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Nutritional Pathology Online

As a doctor today I prescribe nutritious food for every hungry child. 

Dr Sampurna Roy MD                                             

"Pathology of Marasmus and Kwashiorkor"


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You cannot tell a hungry child that you gave him food yesterday. Zimbabwean Proverb.


Obesity is a common problem in both developed and developing urban cities. Numerous blog posts and articles have been written about how to lose weight, health benefits of yoga and regular exercise to stay fit and trim.

As a doctor of a developing urban city, which has faced some of the worst famines in the history of India my today's post is on pangs of hunger due to poverty and serious diseases caused by malnutrition.

Malnutrition is indeed a major health problem in the developing countries particularly Asia and Africa.

The United Nations Food and Agriculture Organization estimates that nearly 870 million people of the 7.1 billion people in the world, or one in eight, are suffering from chronic undernourishment. There are 16 million people undernourished in developed countries. ( 2014 World Hunger and Poverty Facts and Statistics).

Children are the most common victims of hunger.

More than one billion people in the world live on less than one dollar a day. These people cannot buy basic food to protect their children from malnutrition.

Protein-calorie malnutrition is a direct result of inadequate dietary protein together with a deficient intake of the carbohydrates and lipids necessary to provide an adequate energy source.

Marasmus and kwashiorkor are clinically distinct manifestations of severe malnutrition.   

These conditions are typically seen at times of famine when all the people in an area have hardly anything to eat. When it lasts for a long time people die of starvation.


1)Bengal famine images    2)Bengal famine of 1943 - A photographic history  

3) "Bengal Famine of 1943 - A Man-Made Holocaust

A secondary form of this condition arises when disease prevents absorption of nutrients from the intestine or provokes an increased nutritional demand.

It should be recalled that a lack of carbohydrates and lipids results in the oxidation of endogenous protein,a complication that leads to wasting.

These states are found not only in children and adults in endemic areas of restricted food supply, but also in as many hospitalized adult patients, because of the increased nutritional needs associated with the underlying disease.

Manifestations of protein-energy deficiency vary depending on the individual and his or her state of development.

Infants and children are particularly susceptible because of their requirements or growth.

There are two ends of the spectrum of protein-calorie malnutrition, reflecting the relative imbalance between the components of the diet.

A deficiency of calories from all sources leads to marasmus, whereas a diet deficient in protein alone is associated with kwashiorkor.

The classic manifestations of either of these conditions are rare when compared with the high incidence of intermediate states of undernutrition.

Both marasmus and kwashiorkor, as well as their intermediate states, are often complicated by deficiencies in vitamins and minerals.


Marasmus is a condition which is common throughout the developing world, specially when breast feeding is stopped and the child must subsist on inadequate diet with low calories.

The disastrous consequence of inadequate food is growth failure of the child.

Features of Marasmus:

- Decreased body weight and decrease in subcutaneous fat

- Protuberant abdomen

- Shrunken body and wrinkled face like an old person

- Severe muscle wasting

- There increase in lipofuscin pigment in various internal organs of the body. Example: Lung and heart

-  The pulse, blood pressure, and temperature are low

-  Diarrhea is common

- There is absence of edema.

- The child suffers from various infectious disease due to impaired immune system. (malaria, pneumonia , and measles.



Another common diseases of infancy and childhood in the developing world is kwashiorkor, a syndrome that results from a deficiency of protein in a diet relatively high in carbohydrates. 

As in the case of marasmus, the disorder commonly occurs after the baby is weaned. Mother's milk is replaced by a protein-poor diet and it usually consists of cheap carbohydrate food.

Features of Kwashiorkor:

Although there is a generalized growth failure and muscle wasting, as in marasmus, the subcutaneous fat is normal, due to adequate caloric intake.

Extreme apathy is a striking feature, in contrast to children with marasmus, who are usually alert.

Also in contrast to marasmus, severe edema, hepatomegaly, ascites, depigmentation of the skin, and dermatoses are present.

The abdomen is distended due to flaccid abdominal muscles

The skin lesions are located on the face, extremities and perineum. It appears dry and hyperkeratotic and has been compared to "flaky skin".

The hair has a reddish- brown, sandy colour and there is linear depigmentation of the hair. This is described as 'flag sign'. These features indicate long periods of protein deficiency.

There generalized atrophy of the internal organs.

Villous atrophy of the intestine is a characteristic feature which affects nutrient absorption.

Diarrhea is a common problem in Kwashiorkor and severe diarrhea is complicated by septicaemia.

Anemia is a usual feature, although it is usually not life-threatening.

The nonspecific effects on growth, pulse, temperature, and the immune system are similar to those in marasmus.

It has has been reported that in kwashiorkor along with impairment of physical development there is  impaired intellectual growth of the affected child.

Microscopic features:

The liver in kwashiorkor shows prominent fatty change.

There accumulation of lipid within the cytoplasm of the hepatocytes which displaces the nucleus to the periphery of the cell.

The adequacy of carbohydrate provides the lipid to the hepatocytes, but the inadequate protein stores do not permit the synthesis of enough apoprotein carrier to transport the lipid from the liver cell.

These changes  are reversible when adequate protein is given to the patient.

The fatty liver reverse to normal after early childhood, even though the diet may remain deficient.

The hepatic changes are not progressive and are not associated with the development of chronic liver disease.

Intellectual disability is usually irreversible.


During the famine of 1968 in Biafra, the Ibos were cut off from fish and legumes, their major sources of protein, and for months subsisted on little more than their main staple: cassava, an almost protein-free root.

A huge epidemic of kwashiorkor ravaged their children and made their rehabilitation with milk particularly hazardous. When the supplies of cassava were exhausted, the surviving children became marasmic.

Starvation in the modern world. N Engl J Med. 1993 Apr 8;328(14):1058-61.

The Right to Adequate Food is a fundamental human right firmly established in international law (Article 25).

According to World bank report  nearly half of India's children- approximately 60 million - are underweight, 45% have stunted growth, 20% are wasted (too thin for their height, indicating acute malnutrition), 75% are anaemic, and 57% are deficient in Vitamin A.

The key long term goal should be prevention and active approach. 

According to Dr. Olaf Müller a variety of actions are needed, including agricultural and micronutrient interventions, improvement of the quality of health care  ; provision of safe drinking water and sanitation ; education about and support for better diets ; attention to vulnerable groups such as pregnant women and young children;  education about locally available protein- and micronutrient-rich plants.

A new born child is an asset to the society. Younger population of our country from every section of the society should be healthy and productive. India should make it a top priority to closely monitor the nutritional status of every pregnant mother and young children.



Visit: Pathology of Vitamin A deficiency: Importance of Vitamin A in our daily diet

Visit: As a doctor today I prescribe Thiamine  (Vitamin B1) rich foods :Prevent Beriberi,Wernicke’s Encephalopathy, and Korsakoff’s Psychosis.

Visit:  As a doctor today I prescribe  Riboflavin  (Vitamin B2) rich foods to prevent mucocutaneous and ocular lesions

Visit: As a doctor today I prescribe Niacin (Vitamin B3) rich foods to eradicate Pellagra - Prevent the 4 Ds - Dermatitis ; Diarrhea ; Dementia and Death

Visit: Eat Citrus Fruits everyday and keep Scurvy away - Pathology of Vitamin C Deficiency

Visit: As a doctor today I prescribe Vitamin K to prevent hemorrhage -The most important health problem of Vitamin K deficiency is Hemorrhagic Disease of the Newborn


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Dr  Sampurna Roy  MD

Consultant Histopathologist (Kolkata - India)







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