Public Health aspects of Macronutrient

Malnutrition (PEM)

Gudina Egata ( PhD )

Addis Ababa University,

January , 2024

1
 Learning Outcomes
• At the end of this sub-topic the student will be able to :-
─ Define Protein Energy Malnutrition (PEM)
─ Describe pathophysiology and causes of PEM
─ Identify the types of malnutrition
─ Discuss the prevention strategies of PEM

2
 Introduction . . . .
Malnutrition
• Malnutrition essentially means “bad nourishment” which
generally refers both to undernutrition and overnutrition.

• Mostly equated with undernutrition

• Malnutrition is characterized by inadequate or excess

intake of protein, energy, and micronutrients such as
vitamins and minerals.

3
 Introduction . . . .

• Malnutrition (definition)
– defined as imperfect or faulty nutrition.

– an imbalance between body needs for certain nutrient and their

intake

4
 Introduction . . . .

• Malnutrition is not a disease that runs its course,

bringing immunity.

• Rather it is a process, with consequences that may

extend not only into later life, but also into future
generations.

5
 Introduction . . . .

• The process of becoming malnourished often starts in

utero and may last, particularly for girls and women,
throughout the life cycle.

• It also spans generation

• Women and young children are the ones bearing the

brunt of malnutrition

6
 Types of Malnutrition

• Undernutrition: too little

• Protein Energy Malnutrition (PEM)
• Micronutrient deficiencies
• Overnutrition: too much
• Obesity
• Chronic diseases (diabetes, hypertension, ...)

7
 Growth deficit is also categorized as

• Clinical forms
– Marasmus
• Retarded growth with wasting of
subcutaneous fat
– Kwashiorkor
• Growth failure with wasting of muscles and
preservation of subcutaneous fat and
pitting type of edema
– Mixed: Marasmus - Kwashiorkor (MK)
• Edema of kwashiorkor with wasting of
marasmus
8
 Growth deficit . . . .

• Milder forms
• Wasting
• Thinness using weight for height (W/H)
• Stunting
• Linear growth retardation using height for age (H/A)
• Underweight
• A result of wasting and/or stunting
• Using weight for age (W/A)

9
Malnutrition of significant public health
importance

• Protein-Energy Malnutrition:
– Marasmus
– Kwashiokor
• Micronutrient deficiency:
– VAD
– IDA
– IDD
– Others emerging ones

10
 Definition of Protein-Energy
Malnutrition(PEM)
• … broadly defined as a multi-deficiency state which arises from
inadequate energy, protein and micronutrient supply to
the cells in the body to satisfy physiological requirements.

• A diagnosis which includes several overlapping syndromes

• There were different views as to its etiology

11
 Definition of PEM . . . .
• Controversies since 1930 but in 1985 Cicely William
introduced the Ghanian diagnosis Kwashiorkor ( a disease
of a child disposed from breast by birth of the next one )

• Over next 20 years around 50 different alternative names

were given

• In 1959 , Jellife, proposed Protein Calorie Malnutrition

(PCM) to include all syndromes relating to inadequate
feeding and later on largely replaced by PEM

12
 Definition of PEM . . . .
• Other synonymous terms to 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

13
 Nutritional marasmus
• Is the common form of undernutrition
• It is starvation in an infant or young child
• Derived from the Greek word , „marasmos‟, meaning
„wasting‟.
• Progressive wasting of the body and is associated with
insufficient intake or malabsorption of nutrients

14
Nutritional marasmus . . . .
• Characteristics
• Occurs in children < 2 yrs of
age
• Severe deprivation
• Develops slowly
• Severe weight loss
• Severe muscle wasting
• Low growth (<60%), Low WAZ
• No edema, no fatty liver
• Anxiety, apathy
• Possible good appetite
• Hair thin, dry; skin dry
• “Old Man“ face, wrinkled
appearance

15
 Kwashiorkor
• Caused by lack of nutrients including
protein in the diet
• Characteristics
• 1st to 3rd yrs of life
• Edema; enlarged fatty liver
• Low protein, infections
• Rapid onset
• Some weight loss
• Some muscle wasting
• Growth: 60-80%
• Moderate - low WAZ
• Apathy, misery, irritable
• Loss of appetite
• Hair dry
• Dermatosis (skin lesions)
16
Causes of PEM
 Multifactorial
• Having a number of interwoven factors operating
simultaneously
• Three causes

• Basic causes(societal factors)

• Underlying causes (behavioural factors)

• Immediate causes (proximal/direct factors)

