Severe Protein-calorie Malnutrition Research Articles

Determinants of nutritional status in hospital patients in Italy.

The prevalence of protein-calorie malnutrition (PCM) and micronutrient deficiency (MND) at the time of admission and discharge from hospital was evaluated in 91 patients consecutively admitted to the Surgery Clinic of the University Hospital of Rome. Anthropometric parameters and circulating levels of vitamins (A, E, C, B1, and B2) and visceral proteins [retinol-binding protein (RBP, prealbumin (PA), and transferrin] were measured. Twenty-one patients (23%) had moderate to severe PCM, and 70 patients (77%) had normal nutritional status (NNS) at admission. Two patients with PCM died in the hospital. At discharge, the prevalence of PCM was unchanged in the remaining 19 patients. Single or multiple MND was observed initially in 71% of patients with PCM and in 36% with apparently normal nutritional status. Despite vitamin supplementation, MND was present at the time of discharge in 73% of patients with PCM and 44% with NNS. Nutritional status at the time of admission was assessed in hospitals in six different Italian cities. The criterion for admission to the study was the diagnosis of chronic (greater than 1 yr duration) illness (excluding cancer and multiple organ disorders). Two hundred eighty-four patients (145 males, 139 females), ages 25-88 yr, were selected. The findings indicated a high prevalence of MND (64%). Also, in disorders that usually do not have significant alterations of digestion or absorption, such as uncomplicated cardiorespiratory disease, the prevalence of MND was high (9-38%). The prevalence of MND was not related to body mass index (BMI). PCM was more common among patients with chronic gastrointestinal disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Reply to Friedman

To the Editor:—Dr. Friedman is correct in stating that severe protein calorie malnutrition is consistantly mirrored in an abnormal arm muscle area. Unfortunately, when malnutrition is so advanced, nutritional intervention is unlikely to succeed, as Dr. Friedman himself and his colleagues have demonstrated.1 In our article we state (page 224) that “anthropometric measurements are reliable indices of moderate malnutrition but are not sensitive enough to indentify early states of malnutrition when nutritional support may be quite effective”.2 The problem of diagnosing early malnutrition in the elderly is complicated by the wide range of variation in anthropometric indices in healthy elderly, reported by many studies quoted in our review (references 71–76). Thus, we cannot see any contradiction between Dr. Friedman's position and ours. We believe, however, that nutritional support may be more effective especially in the elderly if instituted early,3 and we do not believe anthropometric indices a sensitive enough detector of malnutrition to allow prompt initiation of nutritional therapy.

Selenium deficiency in the acquired immunodeficiency syndrome.

Severe protein-calorie malnutrition is common in patients with AIDS (acquired immunodeficiency syndrome). These nutritional deficits are likely to further impair immune responses and other organ functions vital for recovery from serious infectious diseases. Since selenium deficiency is known to be associated with oral candidiasis and abnormal phagocytic function in animals and depressed helper T-cell numbers in man, we evaluated both selenium status and other nutritional parameters in 12 patients with AIDS compared to 27 healthy controls. Selenium was measured by a spectrofluorometric method. The mean (+/- SD) plasma selenium level in AIDS was 0.043 +/- 0.01 microgram/ml vs 0.095 +/- 0.016 microgram/ml in controls (p less than 0.001). Whole blood selenium and red blood cell selenium levels were also significantly reduced in AIDS (p less than 0.005). The mean weight loss in AIDS patients was 35.5 +/- 21.2 pounds. Serum albumin was significantly (p less than 0.01) lower in AIDS patients compared to controls. A good correlation between serum albumin and plasma selenium was noted (r = 0.77; p less than 0.001). We conclude that selenium deficiency is a common component of the malnutrition seen in AIDS patients. Therefore, aggressive nutritional support, including attention to selenium status, should be considered an integral part of the therapy of AIDS patients.

Effect of protein calorie malnutrition on peripheral nerves. A clinical, electrophysiological and histopathological study.

