                             
             y Mashed  and  semi  -  soft  Vitamin  A  rich          
                  vegetables such as tubua, pumpkin, rourou, 
                  tomatoes, carrots or vegetable soup  
             y Soft-cooked eggs, meat, chicken, fish and/or 
                  dhal. 
             y Mashed local starchy foods - kumala, yams, 
                  dalo, breadfruit and cassava.  The starchy 
                  foods should always be softened and enriched 
                  with bodybuilding foods by adding egg, strained 
                  dhal, or mashed fish.  Adding a spoonful of  
                  butter, ghee, margarine, cooking oil or even 
                  lolo will increase the calories in the meal. 
                  These will enhance the nutrient content of the 
                  baby's diet. 
             y At the age of 12 months, the child can be fed                                  Picture shows a Marasmic                  Picture shows a Child 
                  with foods from the family diet.                                                          Child                          with kwashiorkor  
                                                                              References 
             1. Website: http://www.who.int 
             2.        Pictures on page 2 were obtained from Training Course on Growth Assessment - WHO Child Growth         
                       Standards, Photo Booklet 
             3. NFNC, 2007. 2004 Fiji National Nutrition Survey (NNS) - Main Report, NFNC, Suva 
             Fact Sheets Available in this series: 
             Fact Sheet 1:    Anaemia                                                         This Nutrition Fact sheet is intended for    
             Fact Sheet 2:    Cancer                                                          information only. It is not a substitute for 
             Fact Sheet 3:    Coronary Heart Disease                                          proper medical diagnosis or dietary advice 
             Fact Sheet 4:    Dental Caries                                                   given by a dietitian. For further information 
             Fact Sheet 5:    Diabetes                                                        contact a Doctor or Dietitian at your nearest 
             Fact Sheet 6:    Diarrhoeal Disease in Children                                  hospital /Health Centre or contact: 
             Fact Sheet 7:    Gout                                                             
             Fact Sheet 8:    Hypertension & Stroke                                           National Food and Nutrition Centre 
             Fact Sheet 9:    Iodine Deficiency Disorder                                      P.O. Box 2450  
             Fact Sheet 10:  Overweight & Obesity                                             Government Buildings 
                                                                                              Suva, Fiji 
             Fact Sheet 11:  Protein Energy Malnutrition                                      Office Location: 1 Clarke Street, Suva 
             Fact Sheet 12:  Vitamin A Deficiency                                             Phone: 331 3055                     Fax:        330 3921  
             Fact Sheet 13:  Zinc Deficiency                                                  E-mail: nfnc@connect.com.fj  
                                                                                              Website: www.nutrition.gov.fj