17
Causes of PEM . . . .

18
19
 Etiology of Severe edematous
malnutrition(Kwashiorkor)
1 ) Theory of Low Protein Intake
• Low protein intake, which leads to hypo-
albuminemia, which in turn leads to edema.
2 ) Theory of Dys-adaptation
• Edema is determined not only by diet but also by
intrinsic differences among children with regard
to their protein requirement or hormonal response.
Hence, kwashiorkor develops in children that poorly
adapted and Marasmus develops in children that
are well adapted to the states of lower nutrient
intake.
3 ) Theory of Aflatoxins
• Hendricks reported from a study in Sudan that
children with Aflatoxins developed edema compared
to those with no aflatoxin intake. 20
Etiology of Severe edematous . . . .
4 ) Free Radical theory of etiology of
PEM

21
FREE RADICALS
• Any molecular species capable of independent existence that
contains an unpaired electron in an atomic orbital.

• Many radicals are unstable and highly reactive

• Can either donate an electron to or accept an electron from other

molecules, therefore behaving as oxidants or reductants.

22
FREE RADICALS . . . .
Derived either from normal essential metabolic processes in
the human body or from external sources such as exposure
to X-rays, ozone, cigarette smoking, air pollutants, and
industrial chemicals

23
 FREE RADICALS . . . .
• Damage biologically relevant molecules such as DNA,
proteins, carbohydrates, and lipid

• Attack important macromolecules leading to cell damage and

homeostatic disruption.

• Targets of free radicals include all kinds of molecules in the body

(lipids, nucleic acids, and proteins )

24
 ANTI- OXIDANTS
• A molecule stable enough to donate an electron to a rampaging
free radical and neutralize it, thus reducing its capacity to
damage.

• Delay or inhibit cellular damage mainly through their free radical

scavenging property

• Can safely interact with free radicals and terminate the chain of
reaction before vital molecules are damaged

25
 Examples of Anti - oxidants
• Glutathione, ubiquinol, and uric acid, are produced during
normal metabolism in the body
• Vitamin E (α-tocopherol), vitamin C (ascorbic acid), and B-carotene
( body cannot manufacture these micronutrients, so they must be
supplied in the diet ) .

26
 Classification of PEM
A. Gomez classification (wt –for- age – old classification)

% of NCHS reference Level of malnutrition

90- 109% Normal

75-89% Mild (Grade I)

60-74% Moderate (Grade II)

<60% Severe (Grade III)

Disadvantages:
• Cut off point 90% may be too high as normal well-
nourished children are below this value
• Oedema is ignored and it contributed to weight 27
 Classification of PEM . . . .

B ) Well- come classification (wt -for -age)

% of NCHS Level of malnutrition
reference
Oedema No oedema
60-79% Kwashiorkor Undernourished
< 60% Marasmic - Kwash Marasmus

Shortcomings: It does not differentiate between acute

and chronic form of malnutrition

28
 Classification of PEM . . . .
C) Waterlow Classification (Ht- for-age , wt-for –Ht)
Index % of NCHS Level of Type of malnutrition
reference malnutrition

Ht-for- age 90-94% Mild

Stunting (chronic
85-89% Moderate malnutrition )
<85% Severe
Wt-for-Ht 80-89% Mild
Wasting (acute malnutrition)
70-79% Moderate
<70% Severe

NB: A combination of well come and waterlow

classification will give better prediction
29
 Classification of PEM . . . .
Water low classification . . . .
• Weight-for-height and height-for-age are used
together in a two by two table

Water low classification Weight for height

>= 80% < 80%

Height for age >= 90% Normal Wasted

< 90% Stunted Wasted and stunted

NB: A combination of well come and waterlow

classification will give better prediction
30
Classification of PEM . . . .

31
Classification of PEM . . . .

32
 Classification of PEM . . . .
• Children and pregnant and lactating women who are
found to have a MUAC below the cutoff point of ≥
11.5 to <12.5 and < 23.0cm), respectively are
moderately malnourished and given a ration card and
referred to the TSF.

• Whereas those children with a MUAC below 11.5 cm

and/or with edema are considered severely
malnourished and referred to the TFP.

• For pregnant women/Adults MUAC of <17cm or <

18cm with recent weight loss is considered as
having severe form of malnutrition
33
 Classification of PEM . . . .
D) Classification of overweight ,obesity and CED in adults
• Classified based on BMI (Kg/Ht in m2)
• Chronic energy deficiency (CED) is used
overweight ,obesity Body mass Index (BMI)
Class III severe obesity >40
Class I obese 30-34.9
Overweight 25- 29.9
Normal 18.5-24.9
Grade of CED
0 18.5Kg/m2
I 18.4- 17.0 Kg/m2
II 16.9 -16.0Kg/m2
III <16.0Kg/m2

BMI <16.0Kg/m2 is associated with :