Forty-three children (aged 7 to 62 months) with protein calorie malnutrition (PCM) were studied; 13 had mild to moderate PCM and 30 severe PCM. A reduction of motor nerve conduction velocity and abnormalities of sensory conduction were present in both groups. The abnormality of motor nerve conduction was directly related to the severity of PCM and the presence of hypotonia and/or hyporeflexia. Sural nerve biopsies from both groups were studied for myelinated fibre density, fibre size spectrum, relationship of internodal length with diameter and qualitative light microscopic changes. The biopsies from children with mild to moderate PCM were characterized by a normal developmental change in myelinated fibres with an increasing proportion of medium and large size fibres, a transition from a unimodal to a bimodal distribution and an appropriate relationship of internodal length to fibre diameter. Evidence of mild segmental demyelination was observed in only one patient of this group. In contrast, in the biopsies from children with severe PCM, the normal developmental pattern for myelinated fibre size distribution was impaired with a persistence of small myelinated fibres, and there was a failure of internodal segments on large fibres to elongate with increase in age and significant segmental demyelination in about 50 per cent of cases. Retarded myelination and segmental demyelination probably form the morphological basis for impaired peripheral nerve function in PCM. Short internodes on large diameter fibres may also contribute to this effect.

1618 CELLULAR MALNUTRITION IN UREMIA

Some of the cellular abnormalities of severe protein-calorie malnutrition in children (PCM), e.g., reduced energy-related enzyme activities, energy and protein synthesis levels and intracellular amino acid deficits, are also thought to occur in chronic uremics. Improvement of these abnormal cell bioactivities, characterizing cellular malnutrition, should stabilize and possibly retard progressive cellular deterioration in uremics. We have used the circulating granulocyte as a cell model to study energy-related enzyme activities (pyruvate kinase (PK), phospho-fructokinase (PFK), adenylate kinase (AK), energy charge (Ech=ATP+0.5ADP/(ATP + ADP + AMP)), protein synthesis (3 H-leucine incorp.) and amino acid pools in 52 adult uremics (9 not dialyzed (ND), 40 hemodialyzed (HD) and 13 peritoneally dialyzed (CAPD)) and 61 normal control (C) subjects. Gross clinical estimators of chronic malnutrition (Wt/Ht ratio, skinfolds, arm muscle area, plasma albumin and total lymphocyte count) were within normal limits for the dialyzed uremics. In the ND uremics, all clinical and cell measures were abnormal. In the HD uremics, cell PK, AK, ATP, Ech and PS were significantly (p < .05) better than ND but less than C. A significant reduction in branched-chain amino acids (BCAA=valine, leucine, isoleucine) and methionine (MET) were noted in both ND and HD patients. In the CAPD patients, after 18 ±9 (SD) months of dialysis PK, PS, BCAAs and MET levels were normalized. Ech was 90% of normal and >HD, but ATP and AK were not improved. We conclude that cellular malnutrition occurs in apparently stabilized adult uremics without clinical signs of malnutrition. CAPD seems to improve many cell bioactivities, and therefore, cellular malnutrition in uremics.

Management of severely malnourished children by village workers in integrated child development services in India.

4292 children with severe protein-calorie malnutrition were managed by village level workers at village centers in India. Treatment included provision of 700 to 900 calories and 15-20 g protein as supplement to the breast milk and weaning food being received at home and simple drug therapy for associated diseases. 85% of the children improved; 6.3% had no change; 3.6% deteriorated; 3.0% died and 2.1% were lost to follow up. Diarrhea short fever and apparent respiratory illness were associated illnesses contributing to the deaths in 42.6%; 38.0%; 34.9% of fatal cases. Prevalence of severe malnutrition and fatality were higher in younger children 3 years of age compared to older ones between 3 to 6 years of age. Referral from village center to larger health facilities was not utilized by the majority of the relatives of the sick children. It is concluded that village level management of severely malnourished children by a local worker is an acceptable and effective approach at less cost. It is recommended for countries with endemic protein-calorie malnutrition. (authors modified)

Nutritional evaluation of gynecologic cancer patients during initial diagnosis of their disease

Ninety-seven gynecologic cancer patients received a thorough nutritional assessment during the initial evaluation of their disease. Patients with Stages III and IV ovarian cancer were shown to have severe protein-calorie malnutrition (p < 0.01) unrelated to any gastrointestinal obstruction or laparotomies. Patients with other types of gynecologic cancers at all stages demonstrated nearly normal nutritional assessment parameters, with the exception of recent weight loss. Nutritional assessment and active nutritional intervention therapy are suggested especially for patients with advanced ovarian cancer.

The effects of severe protein-calorie malnutrition on antibacterial defense mechanisms in the rat lung.

