Rahardjo, et al.

Medical Clinical Update Journal (2022) vol. 1, no.1 Medical Clinical Update Journal

CASE REPORT
Severe Protein-Energy Malnutrition With Type 2
Diabetes Mellitus
Theresia Monica Rahardjo, Nuri Nurhasanah Sugandi, Aulia Chairani, Beby Maulinda, Jonathan
Salim, Kaleb Reynaldo, Keysha Vinora Abigail, Nisrina Hasna Fatin, Maria Vianny, Pangastuti Retno.

Abstract
Diabetes mellitus (DM) is a disease of inadequate control of blood levels of glucose. It has many
subclassifications, including type 1, type 2, maturity-onset diabetes of the young (MODY), gestational
diabetes, neonatal diabetes, and steroid-induced diabetes. Globally, 382 million adults (8.3%) are living
with diabetes, and the estimate is projected to rise to over 592 million by 2035. The etiology of T2DM is
complex and is associated with irreversible risk factors such as age, genetic, race, and ethnicity and
reversible factors such as diet, physical activity and smoking.
Food intake has been strongly linked with obesity, not only related to the volume of food but also in
terms of the composition and quality of diet. High intake of red meat, sweets and fried foods, contribute to
the increased the risk of insulin resistance and T2DM. Consumption of fruits and vegetables may protect
the development of T2DM, as they are rich in nutrients, fiber and antioxidants which are considered as
protective barrier against the diseases. This demands an urgent need for changing lifestyle among general
population and further increase the awareness of healthy diet patterns in all groups. Balanced diet and
regular physical activity improves insulin sensitivity and beta cell preservation.

Keywords: diabetes mellitus, type 2 diabetes mellitus, dietary pattern, nutrition

Background
Diabetes mellitus (DM) is a disease of
inadequate control of blood levels of glucose. It has
many subclassifications, including type 1, type 2,
maturity-onset diabetes of the young (MODY),
gestational diabetes, neonatal diabetes, and steroid-
induced diabetes. T1DM is characterized by the
destruction of beta cells in the pancreas, typically
secondary to an autoimmune process. The result is
the absolute destruction of beta cells, and
consequently, insulin is absent or extremely low.
T2DM involves a more insidious onset where an
imbalance between insulin levels and insulin
sensitivity causes a functional deficit of insulin.
Insulin resistance is multifactorial but commonly
develops from obesity and aging. T2DM is at present
one of the most common diseases and its levels are
progressively on the rise. It has been evaluated that
around 366 million people worldwide or 8.3% in the
age group of 20-79 years had T2DM in 2011.
Globally, 382 million adults (8.3%) are living with
diabetes, and the estimate is projected to rise to over
592 million by 2035.1
Few studies have found strong association of
T2DM with high intake of carbohydrates and fats.
Many studies have reported a positive association
between high intake of sugars and development of
T2DM. Many of prospective studies have found
relations between fat intake and subsequent risk of
developing T2DM.2
Food intake has been strongly linked with
obesity, not only related to the volume of food but
also in terms of the composition and quality of diet.3
High intake of red meat, sweets and fried foods,
contribute to the increased the risk of insulin
resistance and T2DM. Consumption of fruits and
vegetables may protect the development of T2DM, as
they are rich in nutrients, fiber and antioxidants which
are considered as protective barrier against the
diseases. This demands an urgent need for changing
lifestyle among general population and further
increase the awareness of healthy diet patterns in all
groups. Balanced diet and regular physical activity
improve insulin sensitivity and beta cell preservation.
The major goals of dietary strategies were to restrict
fat to >30% of calorie intake and reduce intake
of high-GI carbohydrates such as sugar, flavored
beverages and high-calorie snacks.4
Malnutrition is a nutritional condition which
results from the imbalance of energy, protein and
nutrients, and poses effects in the form of
composition and function of body tissues.
Malnutrition related diabetes mellitus (MRDM) is
characterized by insulinopenia, insulin resistance,
hyperglycemia and partial failure of the beta-cells in
the pancreas, insulin resistance, hyperglycemia and
partial failure of the beta-cells in the pancreas. It is
classified in 2 subgroups by the American Diabetes
Association as Fibrocalcific or fibrocalculous
pancreatic diabetes (FCPD) and Protein-deficient
pancreatic diabetes (PDPD)/protein-deficient diabetes
mellitus (PDDM).5
 Rahardjo, et al.

