Providing an in-depth about
1) MAJOR DEFICIENCY DISEASES-I : PROTEIN ENERGY MALNUTRITION AND XEROPHTHALMIA
2)MAJOR DEFICIENCY DISEASES-II : ANAEMIA AND IODINE DEFICIENCY DISORDERS
3)OTHER NUTRITIONAL PROBLEMS
4)NUTRITION AND INFECTION
5)DIETARY MANAGEMENT OF OBESITY, HEART DISEASE AND DIABET...
UNIT 17 MAJOR DEFICIENCY DISEASES-I :
PROTEIN ENERGY MALNUTRITION
AND XEROPHTHALMIA
Structure
17.1 Introduction
17.2 Protein Energy Malnutrition (Nature, clinical features, causes, treatment and
prevention)
17.3 Xerophthalmia (Nature, clinical features, causes, treatment and prevention)
17.4 Let Us Sum Up
17.5 Glossary
17.6 Answers to Check Your Progress Exercises
17.1 INTRODUCTION
This unit will deal with two of the major deficiency diseases, namely Protein energy
malnutrition (PEM) and Xerophthalmia (Vitamin A deficiency).
.
You learnt earlier that the human body requires energy to carry out the different
activities and proteins are necessary for growth and repair. In this unit we shall learn
as to what happens when there is deficiency of energy and protein in the diet. The
deficiency of these two basic nutrients in our body leads to protein energy
malnutrition. Similarly due to lack of Vitamin A rich foods in the diet, vitamin A
deficiency or xerophthalmia results. These two deficiency disorders have very serious
consequences and are major nutritional problems in India.
Which section of the population group is more vulnerable to these diseases? What
are the major features, causes, clinical features of these two widespread disorders?
How can we prevent them? What treatment can be prescribed? These are some of the
issues which are discussed in this unit.
After studying this unit, you will be able to:
describe the nature and causes of PEM and xerophthalmii,
enumerate the clinical features of PEM and xerophthalmia and
discuss the treatment and prevention of these disorders.
17.2 PROTEIN ENERGY MALNUTRITION
Protein energy malnutrition (PEM) is widely prevalent among young children (0-6
years) but is also observed as starvation in adolescents and adults, mostly lactating
women, especially during periods of famine or other emergencies. PEM has serious
consequences for the health of individuals particularly children and can even result in
death.
Let us first define PEM. PEM can be dejined as a range of pathological conditions
arising from a dejiciency of protein and energy, and is commonly associated with
infections. What kind of adverse changes take place in the body as a result of PEM?
The adverse changes which are externally noticeable are referred to as clinical
features about which we will read as we go through this section.
,Nntrition-Relafed Disorders In Unit 1 of Block 1, you may recall reading about signs of good health related to
different body pan? like the eyes, the skin, the teeth, etc. Many diseases result in
adverse changes in the appearance and functions of one or more body parts. For
example a healthy person has clear eyes. But in a person with severe vitamin A deficiency,
eyes lose their clarity and become muddy o r cloudy. Similarly, a child suffering from
PEM is shorter than other children of the same age. Such changes in appearance
relating to the body as a whole o r its parts are referred to as clinical j'eahtres of a
disease. The clinical features can be easily detected by trained individuals. Let us
now study about the clinical features of PEM.
CIinical features of PEM
?EM is a condition characterized chiefly by the following two forms:
a) Marasmus
b) Kwwhiorkor
Marasmu.s is a condition characterized by very low body weight for age, loss of
s a b c u t ~ n e o wfat (fat under the skin), gross muscle wasting. It is observed more
frequently in inf~ntsand very young children.
\
Kwashiorkor on the other hand is a condition charactenzed by oedema (excessive
arcumulation of fluid in the intercellular spaces of tissue) and very low body weight
for hge. ?'he syndrome is most frequently observed in children aged 1-3 years and is
prec~pitatedby a n infection o r more commonly by a series of infections.
However, there are also children who show some of the characteristic signs of both
marasmus and kwashiorkor. Such children are said t o suffer from Marasmic
Kwashiorkor. Then there are children whose heights and weights are considerably
below that of healthy children of the same age. These children may not show any
typical clinical signs of either kwashiorkor or marasmus, and as such they are placed
in the category of subclinical forms of PEM which farms a large proportion of the
disease In the community. Subclinical condition meatls that we d o not see the clinical
features of the disease. These forms of the disease can be ident~fiedonly on special
investigations o r tests. In the case of PEM, we can detect subclinical status by
measuring body weight.
In all the forms of PEM, remember, growth failure or low body weight is a common
sign. So then, how are these ferms different from each other? The description below
presents a clear picture of the different forms of PEM and lists signs and symptoms
specific to each form. which will help us identify individuals suffering from different
forms of PEM. We begin our study by identifying signs and symptoms of marasmus.
