Causes Of Protein-energy Malnutrition Research Articles

Healthy aging and chronic kidney disease.

The world population is aging and the prevalence of noncommunicable diseases such as diabetes, hypertension, and chronic kidney disease (CKD) will increase significantly. With advances in medical treatment and public health, the human lifespan continues to outpace the health span in such a way that the last decade of life is generally spent in poor health. In 2015, the World Health Organization defined healthy aging as 'the process of developing and maintaining the functional ability that enables wellbeing in older age.' CKD is increasingly being recognized as a model of accelerated aging and is associated with physical performance decline, cognitive decline, falls and fractures, poor quality of life, loss of appetite, and inflammation. Frailty and dementia are the final pathways and key determinants of disability and mortality independent of underlying disease. CKD, dementia, and frailty share a triangular relationship with synergistic actions and have common risk factors wherein CKD accelerates frailty and dementia through mechanisms such as uremic toxicity, metabolic acidosis and derangements, anorexia and malnutrition, dialysis-related hemodynamic instability, and sleep disturbance. Frailty accelerates glomerular filtration decline as well as dialysis induction in CKD and more than doubles the mortality risk. Anorexia is one of the major causes of protein-energy malnutrition, which is also prevalent in the aging population and warrants screening. Healthcare systems across the world need to have a system in place for the prevention of CKD amongst high-risk older adults, focusing on screening for poor prognostic factors amongst patients with CKD such as frailty, poor appetite, and cognitive impairment and providing necessary person-centered interventions to reverse underlying factors that may contribute to poor outcomes.

Diversified nutritional support of patients in severe forms of COVID-19

The Coronavirus Disease 2019 (COVID-19) pandemic, declared by the World Health Organization on March 11, 2020, has made significant adjustments to the principles of organizing medical care, including treatment, nutrition, and care of patients in infectious hospitals. The disease has different clinical courses: from mild asymptomatic to extremely severe, requiring aggressive medical interventions, such as organ replacement therapy to replace vital body functions.
 The spread of viral infection was global, but the pathophysiological aspects of the course of COVID-19 have not been studied comprehensively. The development of acute respiratory distress syndrome and systemic inflammatory response syndrome as part of the severe course of the disease is accompanied by severe metabolic disorders that require close attention. It is necessary to correct the clinical manifestations of organ dysfunction under severe hypercatabolism. Considerable importance is given to the peculiarities of providing nutritional support to patients using specialized nutritional mixtures to prevent conditions that worsen the prognosis of recovery and survival of patients.
 The target cells of the virus are angiotensin-converting enzyme receptors of the respiratory, nervous, urinary, and cardiovascular systems and organs of the gastrointestinal tract. Consequently, the site of the infection at different organs and systems gives rise to the phenomena of respiratory failure and several heterogeneous clinical manifestations of the disease, which can affect all ties in the pathogenesis of nutritional deficiency. Malnutrition is usually due to the mismatch between the intake and consumption of nutrients, micro- and macroelements.
 The causes for the imbalance of the intake-expenditure system can be divided into three groups: reduced nutrient intake, increased consumption due to hypercatabolism or hypermetabolism, and malabsorption and increased nutritional losses due to direct and indirect damages to the gastrointestinal tract. The division is traditional because, in the case of severe forms of coronavirus infection, there is always the presence of two or more factors leading to nutritional deficiencies.
 In this study, we systematized the ways in which we provide nutritional support based on the prevalent causes of protein-energy malnutrition, taking into account the patients individual needs and the extent of respiratory support. Several articles published by foreign colleagues and our own experience in the Department of Anesthesiology and Intensive Care for Patients with a New Coronavirus Infection COVID-19 at the Russian Academy of Sciences Central Clinical Hospital in Moscow in 2020 were analyzed.
 This study discusses in detail the problems and characteristics of clinical nutrition that a practicing intensive care specialist faces when enduring all possible measures to maintain the stable homeostasis of the patient.

