PEM

❧
Dr dr. Joko Wahyu Wibowo, MKes
Bagian Gizi – IKM- FK Unissula
 Marasmus
❧
❧ Weight for age < 60% expected
❧ No edema
❧ Often stunted
❧ Hungry, relatively easier to feed
❧ CFR=20-30%
 Marasmus

Wajah spt orang

❧
tua
Rambut masih
hitam

Atrofi otot,
Lemak sangat
Iga gambang, sangat tipis/habis
Kwashiorkor

Hepatomegal
i Edema
 Kwashiorkor
(Edematous❧
Malnutrition)
❧ Underweight with edema
❧ Irritable, difficult to feed
❧ Electrolyte abnormalities
❧ Highest mortality – 50 to 60%
❧
Direct causes of death:
1. Hypoglycemia

❧ 1. Hypothermia

1. Dehydration

1. Infection

1. Severe anemia

Time Magazine, August, 2008

❧
 Causes of malnutrition
Child malnutrition

❧
death and disability

Inadequate Disease
Diet

Poor water/ sanitation Inadequate

Insufficient
inadequate health maternal and
access to food
services child care
 Higher Impaired
mortality rate mental
development
Reduced Increased risk of
capacity adult chronic disease
Baby
to care
Low Birth Untimely/inadequate
Elderly for baby
Weight weaning
Malnourished
Frequent
Infections
Inadequate Inadequate
catch up food, health
Inadequate
Inadequate growth & care
fetal Child
food, nutrition
health Stunted
& care Reduced
mental
Woman capacity
Malnourished
Start Adolescent
Pregnancy Inadequate
here Stunted
Low Weight food, health
Gain & care

Reduced
Inadequate mental
Higher
food, health capacity
maternal
& care
mortality
 Causes/correlates
❧
❧ Malnutrition rarely exists in isolation, and many
other factors contribute to its detrimental impact;
❧ Poor physical resources, and overcrowded homes
❧ Poor sanitation and water supply
❧ Low income
❧ Parents with little education
❧ Minimal interaction/stimulation in the home

❧ Malnutrition has repercussions throughout the

life cycle and is thus multi-generational (diagram
with lots of arrows)
 MASALAH GIZI
❧
❧ Genetik
❧ Lingkungan
❧ Faktor sosio budaya
Caloric restriction–induced alterations in
gene expression

1/16/2019 Science (1999) 285:1390-1393

16
 Definition of malnutrition
❧
❧ Malnutrition is having the inappropriate
level of a micro- or macro- nutrient;
❧ In some cases (i.e. the US), malnutrition can
be associated with being grossly overweight;
❧ In most of the world, malnutrition is defined
as a LACK of nutrients;
❧ Malnutrition contributes to over 50% of
deaths in children in the world.
 HUMAN
NUTRITION..................
❧
❧ Obesity & under-nutrition are the 2 ends of the
spectrum of malnutrition.
❧ A healthy diet provides a balanced nutrients that
satisfy the metabolic needs of the body without
excess or shortage.
❧ Dietary requirements of children vary according to
age, sex & development.
 EPIDEMIOLOGY
❧
❧ The term protein energy malnutrition has been
adopted by WHO in 1976.
❧ Highly prevalent in developing countries among <5
children; severe forms 1-10% & underweight 20-
40%.
❧ All children with PEM have micronutrient
deficiency.
 Assessment of
❧ status
Nutritional
❧Direct
❧Clinical
❧Anthropometric
❧Dietary
❧Laboratory
❧Indirect
❧Health statistics
❧Ecological variables
 Clinical Assessment
❧
❧ Useful in severe forms of PEM
❧ Based on thorough physical examination for features
of PEM & vitamin deficiencies.
❧ Focuses on skin, eye, hair, mouth & bones.
❧ Chronic illnesses & goiter to be excluded
❧ ADVANTAGES
❧ Fast & Easy to perform
❧ Inexpensive
❧ Non-invasive
❧ LIMITATIONS
❧ Did not detect early cases
❧ Trained staff needed
 ANTHROPOMETRY
❧
❧ Objective with high specificity & sensitivity
❧ Measuring Ht, Wt, MAC, HC, skin fold thickness,
waist & hip ratio & BMI
❧ Reading are numerical & gradable on standard growth
charts
❧ Non-expensive & need minimal training
 ANTHROPOMETRY.........
❧
❧LIMITATIONS
❧Inter-observers’ errors in measurement
❧Limited nutritional diagnosis
❧Problems with reference standards
❧Arbitrary statistical cut-off levels for
abnormality
 LAB ASSESSMENT
❧Biochemical
❧
❧Serum proteins,
creatinine/hydroxyproline
❧Hematological
❧CBC, iron, vitamin levels
❧Microbiology
❧Parasites/infection
 DIETARY ASSESSMENT
❧
❧ Breast & complementary feeding details
❧ 24 hr dietary recall
❧ Home visits
❧ Calculation of protein & Calorie content of
children foods.
❧ Feeding technique & food habits
 Types of malnutrition
❧
❧ Severe Protein-Energy Malnutrition (>3 S.D.)
❧ Kwashiorkor (low protein)
❧ Marasmus (low calories)
❧ Mild/moderate undernutrition (>2 S.D.)
❧ Stunting
❧ Underweight
❧ Wasting
❧ Micro-nutrient deficiency
❧ Iodine
❧ Iron
❧ Vitamin A
❧ Vitamin D
Penyakit gizi lain yang menyertai KEP