Case presentation PEM is graded as mild, moderate, or severe. Grade is

determined by calculating weight as a percentage of
expected weight for length or height using
A 66-year-old woman presented to the emergency international standards (normal, 90 to 110%; mild PEM,
department with 2 days of sudden onset of severe 85 to 90%; moderate, 75 to 85%; severe, < 75%). PEM
right upper quadrant pain, radiating across her right may be Primary Caused by inadequate nutrient intake
costal margin towards her back. The pain was Secondary Results from disorders or drugs that
associated with fever, shortness of breath, nausea and interfere with nutrient use.6
vomiting. The patient had vomited more than 10 times
within the last 24 hours. The patient had difficulty Worldwide, primary PEM occurs mostly in
eating and drinking for 2 days. The patient had a children and older people who lack access to nutrients,
background medical history of type 2 diabetes although a common cause in older people is
mellitus, hypertension, hypercholesterolemia, and depression. PEM can also result from fasting or
anorexia nervosa. Child or elder abuse may be a cause.
chronic heart failure. The patient routinely took In children, chronic primary PEM has 2 common
medication for diabetes mellitus, hypertension, forms, Marasmus and Kwashiorkor. The form depends
hypercholesterolemia, and chronic heart failure. The on the balance of nonprotein and protein sources of
patient has a history of diabetes mellitus for 7 years. energy. Starvation is an acute severe form of primary
The patient has irregular eating habits, likes sweets for PEM. Marasmus (also called the dry form of PEM)
snacks. The patient still can be active and usually takes causes weight loss and depletion of fat and muscle. In
walk in the morning. countries with high rates of food insecurity, marasmus
is the most common form of PEM in children.
At the time of examination, the patient's temperature Kwashiorkor (also called the wet, swollen, or
was 36.9oC, blood pressure was 90/60 mmHg, pulse edematous form) is a risk after premature
was 95 times/minute, respiratory rate was 36 abandonment of breastfeeding, which typically occurs
times/minute, oxygen saturation was 97%. On physical when a younger sibling is born, displacing the older
examination, her abdomen was soft with right upper child from the breast.
quadrant tenderness. Anthropometry obtained from So, children with kwashiorkor tend to be older
this patient had a height of 155 cm, body weight 70 kg, than those with marasmus. Kwashiorkor may also
ideal body weight 49 kg, body mass index 29.44 kg/m2, result from an acute illness, often gastroenteritis or
muscle wasting +2/+2, Loss of Subcutaneous Fat another infection (probably secondary to cytokine
(LOSF) +2/+2, and there was no edema on the patient’s release), in a child who already has PEM. A diet that is
body. more deficient in protein than energy may be more
likely to cause kwashiorkor than marasmus. Less
Admission blood tests revealed a decreased common than marasmus, kwashiorkor tends to be
haemoglobin (9.3g/dl) and hematocrit (29%), elevated confined to specific parts of the world, such as rural
leukocyte (13.6 103/mm3), decreased erythrocytes (3.2 Africa, the Caribbean, and the Pacific islands. In these
106/mm3) and MCHC (32 g/dL). Clinical chemistry areas, staple foods (eg, yams, cassavas, sweet potatoes,
examination on the patient showed decreased green bananas) are low in protein and high in
albumin (2.86 g/dL) and natrium (130 mEq/L), and carbohydrates. In kwashiorkor, cell membranes leak,
causing extravasation of intravascular fluid and protein,
elevated random blood sugar test (149 mg/dL) resulting in peripheral edema.

