Protein-energy Malnutrition
(PEM)
Definition
? PEM is manifested primarily by inadequate
dietary intakes of protein and energy,
? PEM is almost always accompanied by
deficiencies of other nutrient.
? PEM can be divided as primary PEM and
secondary PEM.
? Causes of Primary PEM
Inadequate food intake
Inadequate infant and child feeding practices
? Secondary causes
Increased nutrient needs
Decreased nutrient absorption
Increased nutrient losses
Causes
Pathophysiology of PEM
? Disorder of metabolism
? Protein,Protein catabolism,hypoalbuminemia
? Fat,mobilized fat store,emaciation,fatty infiltration,
fatty liver
? Carbohydrate,low hepatin,hypoglycemia
? Water,minerals,dehydration,low serum Ca
concentration
1,Failure to thrive
2,lower digested function,diarrhea
3,Central nerve system,apathy,or irritability
4,Cardiovascular system,pulse slow,Low BP
5,lower renal function,urine amount decrease
6,low immunologic function,easy to infect
?Disorder of organs and tissues
Clinical manifestations
Nonedematous PEM (marasmus)
? Failure to gain weight
? Irritability
? Weight loss and listlessness
? skin become wrinkled and loose
? Subcutaneous fat disappear
? Muscle,atrophy,hypotonia
? Pulse slow
? Constipation,a starvation diarrhea
Vague manifestations
? Lethargy,apathy,or irritability
? Inadequate growth
? Increased susceptibility to infectious
? Vomiting,diarrhea,anorexia
? Flabby subcutaneous tissue
? Edema
? Liver enlargement
? Dermatitis
? Hair sparse and thin
Edematous PEM (Kwashiorkor)
Laboratory examination
? Serum albumin concentration
? Retinal combined protein
? Pre-albumin
? transferrin
? IGF-I
Diagnosis
? History
? Clinical manifestations
? Laboratory examination
? Anthropometric indicators
WHO Z-score system
? underweight
chronic or acute malnutrition
X－ 3SD≤W/A<X － 2SD moderate
W/A<X－ 3SD severe
? stunting
long-term chronic malnutrition
X－ 3SD≤H/A<X － 2SD moderate
H/A<X－ 3SD severe
? wasting
recent acute malnutrition
X－ 3SD≤W/H<X － 2SD moderate
W/H<X－ 3SD severe
The degree of malnutrition
I
（ mild ）
II
(moderate)
III
（ severe ）
Weight<X 15 ～ 25 ％ 25 ～ 40 ％ 40 ％以上
S u b c u t a n e o u s f a t
o f a b d o m e n
0.8 ～ 0.4cm > 0.4cm disapear
Length normal
Little lower
than normal
Much lower
than normal
S pirit status N o change L ow emotion
Irritability
ap ath y
muscle n ormal Hypotonia atrophy
Treatment
Including three phases
?First phase,corrected dehydration,oral dehydration is
preferred; control infection,antibiotic therapy
?Second phase,continued antibiotic therapy;
introduction of a diet providing maintenance requirements of
energy and protein,and other nutrient,~75cal/kg and ~1
g/kg/24 hr
?Final phase,recovery diet providing up to 150
kcal/kg/24hr and 4g/kg/24hr of protein
Prevention
? promotion of more optimal breast-feeding
and complementary feeding practices
?Nutrition education
?growth monitoring
?prevention and treatment of infectious
diseases
Recognition of Malnutrition
Malnutrition is a biologic manifestation of the
combined effects of inadequate dietary intake
and diseases,both of them are closely related
to social and economic development,
Thus,malnutrition cannot be viewed as
distinct from other developmental problems
but rather,as a reflection of these other
problems.
obesity
Definition
? Obese,Body mass index (BMI kg/m2)
exceeds the age-gender-specific 95th
percentile
? Overweight,BMI is between the 85th
and 95th percentiles
Prevalence
In USA,10-15%
girls>boys
In China,1986 0.91%
1996 1.71%
boys > girls;
preschool age> toddler
Etiology
Multifactors
? Genetic,Genetic background
Recessive gene
? Environmental stimuli
Food intake
Physical activity
Television viewing
Pathogenesis
? The genes responsible for human obesity,
Leptin,Leptin receptor
? Control of feeding,peripheral signaling and
effector systems (plasma concentration of leptin
and insulin) and neuroendocrine system
(neuropeptides)
? The hypothalamic-pituitary-adrenal axis
? Polygenic models,multiple genetic loci
? Gene-targeting and effects of body fat/feeding
Clinical manifestations
? Easy in infancy,school age,adolescence,tall stature
slightly advanced bone age,and somewhat early
puberty
? Psychological disorders,self-contempt,timidity,
lonely anxiety,discrimination in social life
? Laboratory examination,Plasma lipid profiles，
cholesterol↑,?－ lipoprotein↑
Diagnosis
?Weight/Height:
? W/H> Mean＋ 20％ Obesity
? W/H> Mean＋ 20％～ 29％ Mild
? W/H> Mean＋ 30％～ 39％ Moderate
? W/H> Mean＋ 40％～ 59％ Severe
? W/H> Mean＋ 60％ Extremely severe
? BMI,95%> BMI> 85% Obesity
BMI > 95% Overweight
Treatment
Basic goal,Reduction in energy intake and
increase energy expenditure
? Reduction of dietary calories and fat and increasing
dietary fiber,good lifestyle
? increase in physical activity
? decrease in television viewing and computer games
? Psychological treatment,self-demand,self-
confidence,persist
? medications,not approved for in youth
Prevention
?Prevent high-birth-weight babies born
?Nurture good lifestyle,avoiding over- feeding
?Growth monitoring
(PEM)
Definition
? PEM is manifested primarily by inadequate
dietary intakes of protein and energy,
? PEM is almost always accompanied by
deficiencies of other nutrient.