Protein-calorie malnutrition (PCM) impairs systemic immunity in humans and animals, but its effects on regional defense mechanisms in the lung are not clear. Therefore, we investigated lung phagocytic antibacterial defenses in vivo and in vitro in an animal model of PCM. Matched groups of weanling rats consumed Isocaloric diets containing either 0.8% (PCM) or 24% protein (Control, C). A third group of animals was fed the C diet in restricted amounts to match the daily caloric intake of the PCM animals (pair-fed control, PF). After 4 wk on the diet, PCM animals were hypoproteinemic, hypoalbuminemic, and anemic and had depressed systemic cell-mediated immunity. In vivo, the lung clearance rate of Listeria monocytogenes was markedly delayed in PCM animals (% bacterial recovery at 9 days, mean +/- SE:PCM = 120 +/- 25.1; PF = 5.2 +/- 3.0; C = 0.6 +/- 0.6; p less than 0.001 for PCM versus C). Only 36% of the PCM animals survived for 9 days after Listeria exposure, whereas more than 94% of the C and PF animals survived (p less than 0.01). Recruitment of macrophages to the lungs of PCM animals after Listeria aerosolization was markedly impaired compared with that in the PF and C animals (p less than 0.001). By contrast, lung clearance rates of 2 pyogenic organisms, Staphylococcus aureus 502a and Pseudomonas aeruginosa 177, were similar in all groups. In vitro, alveolar macrophage chemotaxis toward zymosan-activated serum, and microbicidal activity against Staphylococcus epidermidis were also similar in all groups of animals. Our findings indicate that in the rat, PCM impairs the pulmonary clearance of L. monocytogenes, and that this defect is associated with impaired macrophage recruitment to the lung after Listeria inhalation.(ABSTRACT TRUNCATED AT 250 WORDS)

Defective thyroidal iodine concentration in protein-calorie malnutrition.

Although protein-calorie malnutrition (PCM) is known to result in various abnormalities of thyroid function, the exact relationship between the two is not clearly understood. Therefore, the thyroid function of 10 men, 13-55 yr of age, with severe PCM was studied in a clinical research ward before and 3-4 months after protein-calorie repletion. Before repletion, all subjects had low serum T4 (mean +/- SEM, 5.1 +/- 0.5 micrograms/dl) and T3 (74 +/- 6 ng/dl) concentrations. Eight subjects were chemically euthyroid, and their free T4 (1.5 +/- 0.1 ng/dl) and serum TSH (2.9 +/- 1.4 microU/ml) values were normal. Two subjects were chemically hypothyroid, with low free T4 values and high serum TSH values. After repletion, the 8 euthyroid subjects had significant increases in serum T4 (P less than 0.01) and T3 (P less than 0.005), but TSH did not change. Serum T4 and T3 were still lower (P less than 0.05-0.001) and TSH higher (P less than 0.01) than in 28 normal men of comparable age coming from the same area. After repletion, values remained unchanged in the 2 hypothyroid subjects, except for moderate increases in serum T3 and slight decreases in TSH. In all PCM subjects, values of thyroidal exchangeable iodine (23.1 +/- 7 vs. 42.9 +/- 8 mg; P less than 0.02), estimated thyroidal I per g wet wt (1.05 +/- 0.3 vs. 1.99 +/- 0.36 mg; P less than 0.02), and thyroidal iodide clearance (13.8 +/- 1.6 vs. 19.4 +/- 1.3 ml/min; P less than 0.002) were lower before repletion than after; the protein-bound 131I level (72 h; 0.27% vs. 0.08 dose/liter; P less than 0.05) was higher, but thyroid hormone secretion rates (200 +/- 49 vs. 153 +/- 25 micrograms/day) were not significantly different. Thyroid iodide clearance was lower even though plasma inorganic iodine (6.3 +/- vs. 12.5 +/- 3 micrograms/liter; P less than 0.05) and daily urinary iodine excretion (158 +/- 43 vs. 395 +/- 62 micrograms; P less than 0.01) were lower before than after repletion. In 2 PCM euthyroid subjects, baseline thyroid 131I uptake was lower before than after repletion, and the magnitude of the increase after TSH (10 U, im) stimulation was greater when the malnourished state improved. TSH increased concentrations of serum T4 and T3 both before and after protein repletion. After repletion, one hypothyroid patient failed to respond to TSH; the other had a small increase in 131I uptake but not in serum T4 or T3. The results indicate defective thyroid iodine concentration in human PCM, but adequate hormone secretion. This situation leads to depletion of thyroid iodine stores. This alteration, if extreme, might result in hypothyroidism. Adequate protein-calorie intake tends to reverse these abnormalities.

