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  • Decreased intake of energy or protein, increased nutrient losses, or increased nutrient requirements.

  • Kwashiorkor: caused by protein deficiency.

  • Marasmus: caused by combined protein and energy deficiency.

  • Protein loss correlates with weight loss: 35–40% total body weight loss can be fatal.


Protein–energy malnutrition occurs as a result of a relative or absolute deficiency of energy and protein. It may be primary, due to inadequate food intake, or secondary, as a result of other illness. For many developing nations, primary protein–energy malnutrition remains a significant health problem. It occurs in two distinct syndromes. Kwashiorkor, caused by a deficiency of protein in the presence of adequate energy, is typically seen in weaning infants at the birth of a sibling where foods containing protein are insufficient. Marasmus, caused by combined protein and energy deficiency, is seen where adequate quantities of food are not available.

In industrialized societies, protein–energy malnutrition is most often secondary to other diseases. Kwashiorkor-like secondary protein–energy malnutrition occurs primarily in hypermetabolic acute illnesses such as trauma, burns, and sepsis. Marasmus-like secondary protein–energy malnutrition typically results from chronic diseases such as chronic obstructive pulmonary disease (COPD), heart failure, cancer, or AIDS. A substantially greater number of patients have risk factors that could result in them. In both syndromes, protein–energy malnutrition is caused either by decreased intake of energy and protein or by increased nutrient losses related to underlying illness. For example, diminished energy intake may result from poor dentition or various gastrointestinal disorders. Increased nutrient losses may result from malabsorption, diarrhea, and glycosuria. Increased nutrient requirements occur with fever, surgery, neoplasia, and burns.


Protein–energy malnutrition affects every organ system. The most obvious results are loss of body weight, adipose stores, and skeletal muscle mass. Weight losses of 5–10% are usually tolerated without loss of physiologic function; losses of 35–40% of body weight can result in death. Loss of protein from skeletal muscle and internal organs is usually proportionate to weight loss. Protein mass is lost from the liver, gastrointestinal tract, kidneys, and heart.

As protein–energy malnutrition progresses, organ dysfunction develops. Hepatic synthesis of serum proteins decreases, and depressed levels of circulating proteins are observed. Cardiac output and contractility are decreased, and the electrocardiogram (ECG) may show decreased voltage and a rightward axis shift. Autopsies of patients who die with severe undernutrition show myofibrillar atrophy and interstitial edema of the heart.

Respiratory function is affected primarily by weakness and atrophy of the muscles of respiration. Vital capacity and tidal volume are depressed, and mucociliary clearance is abnormal. The gastrointestinal tract is affected by mucosal atrophy and loss of villi of the small intestine, resulting in malabsorption. Intestinal disaccharidase deficiency and mild pancreatic insufficiency also occur.

Changes in immunologic function are among the most important changes seen in protein–calorie undernutrition. T lymphocyte number and function are depressed. ...

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