PROTEIN ENERGY MALNUTRITION INTRODUCTION: Nutrition is essential for human survival and Nutrients are substances that are essential for growth, human life, well being and the totality of a person. Nutrients are necessary for our physical state, sharpen the mind and brain, makes us think wisely and intelligent. Basically it makes us full of life and vigour. When the body is deficient of certain nutrients or has more than is required by the body, malnutrition comes in, making the individual weak, sick ling, mentally retarded, discolouration in certain parts of the body. Victims of malnutrition are mainly children. Nutrient can be divided into macronutrients and micronutrients. Macronutrients are Carbohydrate, Protein, Lipids and Water. These macronutrients provide the body with energy, help in cell replication and growth. Micronutrients are trace elements and vitamins that are essential for metabolic process. Nutrients play vital roles in the body, hence a healthy child is more intelligent and attractive that a child that is malnourished. Two main ends of malnutrition are under-nutrition and obesity. A diet can be termed Healthy if it provides balanced nutrients that satisfy the metabolic needs of the body without excess or shortage. Dietary requirements of a child vary according to age, sex, and development. Protein consist of carbons, hydrogen, oxygen, and nitrogen. Amino acids are the basic building blocks of protein. Amino acids can be divided into either essential amino acids or non-essential amino acids. Protein and carbohydrate contain 4 Calories per gram as opposed to lipids which contain 9 Calories per gram. The liver, and to a much lesser extent the kidneys, can convert amino acids used by cells in protein biosynthesis into glucose by a process known as gluconeogenesis.The essential amino acids, which must be obtained from food sources, leucine, isoleucine, valine, lysine, threonine,tryptophan, methionine, phenylalaline and histidine. On the other hand, non-essential amino acids can be made by the body from other amino acids. The non-essential amino acids are argine, asparagines, aspartic acid, cysteine, glutamine, glutamic acid, glycine, proline, serine, tyrosine.In nutrition, proteins are broken down in the stomach during digestion by enzymes known as proteases into smaller polypeptides to provide amino acids for the body, including the essential amino acids that the organism cannot be biosynthesized by the body itself. Thus, protein from one's diet should provide both essential and non-essential amino acids for protein synthesis.Most animal sources and certain vegetable sources have the complete complement of all the essential amino acids in adequate proportions. However, it is not necessary to consume a single food source that contains all the essential amino acids, as long as all the essential amino acids are eventually present in the diet. Fig 1 : Diagrammatic representation of the basic structure of Amino acids which are the building blocks of protein.Protein Functions in BodyProtein is a nutrient needed by the human body for growth and maintenance. Aside from water, protein is the most abundant molecule in the body. Protein is found in all cells of the body and is the major structural component of all cells in the body, especially muscle. This also includes body organs, hair and skin. Proteins also are utilized in membranes, such as glycoprotein. When broken down into amino acids, they are used as precursors to nucleic acid and vitamins. Hormones and enzymes are also formed from amino acids in which they help regulate metabolism, support the immune system and other body functions. Finally, protein is needed to form blood cells. Protein Function in Exercise Proteins is one of the key nutrients for success in terms of sports. They play a major role in the response to exercise. Amino acids, the building blocks of proteins, are used for building new tissue including muscle, as well as repairing damaged tissues. Proteins, however, only provide a small source of fuel for the exercising muscles when carbohydrates and lipid resources are low.Sources

Fig 2 Picture Representation of Protein milkshakes, made from protein powder (center) and milk (left), are a common bodybuilding supplement.There are many different sources of protein ranging from whole protein foods (such as milk, meat, fish, egg, and vegetables) to a variety of protein powders (such as casein, whey, soy). Protein powders are processed and manufactured sources of protein. Protein powders may provide an additional source of protein for exercising muscles. The type of protein is important in terms of its influence on protein metabolic response and possibly on the muscle's exercise performance. The different physical and/or chemical properties within the various types of protein may affect the rate of protein digestion. As a result, the amino acid availability and the accumulation of tissue protein is altered