Protein-Calorie Malnutrition Impairs Cell-Mediated Immunity in the Rat Lung

Malnutrition is often cited as a risk factor for lung infections, but the effects of malnutrition on the regional defense mechanisms in the lung are not clear. Severe protein-calorie malnutrition (PCM) impairs systemic immunity in humans and animals. 1 Feigin RD Interaction of infection and nutrition. in: Feigin RD Cherry JD Pediatric infectious diseases. Vol 1. WB Saunders, Philadelphia1981: 17-24 Google Scholar Cell-mediated immunity is profoundly effected, as indicated by abnormal cutaneous delayed hypersensitivity, 2 Good RA West A Fernandes G Nutritional modulation of immune responses. Fed Proc. 1980; 39: 3098-3104 PubMed Google Scholar impaired T-cell proliferative responses, 3 Chandra RK Cell-mediated immunity in nutritional imbalance. Fed Proc. 1980; 39: 3088-3092 PubMed Google Scholar and low thymic hormone levels. 4 Chandra RK Serum thymic hormone activity in protein-energy malnutrition. Clin Exp Immunol. 1979; 38: 228-230 PubMed Google Scholar Immunoglobulin turnover is usually reduced, and phagocyte chemotaxis and microbicidal activity are abnormal in some in vitro systems. 5 Douglas SD Schopfer K Phagocyte function in protein-calorie malnutrition. Clin Exp Immunol. 1974; 17: 121-128 PubMed Google Scholar

Malrotation, malnutrition, and ischemic bowel disease

Ischemic bowel disease (IBD) is the common denominator in determining the mortality and morbidity in children with malrotation and volvulus. Survival in such patients depends on the degree of ischemic intestinal damage. In all patients there is another common factor, namely, host nutritional status. To evaluate host nutritional status in patients with malrotation and volvulus, we reviewed our recent 5-yr experience with 50 patients diagnosed as having malrotation, excluding those with gastroschisis, omphalocele, and diaphragmatic hernia. This review revealed two important clinical findings. First, volvulus was found to be the most frequent complication of the malrotation anomaly; and second, the nutritional status of the patient at operation was extremely poor in the majority of instances. Seventy percent of our patients were classified as having acute protein calorie malnutrition (PCM) by the criteria of McLaren and Read. Mild PCM was present in 28% while 42% had moderate to severe PCM. Three patients had volvulus with gangrene and all were severely malnourished. Thirteen of the 50 patients presented with failure to thrive (FTT). To further examine the relationship between IBD and PCM, we developed a mouse model of midgut ischemia. Normally nourished animals demonstrated an incidence of IBD of 1/60 (1.6%), 2/70 (2.9%), and 14/40 (35%) when made ischemic for intervals of 10, 15, and 20 min, respectively. The malnourished mice developed IBD at an incidence of 13/37 (36%), 32/49 (66%), and 30/40 (75%) after respective ischemic intervals of 10, 15, and 20 minutes (<i>p</i><0.01). These data would suggest that PCM enhances the development of IBD in this animal model. We speculate that children presenting with FTT should be evaluated for the presence of malrotation. Furthermore, children with malrotation have a significant incidence of PCM; and in the presence of vovulus, the associated PCM might predispose the child to irreversible ischemic bowel disease.

Colonization of the oropharynx with Gram-negative bacilli in children with severe proteincalorie malnutrition

Oral pharyngeal isolation of Gram-negative bacteria was compared in four groups of Bengali children: acutely ill, severely malnourished outpatients swabbed on hospital admission; ill but less severely malnourished outpatients from the same area as the malnourished children; orphans also less severely malnourished but not acutely ill; and well controls drawn from a priviledged socioeconomic group. The expected weight for height percentage (National Center Health Statistics/Center for Disease Control median) of the four groups was respectively 67, 91, 97, and 97%. Isolation of Gram-negative bacteria from 74 of 87 (85%) severely malnourished children was significantly greater (p < 0.01) compared to 43 of 113 (38%) outpatients, to 20 of 93 (22%) orphans, and to five of 51 (10%) controls. A total of 71 malnourished children under 5 yr of age (90%) had higher rates of Gram-negative throat colonization than did 16 older children (63%) (p < 0.01). Thus there was an increased rate of Gram-negative colonization in severely malnourished children especially among the younger age group. In the subset of ill children, Gram-negative pharyngeal colonization was significantly associated inversely with nutritional indices and age. The high rate of such carriage may be partly responsible for the increased susceptibility of Gram-negative infection demonstrated in these children.