• LBW in 50% of cases
• Decreased work capacity
• Poor resistance to infection 34
BMI cut-offs for diagnosing overweight and undernutrition (CED)
among Ethiopian adults

35
 Classification of moderate and severe malnutrition
Malnutrition

Moderate Severe

Symmetric edema (bilateral pitting No Yes (edematous malnutrition or

edema) kwashiorkor)

Weight for age

• 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

36
 Weight for height cut-off points
Acute malnutrition Percentage of the Z-scores Odema
using WFH median

Severe <70% <-3 z score Yes/no

Moderate < 80% to >=70% <-2 z-score to >=-3 No

z scores

Global Acute <80% <-2 z-scores Yes/no

Malnutrition (GAM)

37
 Epidemiology of Malnutrition
• Burden of malnutrition across the world remains unacceptably high,
and progress unacceptably slow
• Malnutrition is responsible for more ill health than any other
cause
• Children under five years of age (0 -59 months) face multiple
burdens
• Women have a higher burden than men when it comes to certain
forms of malnutrition

(Global Nutrition Report , 2020)

38
 Epidemiology of Malnutrition . . . .
• Current estimates are that nearly 690 million
people are hungry/undernourished in 2019 (
8.9% of the world population)
• The Prevalence of undernourishment in Africa was
19.1% of the population in 2019, or more than 250
million undernourished people, up from 17.6% in
2014
• It is more than twice the world average (8.9%) and is
the highest among all regions.
• In Asia an estimated 381 million people (8.3%),
below the world average ,in 2019
(Global Nutrition Report , 2020)
39
Epidemiology of Malnutrition . . . .
• Africa is significantly off track to achieve the Zero Hunger target
in 2030

• The world is not on track to achieve Zero Hunger by 2030

• If recent trends continue, the number of people affected by

hunger would surpass 840 million by 2030

(Global Nutrition Report , 2020)

40
Epidemiology of Malnutrition . . . .

41
Epidemiology of Malnutrition . . . .

(Global Nutrition Report , 2020) 42

 Epidemiology of Malnutrition . . . .
― Two (2) billion people - vitamin or mineral deficiency
― One-third of the 9 million annual child deaths are related to
undernutrition.
― 38.9% of adults overweight or obese, and increasing among
adolescents
― One third of all women of reproductive age have anaemia and a
higher prevalence of obesity than men
― Millions of women are still underweight
[[[ [Global Nutrition Report ,2018]

43
Epidemiology of Malnutrition . . . .

44
Epidemiology of Malnutrition . . . .

45
Epidemiology of Malnutrition . . . .
• Undernutrition continues to exert a heavy toll.
• Globally, at least 1 in 3 children under 5 is not
growing well due to malnutrition in its more
visible forms: stunting, wasting & overweight.
• Globally, the proportion and number of stunted children
under 5 has been declining
• Despite the encouraging declines in stunting,
most parts of the world are currently not on course to meet
targets for the SDGs era
(UNICEF,2019)

46
Epidemiology of Malnutrition . . . .
• Almost 150.8 million children under 5 (22.5%) suffered from
stunting

• Globally, wasting threatens the lives of 7.3% of the world’s

under-5s, or around 50 million children

(UNICEF,2019)

47
Epidemiology of Malnutrition . . . .

(UNICEF,2019) 48
(UNICEF,2019) 49
Hidden hunger
• At least 340 million children under 5 (one
in two) suffer from hidden hunger due to
deficiencies in vitamins and other essential
nutrients
• Children and mothers who are deficient in
micronutrients – the vitamins & minerals that
are essential for survival, growth & development –
can suffer devastating consequences.
(UNICEF,2019)

50
 Percentage of children under 5 with hidden hunger, 2018

(UNICEF,2019)
51
Overweight and obesity
• Overweight and obesity continue to rise.

• Globally, about 40.1 million (5.9%) under five children are overweight

• From 2000 – 2016, the proportion of overweight children (5 to 19

years ) rose from 1 in 10 to almost 1 in 5.

• The number of stunted children has declined in all continents,

except in Africa while the number of overweight children has
increased in all continents, including in Africa.

(UNICEF,2019)

52
(UNICEF,2019)

53
 The State of Nutrition & under five mortality in Ethiopia
Generally declining, but still relatively
alarming
Indicator EDHS EDHS EDHS EDHS MEDHS
2000 2005 2011 2016 2019
Neonatal mortality No data 39 37 29 30 (33 2021)
(per 1000 LB)
U5 mortality rate 166 133 88 67 55 (59 -2021)
(per 1000 LB)
IMR (per 1000LBs) 97 77 59 48 43(47 2021)
Child mortality rate (per 1000LB) 77 50 31 20 ? No data

Stunting (HAZ) % 57.8 51.5 44.4 38 37

Wasting (WHZ) % 11 12 9.7 10 7
Underweight (WAZ)% 42.1 34.9 28.7 24 21
Anemia among U5 (%) No data 53.5 44.2 56 ? No data

Exclusive breastfeeding ? No data 49 52 56 59

54
55
56
Current Prevalence of malnutrition in Ethiopia (Children) . . . .