The effectiveness of the use of a specialized formula based on hydrolyzed milk protein in children older than 1 year of age with cystic fibrosis

Introduction. Malabsorption syndrome is one of the most common manifestations of intestinal insufficiency in cystic fibrosis (CF). CF being the cause of protein-energy malnutrition, so diet therapy using specialized enteral nutrition products is an integral part of CF complex treatment. Purpose. Evaluation of the tolerability and effectiveness of the domestic specialized semi-elemental formula based on hydrolyzed milk protein «NUTRIEN® Elemental» in the treatment of protein-energy malnutrition in CF children older than 1 year of age with malabsorption syndrome. Materials and methods. Under supervision were 32 CF one year 3 months to 17-year children with a mixed form of the disease and malnutrition. Twelve (38%) children had hypolactasia. Nutritional status was assessed using the WHO-Anthro for 1-5-year children and WHO-Anthro Plus for patients over 5 years of age) programs, and indices of clinical and biochemical blood tests. The average duration of follow-up was 21 day. Statistical processing was performed using « Statistica 6.0» («StatSoft Inc.», USA) and Microsoft Excel 2010. Results. While taking a specialized product, there was a decrease in the number of patients with severe and moderate forms of protein-energy malnutrition, a significant upward trend in such biochemical markers of nutritional status as prealbumin (p < 0.01), transferrin (p < 0.01), total protein (p < 0.01). Conclusion. The use of a domestic specialized product based on hydrolyzed milk protein «NUTRIEN® Elemental» in the diet therapy of sick children with malabsorption syndrome, including CF patients, indicates its positive effect on the indices of the nutritional status of patients and the course of the underlying disease.

Formulation of a Nutrient-Rich Complementary Biscuit for Children Between Eight Months and Fifty Nine Months

Low breast feeding rates, early introduction of complementary foods, heavy workload of the care givers, lack of ready-to- prepare formulations and the infrequency of feeding of the weaned children are the major causes of Protein Energy Malnutrition in western Uganda. The common complementary foods in Ugandan rural areas are staple cereals gruels and porridges which have low energy density with low animal-protein intake. The study aimed at formulating a nutrient-rich biscuit from locally available materials with the potential to mitigate undernutrition. A low water content biscuit with high energy density and recommendable shelf-life stability under domestic storage conditions was baked from locally available food materials with a composite flour of 24% soya bean flour, 20% pumpkin seed flour, 32% banana flour and 24% wheat flour. Biscuit servings of 66g, 77g, 110g and 132g were sufficient to meet above 50% of the RDA for infants of 8 months to 12months, 12 months to 24months, 24 to 48 and 48 to 59months old children respectively.

Clinical features and rehabilitation of children with protein-energy malnutrition from socially disadvantaged families

Conducted research to identify the frequency and the main causes of protein-energy malnutrition in children without parental care. Investigated the state of the vital systems (nervous, cardiovascular, digestive). Presented the efficiency of rehabilitation of children with malnutrition using probiotic Laminolakt “Chernichka”, confirmed the safety of its use.

Social Determinants of Protein-Energy Malnutrition: Need to Attack the Causes of the Causes

Sir, At the current mortality levels, 1 in every 21 Nepalese children dies before reaching the age of one year, while 1 in every 16 children does not survive to the fifth birthday (1). Nepal has achieved a spectacular success in reducing child mortality in recent decades; however, much must be done to achieve the Millennium Development Goal (MDG). Among different factors, the nutritional status of children plays a key role in determining mortality and morbidity of children. Malnutrition is still a serious threat to child development and survival in Nepal. Protein-energy malnutrition (PEM) and micronutrient deficiency (iodine, iron, and vitamin A deficiency) are the most common forms. Various programmes, such as control of iodine-deficiency disorders and control of vitamin A deficiency, have been undertaken to tackle the problem arisen from deficiency of micronutrients (2). Some programmes, such as the National Vitamin A Programme, have claimed to be successful public-health interventions in Nepal. Similarly, other micronutrient initiatives by different non-governmental organizations are underway. However, the Government of Nepal does not have any strong and effective programmes to tackle the pervasive problem of macronutrients, i.e. PEM. Before 1980, most attention in developing countries was focused on PEM but the attention of the nutrition community and resources of donors were slowly attracted by the glamour of micronutrients, a largely technical, and often top-down, solution (close to a ‘quick fix’ magic bullet) (3). The Nepal Demographic and Health Survey (NDHS) 2006 showed that 49% of children aged less than five years were affected by stunting, 39% were underweight, and 13% were wasted (1). To make the matter worse, the situation of PEM is not evenly distributed across the country. Rural area, far and mid-western region, and poor and uneducated population are badly affected by PEM. When compared with the NDHS 2001, some improvements in the nutritional status of children has been observed in the last five years. The percentage of children stunted fell by 14 percentage points from 57% in 2001 to 49% in 2006. Underweight has declined only slightly (from 43% to 39%), and wasting has risen from 11% in 2001 to 13% in 2006. One of the indicators of MDG in Nepal is to reduce the prevalence of underweight children aged less than five years from 57% in 1990 by half to 29% in 2015 (4). However, the above results indicate that, achieving the MDG of a 50% reduction in the prevalence of underweight children aged less than five years by 2015 continues to be a challenge. The current strategies of the Government of Nepal to control PEM include awareness-raising and nutrition education to the community, growth monitoring, behavioural change and communication, and nutritional rehabilitation. In other words, the response of the Government to tackle the problem is confined to a traditional approach of preventive and promotive care. The mere screening of growth of the children, educational action to change behaviours, and the suggestion of offering nutritious food to poor mothers/caretakers do not solve the problem of PEM. Food and nutrition education, in the presence of widespread food shortages, ends up in teaching people to eat what they cannot afford or do not have and, thus, has only limited potential. It reflects an attitude, such as ‘keep them poor, but teach them’ (5). The crux of the problem is poverty, food insecurity, skewed land distribution, etc. These are the social determinants of PEM. A mere behavioural and medical approach would only deal with the proximal cause but not with the distal and the causes of the causes of PEM. PEM is not a simple problem with a simple solution. It results from the complex interplay of social and biomedical factors. Hence, PEM is a social disease (6). A holistic and multi-pronged approach is needed with a strong socioeconomic policy reform by the Government. The policy of the Government should focus on addressing the underlying causes of malnutrition, with particular attention to the inequities in income distribution, the need for greater agricultural productivity, necessary improvement in the purchasing power of families, and on food conservation, processing, marketing and pricing mechanisms.

