Kwashiorkor: An Example of a Protein Energy Malnutrition Disorder

January 11, 2026 •

4 min read

According to the World Health Organization, malnutrition contributes to about 45% of all deaths in children under five years old worldwide. A classic example of a protein energy malnutrition disorder is kwashiorkor, a condition that results primarily from a severe deficiency of protein.

Quick Summary

Kwashiorkor is a form of protein-energy malnutrition resulting from severe protein deficiency, often recognizable by fluid retention and a swollen abdomen, distinct from marasmus which involves a total calorie deficit. It primarily affects children and requires careful nutritional intervention and medical care for treatment.

Key Points

Kwashiorkor is an example of a protein energy malnutrition disorder: It results from a severe protein deficiency, even when calorie intake may be sufficient.
Edema is a key symptom of kwashiorkor: This fluid retention causes swelling in the hands, feet, and face, and a distended abdomen, masking significant muscle wasting.
Kwashiorkor differs from marasmus: Marasmus is a deficiency of both protein and total calories, leading to a severely emaciated appearance without the edema seen in kwashiorkor.
Multiple factors cause PEM: These include poverty, food insecurity, poor weaning practices, and recurrent infections, particularly in young children.
Treatment requires careful management: The three phases of treatment are stabilization, nutritional rehabilitation with a gradual reintroduction of nutrients, and long-term follow-up to prevent recurrence.
Long-term effects can be permanent: Untreated PEM in children can lead to persistent cognitive impairment, stunted growth, weakened immunity, and organ damage.

Understanding Protein Energy Malnutrition (PEM)

Protein energy malnutrition (PEM), also known as protein-energy undernutrition (PEU), refers to a range of conditions caused by insufficient protein, calories, or both in the diet. While common in low-income areas globally, PEM can also affect individuals in developed countries, particularly those with chronic illnesses or the elderly. The two main types of severe PEM are kwashiorkor and marasmus.

Kwashiorkor: A protein-dominant deficiency

Kwashiorkor is a form of PEM characterized by a more severe deficiency of protein compared to calorie intake. The term originates from Ghana, meaning "the sickness the baby gets when the new baby comes," as it often impacts toddlers recently weaned from protein-rich breast milk and given a diet high in carbohydrates but low in protein.

Common signs and symptoms of kwashiorkor include:

Edema: A hallmark symptom is bilateral pitting edema, causing swelling in the extremities and face due to fluid retention. This swelling can mask underlying muscle and fat loss.
Distended abdomen: A swollen belly is typical, resulting from fluid accumulation (ascites), an enlarged fatty liver, and weakened abdominal muscles.
Skin and hair changes: Skin may appear dry, thin, and peeling, sometimes with lesions. Hair can become brittle, sparse, and discolored.
Apathy and irritability: Affected children are often withdrawn and lethargic but become irritable when handled.
Impaired immunity: A weakened immune system increases vulnerability to infections.

The difference between Kwashiorkor and Marasmus

Kwashiorkor and marasmus are severe forms of PEM with distinct presentations. The following table highlights their key differences:


Feature	Kwashiorkor	Marasmus
Primary Deficiency	Severe protein deficiency with relatively adequate calorie intake.	Deficiency of both protein and total calorie intake.
Appearance	Edema causes a swollen, bloated look, particularly in the abdomen and limbs.	Emaciated and severely wasted, giving a 'skin and bones' or 'old man' appearance.
Body Fat	Some subcutaneous fat may be retained.	Subcutaneous fat is severely depleted or completely lost.
Muscle Wasting	Marked muscle wasting is present but often masked by the edema.	Severe muscle wasting is very obvious due to the absence of fat stores.
Appetite	Often experiences anorexia or loss of appetite.	May initially experience ravenous hunger but later develops a poor appetite.
Fatty Liver	Liver often becomes enlarged and fatty (hepatomegaly) due to impaired fat transport.	No significant enlargement of the liver.