A) 1-low to identih a child suffering from Marasmus?
Some ssmrnon cliri~calfeatures of m a r a m u s include :
: j Muscle Z4as;ting : The characteristic slgn of marasmus is the extensive wasting
of musclc ir;~th Ilttle o r n o fat under the skin. We use the term wasting to mean
entucrat~uni-r !hlnnrys of zhe hody. The ribs become very prominent. Because of
thr r;bcer8ccof f;l* tb- :kin will deve!op a number of folds, particularly on the
b~trnc _ L l r l + khiit:
, n,;,rasmus, thus, can be described as skin and bones.
You ,:pr: zee :nis c!earlg nr: F ~ g u r e17 1.
ii) Failure to thrive : There is fallure to thnve and the child suffering from
rnarasmus usually is irritab!e and fretful. I n fact, the child is often s o weak that
the cry of the child cannot even be heard.
iii) Growth failure : Failure to grow is aiother important feature of the disease.
The children often weigh about 50 per cent or less of normal children for their
age. For example, a healthjl norma: one year old child weighs about 10 kg,
whereas, a maranikc child would weigh only about 5 t o 6 kg.
In :rddltlon ro these clinical featlires there is usucllly watery diarrhoea associated
~ f t e nwith dehydration (loss of fluids). The child may also have other deficiencieq
p::r~is!~l.triy,vifanl~nA deficiency idctalfs of which are glven In Section 17 3 of this
%ad)
, Major Deficiency Diseases-I:
Protein Energy Malnutrition
and Xerophthalmia
,/-
Fig. 17.1 Child with Marasmus (Photo Courtesy : National Institute of Nutrition, Hyderabad.)
B. How to identify a child suffering from Kwashiorkor?
Some common clinical features of Kwashiorkor include:
i) Bedema : .Oedema is the excessive accumulation of fluid in the intercellular
spaces of the tissues. Oedema is usually observed on the lower limbs, but it
may also be distributed all over the body including the face. Remember
kwashiorkor should nor be diagnosed without the presence of oedema. But how
can we detect oedema? We can detect oedema by pressing the skin over the
shin of the leg with your fingers. Because of accumulation of fluid under the
skin, when you press there will be a depression at the place where the pressure
is applied.
ii) Failure of growth : Growth failure is an early sign and we can notice this by
taking body weight. Children ~11th kwashiorkor weigh only about 60 per cent of
the weight of normal children for their age. For example, a three year old
healthy normal boy weighs about 13.5 kgs. whereas, another boy of same age
but suffering from kwashiorkor may only weigh 60 per cent of 13.5 kg i.e
about 8 kg. In other words, they are very much lighter than healthy normal
children of their age.
iii) Irritability : The child suffering from kwashiorkor is generally irritable and has
no interest in hidher surroundings.
iv) Skin changes : In addition to the above manifestations, there may be
characteristic skin changes. The skin becomes thick and appears as though it
has been varnished. The skin of the child may peel off easily leaving behind
cracks or sores.
v) Haix Changes : The hair may become sparse and can be easily pulled off. The
hair usually loses its black colour and appears reddish brown.
, Nutritidn-Related Disorders vi) Moon Face: The face of the child suffering from kwashiorkor may appear puffy
with the cheeks sagging. This sign is normally known as moon face.
Fig. 17.2 shows some of the clmical features like oedema, moon face and skin changes
rly.
Fig.17.2 Child with kwashiorkor (Photo Courtesy : Ha~iunalInstitute of Nutrition, Hyderahad)
vii) Associated deficiencies : The children may have signs of other deficiencies like
those of vitamin A and B-complex deficiencies. What are these signs and symptoms?
You. will
-
Iearn about these deficiencies in the subsequent units of this block.
viii) ,Associated diseases : The child is often brought t o the hospital with watery
diarrhoea (frequent loose motions) or severe respiratory infection (cough). The
children often will be recovering from measles, a childhood disease, which is
characterized by skin rash and fever.
O u r study of the clinical features of kwashiorkor and marasmus, reveal that growth
failure is chatzrt-'-:,, -,;30th these conditions. However, it is much more
pronounceu :n marasmus. Can you now identify what exactly is the difference
between these two conditions? Make a checklist and tally your responses with
principal features of PEM given in Table 17.1.
Table 17.1 : Principal features of PEM
Features Marasmus Kwashiorkor
Essential features * extensive muscle wasting * oedema
(prominent rihs, skln)- * low body we~ghtfor age
* total loss of subcuta- * mental changes
neous fat
* growth relardation in
terms of hodv weight
(low body weight for age)
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