❧
❧Defisiensi vitamin A
❧Defisiensi zat besi,folat dan B12
❧Defisiensi vitamin B2
❧Defisiensi seng/Zn
❧Pada KEP berat selalu disertai
kekurangan vitamin dan mineral
Kondisi villi pada anak
KEP
❧
Normal villi Kerusakan villi
Kejadian KEP
❧
Dampak yang terjadi saat terjadi gangguan 1000 HPK
Indeks anthropometri
❧
 GIZI BURUK DI
INDONESIA
❧
❧ Laporan Global Nutrition pada 2016 menunjukkan bahwa
Indonesia menempati urutan ke-108 di dunia dengan kasus
gizi buruk terbanyak, di atas Laos (124) dan Timor Leste (132).
Posisi ini bahkan lebih tinggi diantara negara-negara di
ASEAN, seperti Thailand (46) Malaysia (47), Vietnam (55),
Brunei (55), Philipina (88), bahkan Kamboja (95).
❧ kekurangan gizi pada anak di awal kehidupan dapat
mempengaruhi metabolisme tubuh agar menyesuaikan
dengan kondisi kekurangan gizi. Namun ketika gizi mudah
diperoleh, tubuh anak menjadi rentan terhadap obesitas dan
mudah terkena penyakit tidak menular seperti hipertensi,
diabetes, jantung koroner hingga stroke.
❧ anak dengan gizi buruk berpeluang mengalami
kematian akibat:
❧ diare lima kali lipat lebih tinggi
❧ radang paru empat kali lebih tinggi,
❧
❧ malaria empat kali lipat lebih tinggi,
❧ Campak btiga kali lipat lebih tinggi
❧ masalah penurunan kecerdasan yang dialami anak
dengan gizi buruk merosot sebanyak 7 hingga 31 poin
dibandingkan anak-anak dengan status gizi yang baik.
❧ tingkat kecerdasan yang rendah menyebabkan anak
dengan gizi buruk rentan mengalami gangguan
perilaku emosi, performa sekolah yang menurun dan
keberhasilan karir di masa mendatang.
❧ “Kenapa berpengaruh ke kecerdasan? Itu karena 95
persen pembentukan otak anak terjadi pada 1000 hari
pertama kehidupan, hingga usia 6 tahun. Ketika balita
berusia 2 tahun maka pembentukan otaknya hampir
mencapai 80 persen, sehingga 2 tahun pertama usia
anak harus termonitor dengan baik berat badannya.
Kalau tidak segera diintervensi, kita terlambat,”
 CHILD MORTALITY
❧
❧ The major contributing factors are:
❧ Diarrhea 20%
❧ ARI 20%
❧ Perinatal causes 18%
❧ Measles 07%
❧ Malaria 05%
55% of the total have malnutrition
• anak yang kekurangan gizi memiliki peluang yang
rendah dalam memperoleh pendidikan dan pekerjaan
yang layak di masa mendatang.

• Tahun 2020-2030, Indonesia akan memasuki masa

bonus demografi, dimana penduduk produktif di
rentang usia 15-64 tahun memiliki porsi yang paling
besar dibandingkan rentang usia lainnya.
• karena masalah malnutrisi, bonus demografi bisa
berubah menjadi beban demografi.