We started the nutritional intervention by In both marasmus and kwashiorkor, cell-

prescribing an energy requirement (target) of 1,470
KCal, 56 grams of protein, 220 grams of
carbohydrates, 40 grams of fat. The patient is given a
diet starting at 15 KCal/KgWeight/day using the NGT
in the form of an oligomeric formula (Peptamen)
6x120 cc. The patient's diet will be increased
gradually according to the patient's hemodynamics,
clinical and nutritional intake.
Discussion
mediated immunity is impaired, increasing
susceptibility to infections. Bacterial infections (eg,
pneumonia, gastroenteritis, otitis media, urinary tract
infections, sepsis) are common. Infections result in
release of cytokines, which cause anorexia, worsen
muscle wasting, and cause a marked decrease in serum
albumin levels. Starvation is a complete lack of
nutrients. It occasionally occurs when food is available
(as in fasting or anorexia nervosa) but usually occurs
because food is unavailable (eg, during famine or
wilderness exposure).6

Protein-energy malnutrition, is an energy Secondary PEM This type most commonly

deficit due to deficiency of all macronutrients. It
commonly includes deficiencies of many
micronutrients. PEM can be sudden and total
(starvation) or gradual. Severity ranges from
subclinical deficiencies to obvious wasting (with
edema, hair loss, and skin atrophy) to starvation.
Multiple organ systems are often impaired. Diagnosis
usually involves laboratory testing, including serum
albumin. Treatment consists of correcting fluid and
electrolyte deficits with IV solutions, then gradually
replenishing nutrients, orally if possible.
results from the following: Disorders that affect
gastrointestinal function: These disorders can interfere
with digestion (eg, pancreatic insufficiency), absorption
(eg, enteritis, enteropathy), or lymphatic transport of
nutrients (eg, retroperitoneal fibrosis, Milroy
disease).Wasting disorders: In wasting disorders (eg,
AIDS, cancer, COPD) and renal failure, catabolism
causes cytokine excess, resulting in undernutrition via
anorexia and cachexia (wasting of muscle and fat).
End-stage heart failure can cause cardiac cachexia, a
severe form of undernutrition; mortality rate is
particularly high.
 Rahardjo, et al.

Factors contributing to cardiac cachexia may
include passive hepatic congestion (causing anorexia),
edema of the intestinal tract (impairing absorption),
and, in advanced disease, increased oxygen
requirement due to anaerobic metabolism. Wasting
disorders can decrease appetite or impair metabolism
of nutrients. Conditions that increase metabolic
demands: These conditions include infections,
hyperthyroidism, Diabetes Melitus,
pheochromocytoma, other endocrine disorders,
burns, trauma, surgery, and other critical illnesses.7
However, later, when these tissues are depleted,
the gluconeogenesis process may happen and use
protein for energy, resulting in a negative nitrogen
balance. Visceral organs and muscle are broken down
and decrease in weight. Loss of organ weight is greatest
in the liver and intestine, intermediate in the heart and
kidneys, and least in the nervous system. Moreover,
this patient came with heavy vomiting that can be
associated with another cause of secondary PEM,
gastropathy, which may be one of longterm
complications Diabetes Mellitus.8

Symptoms of moderate PEM can be This patient’s requirement of energy was 1470
constitutional or involve specific organ systems. kcal, divided to protein, carbohydrate, and fat intakes
Apathy and irritability are common. The patient is every day. Each day the diet was increased as the target
weak, and work capacity decreases. Cognition and corresponding with the hemodynamic, clinical
sometimes consciousness are impaired. Temporary condition, and intake ability of the patient.
lactose deficiency and achlorhydria develop. Diarrhea Consideration to choose the type of diet is important
is common and can be aggravated by deficiency of for diabetic patients with severe malnutrition of
intestinal disaccharidases, especially lactase. Gonadal protein, especially for this patient who had a history of
tissues atrophy. PEM can cause amenorrhea in women several conditions such as hypertension,
and loss of libido in men and women. Wasting of fat hypercholesterolemia, and chronic heart failure.
and muscle is common in all forms of PEM. In adult
volunteers who fasted for 30 to 40 days, weight loss Adjusting the diet with the patient condition, it
was marked (25% of initial weight). If starvation is was given the diabetes type diet with high protein in
more prolonged, weight loss may reach 50% in adults order to correct the protein malnutrition condition.
and possibly more in children.7 Thus, dietary intakes for the patient, as part of
management, have a big role to help patients’ recovery.
In adults, cachexia is most obvious in areas
where prominent fat depots normally exist. Muscles
shrink and bones protrude. The skin becomes thin,
dry, inelastic, pale, and cold. The hair is dry and falls
out easily, becoming sparse. Wound healing is
impaired. In older patients, risk of hip fractures and
pressure (decubitus) ulcers increases. With acute or
chronic severe PEM, heart size and cardiac output
decrease; pulse slows and blood pressure falls.
Respiratory rate and vital capacity decrease. Body
temperature falls, sometimes contributing to death.
Edema, anemia, jaundice, and petechiae can develop.7
People living with type 2 DM are more vulnerable to
various forms of both short- and long-term
complications, which often lead to their premature
death. This tendency of increased morbidity and
mortality is seen in patients with type 2 DM because of
the commonness of this type of DM, its insidious
onset and late recognition, especially in resource-poor
developing countries like Africa. Type 2 DM is
characterized by insulin insensitivity as a result of
insulin resistance, declining insulin production, and
eventual pancreatic beta-cell failure.This leads to a
decrease in glucose transport into the liver, muscle
cells, and fat cells. There is an increase in the
breakdown of fat with hyperglycemia. The
involvement of impaired alpha-cell function has
recently been recognized in the pathophysiology of
type 2 DM.8
In this case, the patient had diabetes mellitus,
which could be one of the causes of secondary PEM.
Insulin resistance in type 2 DM patients eventually
decreases glucose transport to many organs. This
condition leads to mechanisms of compensation due
to the body demands of glucose to produce energy. At
the beginning, the metabolic response of PEM is
decreasing the metabolic rate in the body. To keep
supplying energy, the body first breaks down adipose
tissue.
LRahardjo, et al.
Medical Clinical Update Journal (2022) vol. 1, no.1 Page 3