Long-Term Oral Sodium Bicarbonate Supplementation Does Not Improve Serum Albumin Levels in Hemodialysis Patients

Metabolic acidosis, a frequent event in hemodialysis patients, has been implicated as a potential cause of protein-energy malnutrition. Unfortunately, correction of metabolic acidosis by means of high bicarbonate concentration in the dialysate does not seem to lead to significant changes in nutritional parameters. The project was a single-arm, open-label, 12-month pilot study at a university-based tertiary care center aimed at evaluating whether correction of metabolic acidosis through long-term oral sodium bicarbonate supplementation improves serum albumin levels and other nutritional parameters in patients undergoing maintenance hemodialysis. Twenty highly acidotic hemodialysis patients patients were invited to consume an oral supplementation of sodium bicarbonate (1 g, thrice daily), for 12 months. Patients were followed at baseline and every month, until month 12. At each follow-up visit, dry body weight, BMI, blood pressure, presence of edema, venous bicarbonate, and serum albumin were measured. Total lymphocyte count, fasting total cholesterol and C-reactive protein were assessed every 2 months. At baseline and at 12 months, the subjective global assessment of nutritional status and the protein equivalent of nitrogen appearance normalized to actual body weight were determined. Plasma bicarbonate level rose from 18.1 ± 2.7 to 22.1 ± 4.5 mmol/l after 10 months (p = 0.001). Mean serum albumin levels were 3.8 ± 0.2 mg/dl at baseline and 3.9 ± 0.2 at the end of the study. Repeated measure ANOVA showed that there was no significant effect of bicarbonate treatment on serum albumin levels (p = 0.29), dry weight (p = 0.1), serum total cholesterol (p = 0.97), total lymphocyte count (p = 0.69), or C-reactive protein (p = 0.85). Mean subjective global assessment score was 4.53 ± 0.37 at baseline and 4.58 ± 0.54 at 12 months (p = 0.1). Mean nPNA (g/kg/day) was 0.86 ± 0.05 at baseline and 0.85 ± 0.08 at month 12. The present study demonstrates that long-term oral sodium bicarbonate at the dose of 1 gram thrice daily has no significant effect on nutritional status of HD patients.