Circulating gonadotropin profile in severe cases of protein calorie malnutrition

The circulating levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin (PRL) were studied in children of both sexes between 2 and 14 years of age who were suffering from severe protein calorie malnutrition (PCM), namely, kwashiorkor, marasmic kwashiorkor, and marasmus. LH and FSH levels in all the age groups and in all forms of PCM were found to be significantly lowered, thereby explaining the possible delay in the onset of puberty in these children. Circulating PRL levels, on the other hand, were significantly raised in all patients with PCM studied, with values in children with kwashiorkor and marasmic kwashiorkor higher than in children with marasmus, possibly accounting for the presence of edema in the former cases. The present work, therefore, proposes a possible correlation between gonadotropin levels and PCM in children.

Pneumococcal bacteraemia—a study of 75 black children

Seventy-five black children from 0 to ten years old with pneumococcal bacteraemia, who were hospitalized during a one-year period, were studied retrospectively from case records. Half the children were under one year and 68% under two years of age. Sixty-seven per cent were malnourished, 34% severely so. The overall case-fatality-rate was 26.7% being highest in children presenting in autumn (52.4%) and in those with meningitis (54.5%), severe protein-calorie malnutrition (42.8%) or associated infections (61.5%). Host defences against the pneumococcus are discussed, especially in relation to their deficiencies in malnourished and young children. Special mention is made of early-onset neonatal sepsis due to the pneumococcus and of the association between pneumococcal bacteraemia and acute post-streptococcal glomerulonephritis. This study indicates that pneumococcal bacteraemia is a serious infection in children, especially in those with malnutrition and other infections. In view of the emergence of penicillin-resistant strains, its treatment may become more difficult in the future.

Recovery of cellular immune competence during treatment of protein-calorie malnutrition

Fifty Bangladeshi children with severe protein-calorie malnutrition were randomly allocated at admission to four groups and sensitized to dinitrochlorobenzene either immediately or after 1, 2, or 3 wk of protein-calorie replacement therapy. Ability to initiate cutaneous hypersensitivity to dinitrochlorobenzene on admission was impaired when the total serum proteins was less than 5.5 g/dl, but uniformly recovered after 1 wk of feeding. Three severely malnourished children with total serum proteins less than 4.5 g/dl in whom sensitization was attempted before refeeding failed to respond despite repeated challenge, suggesting immunological tolerance to dinitrochlorobenzene. The data support the concept of a threshold serum protein level, at least as an indicator, below which cellular immunity may be temporarily, or even permanently, impaired.

Infections associated with severe protein-calorie malnutrition in hospitalized infants and children

One hundred Bangladeshi children admitted to hospital for treatment of severe protein-calorie malnutrition were systematically evaluated for the presence of infections. Ninety percent of children had some evidence of systemic infection at the time of admission and 75% had pneumonia, bacteruria, diarrhea in association with a known enteric pathogen, bacteremia, meningitis, or more than one of these major infections. Forty-nine percent of patients had pneumonia, including 14% of admissions with clinical evidence of pulmonary tuberculosis. Forty-three percent of admissions had diarrhea and 40% had evidence of enteric infections, most commonly shigellae or rotavirus. Bacteruria occurred in 30% of admissions, but bacteremia was identified in only 2% of patients initially. The prevalence of intestinal parasites increased with age, both among inpatients and comparison subjects with less severe grades of malnutrition. There did not appear to be important differences in the parasite loads or prevalences between the 2 groups. Twenty-one inpatients died; deaths were more common in younger children. The cause of death was most frequently related to infections. The identification and appropriate treatment of infections must be considered a major component of the rehabilitation of severely malnourished children.

Cell-mediated immune defects and infection. A study of malnourished hospitalized children.