List of abbreviations References

DM - Diabetes Mellitus
MODY - Maturity-Onset Diabetes of The Young (MODY) 1. Sapra A, Bhandari P. Diabetes Mellitus. [Updated 2022
Jun 26]. In: StatPearls [Internet]. Treasure Island (FL):
T2DM - Type 2 Diabetes Mellitus
StatPearls Publishing; 2022 Jan-
T1DM - Type 1 Diabetes Mellitus
MRDM - Malnutrition Relate
2. Sami W, Ansari T, Butt NS, Hamid MRA. Effect of diet
on type 2 diabetes mellitus: A review. Int J Health Sci
Diabetes mellitus (Qassim). 2017 Apr-Jun;11(2):65-71. PMID: 28539866;
FCPD - Fibro Calculous PMCID: PMC5426415
Pancreatic Diabetes 3. Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and
management of type 2 diabetes: dietary components
PDPD - Protein-Deficient
and nutritional strategies. Lancet. 2014 Jun
Pancreatic Diabetes 7;383(9933):1999-2007. doi: 10.1016/S0140-
PEM - Protein-Energy 6736(14)60613-9. PMID: 24910231; PMCID: PMC4751088.
Malnutrition 4. Rajput, S.A.; Ashraff, S.; Siddiqui, M. Diet and
Management of Type II Diabetes Mellitus in the United
Kingdom: A Narrative Review. Diabetology 2022, 3, 72-
78. https://doi.org/10.3390/diabetology3010006
Declarations
5. Sneha S. Malnutrition related diabetes mellitus in
Ethics approval and consent to participate Indian population. International Journal of Research
Informed consent from the patient has been obtained before and Review. 2020; 7(7): 136-142.
the study.
6. Abu-Lebdeh HS, Nair KS. Protein metabolism in
Consent for publication diabetes mellitus. Baillieres Clin Endocrinol Metab. 1996
Oct;10(4):589-601. doi: 10.1016/s0950-351x(96)80741-5.
Consent for publication regarding patient data has been
PMID: 9022953.
obtained beforethe study. All the patient identity has been kept
secret. 7. Atassi, Hadi . January 2019 . Protein - Energy
Malnutrition. Medscape.
Availability of data and materials 8. Olokoba AB, Obateru OA, Olokoba LB. Type 2 diabetes
Not Applicable mellitus: a review of current trends. Oman Med J. 2012
Jul;27(4):269-73. doi: 10.5001/omj.2012.68. PMID:
Competing interests 23071876; PMCID: PMC3464757.
The authors declare that they have no competing interests.

Funding
There is no funding from third party for this case report to be
completed.

Acknowledgements
We acknowledge the help from Unggul Karsa Medika Hospital
wherethis case was found and could be reported in the form of
case report.

Received :
Accepted :
Published Online :
Last Name, et al.
Medical Clinical Update Journal (2022) vol. 1, no.1 Page 3