Nutritional Solutions to Major Health Problems of Preschool Children: How to Optimise Growth and Development

Significant opportunities to improve child health globally were provided in the second half of the 20th century. However malnutrition remains a major problem and in many countries the situation seems to have worsened. In a recent report about survival rate in childhood UNICEF remained that the United Nations first Millennium Goal was to eradicate extreme poverty and to reduce the proportion of people who suffer from hunger by half between 1990 and 2015 as measured by the percentage of children under five years of age who are underweight. The first Millennium Goal of the United Nations is to eradicate extreme poverty and to reduce the proportion of people who suffer from hunger by half between 1990 and 2015 as measured by the percentage of children under 5 y old who are underweight. (excerpt)

Self-reported appetite, hospitalization and death in haemodialysis patients: findings from the Hemodialysis (HEMO) Study

Anorexia is an important cause of protein-energy malnutrition (PEM) in haemodialysis patients. We investigated whether self-reported appetite was associated with death and hospitalization in subjects enrolled in the Hemodialysis (HEMO) Study. The HEMO Study was a 7-year, multicentre, randomized trial (N = 1846), which examined the effects of dialysis dose and membrane flux on mortality and morbidity. Three questions from the Appetite and Diet Assessment Tool (ADAT) were used to determine whether appetite had changed over time in the randomized treatment groups. The relations among ADAT scores, dietary protein and energy intakes, biochemical and anthropometric measures, and quality of life were assessed. We used Cox proportional hazards models to evaluate the relative risks of death and hospitalization associated with static and dynamic ADAT scores, adjusted for demographic factors, dose and flux assignments, and co-morbidity. The average length of follow-up was 2.84 years. After adjusting for demographic factors and randomized treatment assignments, there was a significant association between poorer self-reported appetite and death (RR 1.52, 95% CI 1.16-1.98); however, the association became non-significant with further adjustment for co-morbidity (RR 1.23, 95% CI 0.94-1.62). Poorer appetite was unequivocally associated with increased hospitalization rates (multivariable RR 1.35, 95% CI 1.13-1.61). The longitudinal effect of worsening appetite from baseline to 1 year was not associated with mortality or hospitalization rate after adjusting for co-morbidity. The association between appetite and death was confounded by co-morbidity. Self-reported appetite was associated with hospitalization rate in haemodialysis patients and, thus, it may be a useful screening tool for this outcome. Patients who report poor or very poor appetites should be monitored, and they should receive more comprehensive nutritional assessments.

Intradialytic Parenteral Nutrition Treatment and Biochemical Marker Assessment for Malnutrition in Adolescent Maintenance Hemodialysis Patients

Protein-energy malnutrition (PEM) is a significant cause of morbidity and mortality for patients receiving maintenance hemodialysis. Minimal study has evaluated therapeutic options for and biochemical marker assessment of pediatric patient PEM. In 2001, we expanded the indications for intradialytic parenteral nutrition (IDPN) treatment of PEM to all maintenance hemodialysis patients, regardless of etiology, who had a >10% weight loss and were at less than the 90th percentile of ideal body weight. Nine patients received thrice weekly IDPN from 3 to 22 months with minimal side effects. Six patients had weight and body mass index increase, 1 patient stopped losing weight, and 2 patients continued to lose weight during the initial 5 months of IDPN therapy. Cohort subanalysis showed that all patients with organic PEM responded to IDPN therapy, whereas patients with psychosocial causes of PEM did not. The normalized protein catabolic rate increased significantly for patients whose condition responded to IDPN therapy, whereas serum albumin did not change. The current study suggests that IDPN is effective treatment of organic causes of PEM in pediatric patients receiving maintenance hemodialysis and that normalized protein catabolic rate may be superior to serum albumin as a marker of nutrition status. The observation that IDPN was not sufficient to reverse PEM in patients with psychosocial PEM causes should direct caregivers to address the relevant underlying causes as well as to provide intensive nutrition therapy.

Protein and energy nutrition among adult patients treated with chronic peritoneal dialysis

Protein-energy malnutrition (PEM) in adult patients treated with chronic peritoneal dialysis (CPD), which is highly prevalent and frequently severe in its manifestation, poses a significant therapeutic dilemma. The causes of PEM include inflammation, low nutrient intake, nutrient losses during dialysis, metabolic acidemia, coexisting illnesses, and possibly the endocrine disorders of uremia. Treatment strategies for PEM in CPD patients include the following: attempt to treat the potentially reversible causes of anorexia, increase nutrient intake (by nutritional counseling, oral food supplements, consideration of appetite stimulants and intraperitonial amino acid solutions), and the correction of metabolic acidosis. Coexisting illnesses engendering PEM should be treated. Experimental evidence suggests that such agents as anabolic steroids, human growth hormone, insulin-like growth factor-I, and L-carnitine may engender positive protein balance in these individuals. Finally, the use of anti-inflammatory agents to improve the nutritional status of malnourished CPD patients remains to be defined. There is a need to carry out clinical trials that examine whether an improvement in the nutritional status of CPD patients is associated with an improvement in their mortality, morbidity and/or quality of life.