Causes and risk factors

Factors contributing to PEM include:

Food insecurity and poverty: Limited access to nutritious food is a major cause in developing regions. Families may only be able to afford carbohydrate-rich staples.
Infections and disease: Illnesses, such as diarrheal diseases, increase nutrient needs and impair absorption, worsening malnutrition.
Poor maternal nutrition: Malnutrition during pregnancy can lead to low birth weight, increasing a child's risk of PEM.
Inadequate weaning practices: Weaning infants onto low-protein foods in high-risk areas can precipitate kwashiorkor.

Treatment and long-term consequences

Treating severe PEM involves several phases under medical supervision to avoid complications like refeeding syndrome.

Stabilization: Initial treatment focuses on immediate, life-threatening issues such as low blood sugar, hypothermia, dehydration, and electrolyte imbalances. Antibiotics are administered for infections.
Nutritional rehabilitation: Nutrients are gradually reintroduced using formulas and therapeutic foods, along with micronutrient supplements.
Long-term follow-up: Continued monitoring and education on nutrition, hygiene, and disease prevention are crucial post-discharge.

Untreated PEM, especially in children, can have severe, long-lasting effects, including:

Permanent cognitive impairment: Malnutrition can damage the developing brain.
Stunted growth: Chronic PEM leads to impaired physical growth.
Impaired immune function: A weakened immune system increases the risk of chronic infections.
Organ damage: Long-term malnutrition can damage organs like the heart and liver.

Conclusion

Kwashiorkor exemplifies protein energy malnutrition and the vital role of protein, particularly in childhood development. It is more prevalent in resource-limited settings but can stem from various factors, including chronic illnesses and neglect. Distinguishing kwashiorkor from marasmus is essential for effective treatment. Addressing PEM requires a comprehensive approach, including immediate medical care, nutritional support, education, and tackling underlying socioeconomic issues. Adequate nutrition is fundamental to global public health.

The Role of Zinc in PEM

Zinc deficiency is linked to PEM, especially kwashiorkor, where skin lesions are common. Zinc supplementation can improve outcomes. This highlights that addressing PEM involves treating multiple micronutrient deficiencies, not just protein or calorie deficits.

Education and Prevention

Targeted Nutritional Programs: Educational programs and nutritional interventions are key to preventing PEM. Organizations like UNICEF and WHO provide guidelines for managing childhood malnutrition.
Breastfeeding Promotion: Exclusive breastfeeding for the first six months provides essential nutrition and protection.
Disease Control: Improved sanitation, clean water access, and vaccination programs help prevent infections that worsen malnutrition.

Addressing the Socioeconomic Root

Preventing PEM requires addressing the root causes: poverty, lack of education, and food insecurity. Coordinated efforts from governments, NGOs, and healthcare systems are needed to ensure food security, improve maternal and child health, and provide community education.

World Health Organization. Malnutrition.

Frequently Asked Questions

The primary difference is the nature of the nutritional deficit. Kwashiorkor results mainly from a severe protein deficiency with relatively adequate calories, while marasmus is caused by a deficiency of all macronutrients—protein, carbohydrates, and fats.

The tell-tale signs of kwashiorkor include bilateral pitting edema (swelling), a distended abdomen, skin lesions, discolored or sparse hair, and lethargy or apathy.

Edema occurs in kwashiorkor because of the severe lack of protein. This leads to low levels of albumin in the blood (hypoalbuminemia), which decreases the osmotic pressure and allows fluid to leak out of the blood vessels into surrounding tissues.

Yes, while PEM is most commonly seen in children in developing countries, adults can also be affected, particularly the elderly, those with chronic illnesses like cancer or renal disease, or individuals with eating disorders like anorexia.

Diagnosis typically involves a physical examination to identify clinical signs like edema and wasting, a review of dietary history, and anthropometric measurements. Laboratory tests may also be used to assess serum albumin levels and screen for deficiencies.

Refeeding syndrome is a potentially fatal complication that can occur when a severely malnourished person is fed too aggressively after a period of starvation. The sudden reintroduction of calories causes metabolic shifts that can lead to fluid overload, electrolyte abnormalities, and heart failure.

Prevention involves ensuring access to a balanced and adequate diet, promoting and supporting breastfeeding, and controlling infections through improved sanitation and vaccination programs. Addressing underlying socioeconomic factors like poverty is also crucial.