• Di sisi ekonomi, Bank Dunia menyebut bahwa dampak

malnutrisi diperkirakan setara dengan kehilangan 2-3
persen PDB Indonesia. Jika nilai PDB Indonesia atas
Harga Dasar Berlaku (ADHB) mencapai Rp 12.406,8
triliun maka kasus gizi buruk berpotensi memangkas
hampir Rp 372 triliun.
 CLASSIFICATION
❧
❧A. CLINICAL ( WELLCOME )
❧ Parameter: weight for age + oedema
❧ Reference standard (50th percentile)
❧ Grades:
❧ 80-60 % without oedema is under weight
❧ 80-60% with oedema is Kwashiorkor
❧ < 60 % with oedema is Marasmus-Kwash
❧ < 60 % without oedema is Marasmus
 CLASSIFICATION
............
❧
❧B. COMMUNITY (GOMEZ)
❧Parameter: weight for age
❧Reference standard (50th percentile)
WHO chart
❧Grades:
❧I (Mild) : 90-70
❧ II (Moderate): 70-60
❧ III (Severe) :< 60
 ADVANTAGES
❧
∙ SIMPLICITY (no lab tests needed)
∙ REPRODUCIBILITY
∙ COMPARABILITY
∙ ANTHROPOMETRY+CLINICAL
SIGN USED FOR ASSESSMENT
 DISADVANTAGES
❧
∙ AGE MAY NOT BE KNOWN
∙ HEIGHT NOT CONSIDERED
∙ CROSS SECTIONAL
∙ CAN’T TELL ABOUT CHRONICITY
∙ WHO STANDARDS MAY NOT
REPRESENT LOCAL COMMUNITY
STANDARD
 Measurement of
❧ STUNTING: Height ❧
Malnutrition
for age – height
compared to a reference population of the
same age.
= represents long term growth retardation
❧ UNDERWEIGHT: Weight for age – weight
compared to age in a reference population

❧ WASTING: Weight for height – weight

compared to a reference population of the
same height.
 Kwashiorkor (low
protein)
❧ Decreased muscle mass (failure to gain weight and of linear

❧ Swollen belly (edema and ❧

growth)
lipid build-up around the liver)
❧ Changes in skin pigment (pellagra); may lose pigment where
the skin has peeled away (desquamated) and the skin may
darken where it has been irritated or traumatized
❧ Hair lightens and thins, or becomes reddish and brittle.
❧ Increased infections and increased severity of normally mild
infection, diarrhea
❧ Apathy, lethargy, irritability

➔ Death does not occur from actual starvation but from

secondary infection
 Marasmus
❧
❧ Deficit in calories – “marasmus” comes from Greek
origin of word “to waste”
❧ Gross weight loss
❧ Hyper-alert and ravenously hungry
❧ Children have no subcutaneous fat or muscle

➔ eventually starve to death (immediate cause often is

pneumonia)
Marasmus – mechanism
❧
❧ Energy intake is insufficient for body’s
requirements – body must draw on own stores
❧ Liver glycogen exhausted in a few hours –
skeletal muscle protein used via gluconeogenesis
to maintain adequate plasma glucose
❧ When near starvation is prolonged, fatty acids
are incompletely oxidized to ketone bodies,
which can be used by brain and other organs for
energy
❧ High cortisol and growth hormone levels

➔ Mechanism is same as anorexia

 Severe Malnutrition:
Consequences
❧
❧
Mental development
❧ Lower IQ levels
❧ Poorer school performance
❧ Behaviors of recovered severely malnourished
children
❧ shy, isolated, withdrawn
❧ decreased attention span
❧ immature, emotionally unstable
❧ fewer peer relationships/reduced social skills
❧ played less/stayed nearer to mothers
 Hypothesized
Mechanisms
❧
alterations in
development
of CNS

emotional reactivity, poor mental

poor impaired
development
nutritio stress response
&
n
behavior
“functional
isolation”
 Stunting – Height for Age
❧
❧ Height for age reflects pre- and post- natal linear
growth
❧ “Stunting” refers to shortness that is not genetic, but
due to poor health or nutrition
❧ Most standard definition < 2 S.D.
❧ Stunting is good cumulative measure of “well-being”
for populations of children (because not affected by
weight recovery)
 Stunting: Timing
❧
❧ Age of onset varies, but usually in first 2-3 years of
life
❧ First few months, infants in developing countries
grow just as quickly as children in reference
populations
❧ Growth retardation starts from 2-6 month of life (often
associated with weaning)
❧ Infants at risk during this time because of high
nutritional requirements and high rates of infections
(breast fed infants often protected)
 Stunting: Consequences
❧ Cross-sectional associations – Low height for age
associated with: ❧
❧ Reduced cognitive development
❧ Poor motor skills
❧ Poor neuro-sensory integration
❧ Quiet, reserved, withdrawn, timid, passive
❧ Difficulty making decisions
❧ Decreased involvement with environment,
toys, tasks
❧ Less able to deal with stressor such as hunger
or parasites
 Underweight
❧
❧ Define: weight-for-age less 80% expected
❧ Encompasses both wasting and stunting
❧ Most global data
❧ High correlation with stunting
❧ Prevalence directly describes the magnitude of
the problem of growth faltering and stunting in
young children
❧ 130 million children under the age of five years
Treatment of Malnutrition

❧
Where do we go from here?

Poverty Economic
reduction growth

Increased Social
productivit Improved
sector
y child
investment
nutrition
s

Enhanced
human
capital

From UNICEF, State of the World’s Children: Adapted from Stuart Gillespie, John
Mason and Reynaldo Martorell, How nutrition improves, ACC/SCN, Geneva 1996.
Wassalam

TERIMA KASIH
❧