? PEM can be divided as primary PEM and
secondary PEM.
? Causes of Primary PEM
Inadequate food intake
Inadequate infant and child feeding practices
? Secondary causes
Increased nutrient needs
Decreased nutrient absorption
Increased nutrient losses
Causes
Pathophysiology of PEM
? Disorder of metabolism
? Protein,Protein catabolism,hypoalbuminemia
? Fat,mobilized fat store,emaciation,fatty infiltration,
fatty liver
? Carbohydrate,low hepatin,hypoglycemia
? Water,minerals,dehydration,low serum Ca
concentration
1,Failure to thrive
2,lower digested function,diarrhea
3,Central nerve system,apathy,or irritability
4,Cardiovascular system,pulse slow,Low BP
5,lower renal function,urine amount decrease
6,low immunologic function,easy to infect
?Disorder of organs and tissues
Clinical manifestations
Nonedematous PEM (marasmus)
? Failure to gain weight
? Irritability
? Weight loss and listlessness
? skin become wrinkled and loose
? Subcutaneous fat disappear
? Muscle,atrophy,hypotonia
? Pulse slow
? Constipation,a starvation diarrhea
Vague manifestations
? Lethargy,apathy,or irritability
? Inadequate growth
? Increased susceptibility to infectious
? Vomiting,diarrhea,anorexia
? Flabby subcutaneous tissue
? Edema
? Liver enlargement
? Dermatitis
? Hair sparse and thin
Edematous PEM (Kwashiorkor)
Laboratory examination
? Serum albumin concentration
? Retinal combined protein
? Pre-albumin
? transferrin
? IGF-I
Diagnosis
? History
? Clinical manifestations
? Laboratory examination
? Anthropometric indicators
WHO Z-score system
? underweight
chronic or acute malnutrition
X－ 3SD≤W/A<X － 2SD moderate
W/A<X－ 3SD severe
? stunting
long-term chronic malnutrition
X－ 3SD≤H/A<X － 2SD moderate
H/A<X－ 3SD severe
? wasting
recent acute malnutrition
X－ 3SD≤W/H<X － 2SD moderate
W/H<X－ 3SD severe
The degree of malnutrition
I
（ mild ）
II
(moderate)
III
（ severe ）
Weight<X 15 ～ 25 ％ 25 ～ 40 ％ 40 ％以上
S u b c u t a n e o u s f a t
o f a b d o m e n
0.8 ～ 0.4cm > 0.4cm disapear
Length normal
Little lower
than normal
Much lower
than normal
S pirit status N o change L ow emotion
Irritability
ap ath y
muscle n ormal Hypotonia atrophy
Treatment
Including three phases
?First phase,corrected dehydration,oral dehydration is
preferred; control infection,antibiotic therapy
?Second phase,continued antibiotic therapy;
introduction of a diet providing maintenance requirements of
energy and protein,and other nutrient,~75cal/kg and ~1
g/kg/24 hr
?Final phase,recovery diet providing up to 150
kcal/kg/24hr and 4g/kg/24hr of protein
Prevention
? promotion of more optimal breast-feeding
and complementary feeding practices
?Nutrition education
?growth monitoring
?prevention and treatment of infectious
diseases
Recognition of Malnutrition
Malnutrition is a biologic manifestation of the
combined effects of inadequate dietary intake
and diseases,both of them are closely related
to social and economic development,
Thus,malnutrition cannot be viewed as
distinct from other developmental problems
but rather,as a reflection of these other
problems.
obesity
Definition
? Obese,Body mass index (BMI kg/m2)
exceeds the age-gender-specific 95th
percentile
? Overweight,BMI is between the 85th
and 95th percentiles
Prevalence
In USA,10-15%
girls>boys
In China,1986 0.91%
1996 1.71%
boys > girls;
preschool age> toddler
Etiology
Multifactors
? Genetic,Genetic background
Recessive gene
? Environmental stimuli
Food intake
Physical activity
Television viewing
Pathogenesis
? The genes responsible for human obesity,
Leptin,Leptin receptor
? Control of feeding,peripheral signaling and
effector systems (plasma concentration of leptin
and insulin) and neuroendocrine system
(neuropeptides)
? The hypothalamic-pituitary-adrenal axis
? Polygenic models,multiple genetic loci
? Gene-targeting and effects of body fat/feeding
Clinical manifestations
? Easy in infancy,school age,adolescence,tall stature
slightly advanced bone age,and somewhat early
puberty
? Psychological disorders,self-contempt,timidity,
lonely anxiety,discrimination in social life
? Laboratory examination,Plasma lipid profiles，
cholesterol↑,?－ lipoprotein↑
Diagnosis
?Weight/Height:
? W/H> Mean＋ 20％ Obesity
? W/H> Mean＋ 20％～ 29％ Mild
? W/H> Mean＋ 30％～ 39％ Moderate
? W/H> Mean＋ 40％～ 59％ Severe
? W/H> Mean＋ 60％ Extremely severe
? BMI,95%> BMI> 85% Obesity
BMI > 95% Overweight
Treatment
Basic goal,Reduction in energy intake and
increase energy expenditure
? Reduction of dietary calories and fat and increasing
dietary fiber,good lifestyle
? increase in physical activity
? decrease in television viewing and computer games
? Psychological treatment,self-demand,self-
confidence,persist
? medications,not approved for in youth
Prevention
?Prevent high-birth-weight babies born
?Nurture good lifestyle,avoiding over- feeding
?Growth monitoring