Severe protein calorie malnutrition in children in developing countries has been characterized by noticeable depression of cell-mediated immunity and an increased manifestation of infectious illnesses. We studied 23 hospitalized US children whose admitting diagnoses included severe malnutrition to see if similar findings existed. Children were divided into two groups based on the percentage of E rosettes (T cells) prior to nutritional therapy. Those with E rosette values less than 50% were considered to have noticeably abnormal cell-mediated immunity. Eleven of the 23 patients who had rosette values less than 50% had 18 clinical infections, including four episodes of sepsis. One of the 23 children with normal (> 50%) E rosettes had one minor infection. It was concluded that depressed cellular immunity as measured by E rosette is associated with an increased incidence of infectious illness in the malnourished hospitalized pediatric patient in the United States. Other defects in host defenses, ie, defects in complement and phagocytic function, may also have contributed to the increased number of clinical infections noted in these patients.

Epidemiologic Studies Among Amerindian Populations of Amazônia

The prevalences of intestinal parasites among the residents of three South American Indian villages in the process of acculturation were compared with those found in earlier unpublished surveys in two newly contracted village.s Although one individual in an acculturating village harbored 11 different intestinal parasites, in general the average number of different parasitic species carried per person was somewhat higher in the newly contacted villages. Helminth egg counts, performed on direct smears of each specimen from one newly contacted village, were low. There were no sex-associated differences in prevalences. The overall prevalences, unadjusted for age, were among the highest recorded for Amerindians. No Taenia species were present. Balantidium coli was present in two acculturating villages, concomitant with the beginning of agricultural practices which include raising swine. No cases of moderate or severe protein-calorie malnutrition was observed in any of the villages during the surveys. These limited data provide a baseline for future comparisons and, perhaps, a glimpse into the past.

Breast feeding: a necessity for child health in the tropics.

Attention needs to be directed to the disappearance of human milk and to investing as much in terms of both funds and ingenuity in trying to develop programs to cope with this major nutritional retreat as is now invested in other programs designed to improve the problem of childhood malnutrition. Bottle feeding in the type of circumstances existing in rural and urban areas of resource-poor, less developed countries is very difficult to undertake adequately due to small purchasing power, defective environmental hygiene, and low levels of maternal education. Under these circumstances, infants usually receive dilute, contaminated feeds containing homoeopathic doses of nutrients and massive quantities of bacteria. When breastfeeding is replaced by the necessarily inadequate bottle feeding found in developing countries, nutrition deteriorates, infections increase, and pregnancies become more frequent, closely spaced and risky. In order for bottle feeding to be successful in terms of producing satisfactory infant growth and survival, there must be an adequate economic, hygienic, and educational infrastructure. The size of the public health problems associated with the availability or lack of availability of human milk is huge, increasing, and almost totally unappreciated. In less technically developed and resource-poor nations, Bengoa (1974) estimated that there are 9.4 million cases of severe protein-calorie malnutrition annually. It is unknown how many are suffering from kwashiorkor or from marasmus. In the developed countries of the world, there are over 11 million births annually, and the partial or complete preventive effect of breastfeeding can also be very significant in these communities.

Clinical aspects of protein deficiency with special reference to protein calorie malnutrition (PCM) in children.

We have investigated the pathophysiology and optimum treatment of PCM in Northern Thai children over the past 10 years and have developed what we consider to be an improved scoring system for the diagnosis of the three major forms of severe protein calorie malnutrition, namely: marasmus, marasmic kwashiorkor, and kwashiorkor. We feel that it gives a more definitive classification of these subgroups of PCM than any other system. It takes into account anthropometric and laboratory parameters, as well as clinical ones, and permits hospitals and metabolic units in various parts of the world to make better comparisons of their results.Various aspects of the pathophysiology of PCM have been studied, including hematopoietic, endocrine, and metabolic aspects. We have developed a plan of therapy which has reduced mortality to 6-7%. In support of our plan of treatment, we have presented the clinical and biochemical data, and have demonstrated the protein and calorie requirements for the optimum treatment of severe protein calorie malnutrition.The distribution of the three forms of protein calorie malnutrition clearly differs widely in affected countries throughout the world. In some, marasmus is more prevalent; in others, kwashiorkor. Investigators not familiar with the global distribution of the types of the disease may be regarding their particular population of children in a special way.