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Protein Energy Malnutrition - Causes, Symptoms, Diagnosis, and Prevention

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Protein-energy malnutrition is a condition in which there is a lack of energy due to a lack of all macronutrients and micronutrients. Read the article below.

Written by

Dr. Karthika Rp

Medically reviewed by

Dr. Achanta Krishna Swaroop

Published At March 1, 2023
Reviewed AtMarch 1, 2023


Malnutrition in all forms includes:

  • Undernutrition (wasting, stunting, and being underweight).

  • Insufficient vitamins and minerals.

  • Being overweight or obese.

  • Developing diet-related noncommunicable diseases.

Around 462 million adults worldwide were underweight in 2014, while 1.9 billion were overweight or obese. In 2020, it was estimated that 149 million children under five years were too short for their age, 45 million were too thin for their height, and 38.9 million were obese. Undernutrition is responsible for about 45 percent of deaths among children under five. These are most typical in low and middle-income countries. At the same time, childhood overweight and obesity rates are increasing in these countries. The global burden of malnutrition has severe and long-term developmental, economic, social, and medical outcomes for individuals and their families, communities, and countries.

What Is Protein Energy Malnutrition?

Protein-energy malnutrition, or PEM, is the deficiency of energy due to lacking all the macronutrients and multiple micronutrients. It can occur unexpectedly or slowly. It can be classified as mild, moderate, or severe. It involves children not being provided with calories and proteins in developing countries. In developed countries, it involves the older generation.

Protein-energy malnutrition can be classified into two types,

  • Primary protein-energy malnutrition.

  • Secondary protein-energy malnutrition.

Primary Protein Energy Malnutrition (PEM):

Primary protein energy malnutrition (PEM) is a type of protein-energy malnutrition found in children. It is rarely found in the elderly, the leading cause being depression. However, it can be due to child or elder abuse. In children, protein energy malnutrition (PEM) is of two types:

  • Kwashiorkor.

  • Marasmus.


  • Kwashiorkor occurs due to inadequate breastfeeding before the exact age due to the birth of a younger sibling.

  • Kwashiorkor may also be the result of an acute condition such as gastroenteritis. It is limited only to a few regions of the world. In the rural regions of Africa, the Caribbean, and the Pacific islands, in these areas, the food is lower in protein and high in carbohydrates.

  • It causes cell membrane leakage, releasing intravascular fluid and proteins, resulting in edema.

  • It weakens the person's immunity and increases susceptibility to diseases.


  • Marasmus causes weight loss, fat, and muscle depletion.

  • Most typical in developing countries, which is more expected than in kwashiorkor

  • Marasmus, shows high prevalence among younger children.

  • Cell-mediated immunity is damaged, making children more exposed to infections.

Secondary Protein Energy Malnutrition(PEM):

  • It is induced due to the gastrointestinal tract disorders

  • Other causes include infections, trauma, hyperthyroidism, burns, and other critical illnesses.

  • It diminishes appetite and damages nutrient metabolism.

What Are the Causes of Protein-Energy Malnutrition?

According to the world health organization (WHO), protein energy malnutrition (PEM) is "an imbalance between the protein supply and energy and the demand of the body for them to provide optimal growth and function." Protein-energy malnutrition (PEM) is a significant and common public health problem in developing countries. It mainly concerns preschool children (less than six years), with threatening consequences ranging from physical to mental growth and exposure to infection. This involves the child at the most critical period of growth, which can lead to permanent impairment in life.

Some of the causes of protein-energy malnutrition are mentioned below.

  • Socio-cultural factors affecting feeding practices.

  • Maternal nutrition.

  • Infection.

  • Gender.

  • Mother's literacy status.

  • Poverty and income.

  • Urban-rural difference.

  • Lifestyle and behavior.

What Are the Symptoms of Protein-Energy Malnutrition?

The protein-energy malnutrition or PEM symptoms are many, and some of them are mentioned below.

  • Irritability.

  • Generalized weakness and inefficiency.

  • Cognition and consciousness impairment.

  • Temporary deficiency of lactose.

  • Severe diarrhea.

  • Atrophy of gonadal tissues.

  • Causes amenorrhea.

  • Libido in both men and women.

  • Weight loss.

  • Muscle shrinking.

  • Bony protrusion.

  • Thin, pale, dry, inelastic, and cold skin.

  • Hair loss.

  • Problems in wound healing.

  • High risk of hip fractures.

  • Ulcers develop in elderly patients.

  • In severe cases, heart size and cardiac output decrease.

  • Respiratory rate and vital capacity decrease.

  • Liver, kidney, or heart failure.

  • Acute protein energy malnutrition (PEM) might lead to fatal complications.

How to Diagnose Protein-Energy Malnutrition?

The diagnosis of protein-energy malnutrition can be made clinically based on the history and physical examination. The physical examination includes measuring height, weight, and body mass index (BMI). Blood tests show anemia, low serum protein, and albumin levels, and liver function abnormalities. Skin biopsy reveals skin pallor. Some of the diagnostic tools to diagnose protein-energy malnutrition are given below.

  • A complete workup needs nutritional evaluation and studies for underlying and associated disorders such as cystic fibrosis and human immunodeficiency virus (HIV) infection. Protein-energy malnutrition (PEM) can be diagnosed by evaluating the following factors.

  • The dietary history of the patient.

  • Measuring height, weight, and fat accumulation.

  • Anthropometric measurements should be examined.

  • The body mass index, or BMI, is estimated to calculate the severity of protein energy malnutrition (PEM).

  • Laboratory tests, including serum albumin, transferrin, total lymphocyte count, and response to skin antigens, can assist in detecting the severity of protein energy malnutrition.

  • Levels of hormones, lipids, fats, cholesterol, insulin-like growth factor, prealbumin, fibronectin, calcium, magnesium, and phosphate are decreased.

How to Prevent Protein-Energy Malnutrition?

Protein-energy malnutrition (PEM) can be prevented by providing a balanced diet. The micronutrients can be taken twice, the daily suggested allowance until recovery.

  • Oral feeding should be increased.

  • Supportive care should be given.

  • Poverty reduction.

  • Nutritional education and public health measures must be improved.

  • A balanced diet and multivitamin supplements are provided to prevent starvation.

  • In the case of infections, underlying causes must be treated to avoid fatal complications.

Some of the protein-rich foods are mentioned below.

  • Eggs.

  • Almonds.

  • Chicken breast.

  • Cottage cheese.

  • Greek yogurt.

  • Milk.

  • Lentils.

  • Lean beef.

  • Fish.

  • Quinoa.

  • Pumpkin seeds.

  • Turkey breasts.

  • Peanuts.


Protein-energy malnutrition also referred to as protein-energy undernutrition, most commonly affects children. Protein-energy malnutrition is caused by many factors and shows various symptoms. Therefore, early diagnosis should be made, and malnutrition should be managed. However, a proper protein-rich nutritious diet is provided in addition to multivitamin supplements to prevent the complication of protein energy malnutrition.

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Dr. Achanta Krishna Swaroop
Dr. Achanta Krishna Swaroop



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