EPHI,2023
57
Current Prevalence of hidden hunger (Children) . . . .
• Children aged 6-59 months
Prevalence of anemia among children aged 6-59 months is (16% ) with no urban and
rural differences
• Adolescent girls
1 in 3 adolescent girls are folate deficient
Prevalence of overall anemia among adolescent girls is 9%.
NB:
Overall, 61% of children aged 0–6 months were exclusively breastfed (regional
variation)
Overall, 77% of children were breastfed within an hour of birth(regional variation)

EPHI, 2023
58
Current prevalence of hidden hunger in Ethiopia (women )
• Women of reproductive age(WRA)
Two in three WRA were deficient in one or more micronutrients(urban (73%), rural
(62%).
National prevalence of iron and folate deficiency in Ethiopia ( 13% & 19%)
respectively.
Folate deficiency >50% in most regions except Oromia (48%), SNNPR (39%), and
Sidama (11%).
Vitamin D deficiency (34%) and the lowest prevalence of 1% (Somali region).

EPHI,2023
59
Prevalence of malnutrition & interpretation levels
• The following classifications for malnutrition have been established by WHO as levels for interpreting
WFH, HFA and WFA z-scores (WHO 2002).
• For acute malnutrition (wasting), care needs to be taken to assess the context; a prevalence classified
as “poor/medium” but which is likely to get worst will have different programmatic implications
than a prevalence classified as “serious/high” but where the situation is likely to improve (e.g.
impending good harvest).

60
Public Health Consequences of undernutrition
• Has a series of public health consequences that diminish
the individual quality of life and the prospects for social
progress
 Public Health Consequences . . . .
1) Susceptibility to acute morbidity (disease)
• Compared with people with adequate nutrition, those with
poor nutritional status (determined by anthropometry) are
more likely to contract diarrheal, malarial and respiratory
tract infections and more likely to suffer from these
illnesses for longer duration

• They are also more likely to develop debilitating sequelae

from these common infections
Public Health Consequences . . . .

2) Susceptibility to mortality (death)

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

63
Causes of under five deaths, Ethiopia, 2012

64
Public Health Consequences . . . .

3) Decreased cognitive development

• Associations between taller stature and higher cognitive performance
have been found

• Specific nutrient deficiencies also impaired cognitive development (e.g.

iodine)

65
Public Health Consequences . . . .
4) 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
 Public Health Consequences . . . .
5) 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

67
Effects of Undernutrition
In summary, the functional consequences
of malnutrition are immense:

Deficiency Reduces
VAD survival
PEM Physical
productivity
IDA
intelligence
IDD
Prevention of PEM (options for intervention)
1. Dietary diversification
• Production of food stuffs at the backyard garden and intensification of
horticultural activities
2. Nutrition education
• Focuses on educating mothers/care givers on the importance of having
a balanced diet through diversification of food

70
 Prevention of PEM . . . .

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

71
 Prevention of PEM . . . .
4. Dietary modification
• Focuses on modifying the energy, protein and micronutrient content of the
complementary foods.

• Educate mothers and demonstrate to them the benefits of sprouting

(germination) and fermentation.

72
 Prevention of PEM . . . .
• 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

73
Prevention of PEM . . . .

5. Supplementation

• Could also be considered based on the local needs

74
 Prevention of PEM . . . .
6) Supportive Policies and Strategies
─The Growth and Transformation Plan (GTP),
▬ Health Sector Development Plan IV (HSDP IV)/HSTP
▬ Health Extension Program (HEP), and
▬ National Nutrition Strategy (NNS),
▬ National Nutrition Program (NNP)
▬ National Food & Nutrition Policy
▬ Food Security Strategy and Agriculture Growth Program
▬ School Health and Nutrition Strategy
▬ WASH Strategy (with MOU amongst sectors)
▬ Social Protection Policy
▬ Seqota Declaration
▬ Etc .....
75
 We have to choose . . . .

To pay the consequences of

To pay for eradicating undernutrition
having undernutrition
Source: Francisco Espejo‟s presentation on cost of hunger; Picture design
76
by Jhoram Moya
 Management of Acute
Malnutrition(SAM)

( Reading Assignment _ Revised

Guideline on management of Acute
malnutrition )
Thank You !

78