Nutritional management of maintenance dialysis patients: why aren't we doing better?

About 40% of patients undergoing maintenance dialysis suffer from varying degrees of protein-energy malnutrition. This is a problem of substantial importance because many measures of nutritional status correlate with the risk of morbidity and mortality. There are many causes of protein-energy malnutrition in maintenance dialysis patients. Evidence indicates that nutritional decline begins even when the reduction in glomerular filtration rate is modest, and it is likely that the observed decrease in dietary protein and energy intake plays an important role. The nutrient intake of patients receiving maintenance dialysis also is often inadequate, and several lines of evidence suggest that toxins that accumulate with renal failure suppress appetite and contribute to nutritional decline once patients are on maintenance dialysis. Recent epidemiologic studies have suggested that both increased serum levels of leptin and inflammation may reduce nutrient intake and contribute to the development of protein-energy malnutrition. It is likely that associated illnesses, which are highly prevalent, contribute to malnutrition in maintenance dialysis patients. Recent data from the United States Renal Data System registry suggest that in the United States, the mortality rate of dialysis patients is improving. However, it remains high. We offer suggestions for predialysis and dialysis care of these patients that can result in improvement in their nutritional status. Whether this improvement will result in a decrease in patient morbidity and mortality is unknown.

The relationship between plasma leptin and nutritional status in chronic hemodialysis patients.

Leptin serves an important role in suppressing appetite in mice and is known to be elevated in chronic renal failure (CRF) patients. But clinical significance of leptin as an appetite-reducing uremic toxin, remains to be determined. So we studied the relationship between plasma leptin and nutritional status in 46 chronic hemodialysis (HD) patients. Pre HD leptin was measured and divided by body mass index (BMI) to give adjusted leptin levels. KT/Vurea (K, dialyzer urea clearance; T, duration of HD; V, volume of distribution of urea), C-reactive protein (CRP), plasma insulin and nutritional parameters such as serum albumin, normalized protein catabolic rate (nPCR), subjective global assessment (SGA), BMI and mid-arm muscle circumference (MAMC) were also measured. Mean plasma leptin levels were 8.13+/-2.91 ng/mL (male 3.15+/-0.70; female 14.07+/-6.14, p<0.05). Adjusted leptin levels were positively correlated with nPCR (male r=0.47, p<0.05; female r=0.46, p<0.05), SGA (male r=0.43, p<0.05; female r=0.51, p<0.05) and MAMC (male r=0.60, p<0.005; female r=0.61, p<0.05). They did not correlate with KT/Vurea, serum albumin, hematocrit, bicarbonate, insulin and CRP. Presence of DM and erythropoietin therapy had no effect on leptin levels. These results suggest that leptin is a marker of good nutritional status rather than a cause of protein energy malnutrition in chronic HD patients.

Pathophysiology of Protein-Energy Wasting in Chronic Renal Failure

There is a high prevalence of protein-energy malnutrition in both nondialyzed patients with advanced chronic renal failure and in those individuals with end-stage renal disease who are receiving maintenance hemodialysis or chronic peritoneal dialysis therapy. Approximately one-third of maintenance dialysis patients have mild to moderate protein-energy malnutrition, and about 6 to 8 percent of these individuals have severe malnutrition. These statistics are of major concern because markers of protein-energy malnutrition are strong predictors of morbidity and mortality. The causes of protein-energy malnutrition in patients with chronic renal failure include: (1) decreased energy or protein intake; (2) concurrent chronic illnesses, and superimposed acute illnesses and possibly increased inflammatory cytokines; (3) the catabolic stimulus of hemodialysis; (4) losses of nutrients into dialysate, particularly amino acids, peptides, protein (with peritoneal dialysis), glucose (when hemodialysis is performed with glucose-free dialysate) and water-soluble vitamins; and (5) diagnostic or therapeutic (e.g., prednisone therapy) procedures that reduce nutrient intake or engender net protein breakdown. Other theoretically possible causes for protein-energy malnutrition include (6) chronic blood loss; (7) endocrine disorders (especially resistance to insulin and insulin-like growth factor-I, hyperglucagonemia, hyperparathyroidism and deficiency of 1,25-dihydroxycholecalciferol); (8) products of metabolism that accumulate in renal failure and may induce wasting, such as organic and inorganic acids; (9) loss of the metabolic actions of the kidney; and (10) the accumulation of toxic compounds that are taken up from the environment (e.g., aluminum).

Feeding patterns of infants and children with protein-energy malnutrition (Pem) in the equatoria region of sudan

The infant feeding practices and home environment of346 children aged 0–5 years suffering from proteinenergy malnutrition (PEM) in Sudan was studied. Breast-feeding was the preferred type of infant feeding. The addition of complementary foods (external foods given in addition to breast milk during the breast-feeding period) was delayed in 46% of the children. Weaning or complete withdrawal from breastmilk before one year of age occurred in 35% of the children. The main reasons for weaning were the illness of the baby, illness of the mother and another pregnancy. Complementary and supplementary foods (external foods given at time of weaning or complete withdrawal from bresst milk) such as milk, porridge, soup and family food were improperly prepared. Eighteight percent of households did not have a clean water supply and latrine. It was postulated that improper feeding practices and poor environment was the cause of PEM in these children. Health education of the mother, health professionals and the community were suggested to combat the problem.

Infant protein energy malnutrition in Nigeria.

EIGHTY VILLAGE mothers whose children were suffering from covert or overt malnutrition were interviewed as to the names given to protein energy malnutrition (PEM), its causes, prevention, infant feeding practices and cultural food practices. PEM was recognized as digestive disorder and enlarged spleen by 25% and 31% of the mothers respectively. About 25% and 10% of the participants attributed the cause of PEM to intestinal worms, child's frequent sickness respectively. Means of preventing the disease included the use of charms through scarifications, herbs, and prayers. The majority of the mothers had no idea as to the causes and prevention of PEM. Animal protein sources top the list of foodstuffs proscribed to the infants. The reasons for taking health care and growth monitoring to the rural areas by Community health workers are highlighted.

Feeding patterns of children with protein-energy malnutrition in Nigeria.

The feeding patterns of 115 consecutive cases of children suffering from protein-energy malnutrition (PEM) seen at Ile-Ife University Teaching Hospital, were investigated. The majority of the children were from Ile-Ife township and nearly all their mothers were working outside their respective homes. The survey shows an earlier mean age (27 months) of onset of kwashiorkor compared with Naismith's (1973) study. About two-thirds of the mothers had stopped breastfeeding their children by the age of 17 months. Artificial milk was introduced briefly, in token quantity, and was replaced by “corn-pap” and other starchy foods such as “yam” and “hard-pap”. Over 80% of mothers would not feed their children on meat and fish because they believed these foods would cause worms which, in turn, would cause abdominal pain and loss of weight. Cow's milk, groundnut and cowpeas were said to cause diarrhoea by about two-thirds of the mothers.Our study shows that cessation of breastfeeding, inadequate feeding on artificial milk, and cultural beliefs about appropriate weaning diets for the infants were the major causes of PEM in this part of the world.

Partnership with fathers in combating malnutrition: their views as to causes and treatment of protein energy malnutrition.

Fathers of children suffering from overt protein energy malnutrition (PEM) attending our Nutrition Rehabilitation Clinic in Ile-Ife, Nigeria, were visited at their homes to enquire, by means of interview, about their perceptions of the local names given to PEM, its causes and treatment. From the 56 homes visited, 23 fathers were met and participated in the study. Approximately 44% of the fathers recognized PEM as a cause of childhood disease. About 35% of the respondents attributed the cause of PEM to childhood infection and 26% attributed it to congenital disease transferred from pregnant mothers. One-sixth of the fathers were able to link PEM to lack of good feeding. Hospital-based treatment was advocated by 70% of the fathers, whilst 13% opted for traditional medicine and 17% opted for modern medicine. About 35% of the fathers were of the view that child welfare should be mainly the responsibility of the mother. Ignorance, prolonged absence of fathers from the home and poor sanitation were found to be some of the important aetiological factors of PEM. Strategies for prevention of PEM through active involvement by the fathers, and the vital role of home visits are discussed.

Causes of Protein Energy Malnutrition as Viewed by the Clients' Mother

This study was undertaken to determine the causes of protein energy malnutrition as perceived by the mothers of affected children. A questionnaire was administered to the mothers of 28 children suffering from kwashiorkor and marasmus asking them the names given to the disease causes of the disease and traditional methods of treatment. The study took place in Nigeria in 1977. Various names were given to the disease by the mothers in their native dialects and many ascribed supernatural causes. None of the mothers mentioned inadequacy of diet as a cause of the diseases. Knowing the peoples beliefs about a disease is an important factor in devising successful nutrition education.