because of the various of protein metabolic responses. DigestionDigestion typically begins in the stomach when pepsinogen is converted to pepsin by the action of hydrochloric acid, and continued by trypsin and chymotrypsin in the intestine. The amino acids and their derivatives into which dietary protein is degraded are then absorbed by the gastrointestinal tract. The absorption rates of individual amino acids are highly dependent on the protein source; for example, the digestibilities of many amino acids in humans differ between soy and milk proteins and between individual milk proteins, beta-lactoglobulin and casein. For milk proteins, about 50% of the ingested protein is absorbed between the stomach and the jejunum and 90% is absorbed by the time the digested food reaches the ileum. Biological value (BV) is a measure of the proportion of absorbed protein from a food which becomes incorporated into the proteins of the organism's body. ASSESSMENT OF NUTRITIONAL STATUSNutritional status is the balance between the intake of nutrients by an organism and the expenditure of these in the processes of growth, reproduction, and health maintenance. Because this process is highly complex and quite individualized, nutritional status assessment can be directed at a wide variety of aspects of nutriture. These range from nutrient levels in the body, to the products of their metabolism, and to the functional processes they regulate. Nutritional status can be measured for individuals as well as for populations. Accurate measurement of individual nutritional status is required in clinical practice. Population measures are more important in research. They can be used to describe nutritional status of the group, to identify populations or population segments at risk for nutrition-related health consequences, and to evaluate interventions.The choice of nutritional status assessment method must be made mindful of the level at which one wants information, as well as of the validity and reliability of the method. All methods have error. All methods produce imperfect measures that are indirect approximations of the process. Whatever method is chosen for assessment of nutritional status, the data obtained must be compared with reference data to produce an indicator of nutritional status. The quality of the available reference data is, therefore, another factor that affects the assessment data.Ideal methods are sensitive and specific. Unfortunately, it is difficult to achieve both in the assessment of nutritional status. Sensitivity refers to the ability of a technique to correctly identify those affected by a condition (for example, under nutrition) as having that condition. Specificity refers to the ability of a technique to correctly classify normal individuals as having normal nutritional status. Body mass indexis a global measure of nutritional status that illustrates the difference between these two constructs.The assessment of nutritional status is commonly summarized by the mnemonic "ABCD," which stands for anthropometric measurement, biochemical or laboratory tests, clinical indicators, and dietary assessment. This review will focus on anthropometric and dietary techniques. These four can be categorised under DIRECT assessment of nutritional status. INDIRECT includes health statistics and ecological values.ANTHROPOMETRIC: It is objective with high specificity and sensitivity. Anthropometric approaches are, for the most part, relatively non-invasive methods that assess the size or body composition of an individual. Measuring Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI. For adults, body weight and height are used to evaluate overall nutritional status and to classify individuals as at healthy or non-healthy weights. In the United States of America and other industrialized countries, the emphasis for unhealthy weight is over-weight and obesity. The standards for these have changed over time. The most recent classification is to use body mass index (BMI, in kg/m2) (Kuczmarski and Flegal, 2000). BMI, regardless of age or population, is normal at 18.5 to 25.0 kg/m2, overweight at 25.0 to 29.9 kg/m2, and obese at over 30.0 kg/m2 (USDA & USDHHS, 2000). In general BMI greater than 30 is assumed to be due to excessive adiposity. Reading are numerical and gradable on standard growth chart, this is the approach common to children. For children, low height-for-age is considered stunting, while low weight-for-height indicates wasting. In addition to weight and height, measures of mid-arm circumference and skin-fold measured over the triceps muscle at the mid-arm are used to estimate fat and muscle mass. Anthropometric measures of nutritional status can be compromised by other health conditions. For example, edema characteristic of some forms of malnutrition and other disease states can conceal wasting by increasing body weight. Head circumference can be used in children 36 months and younger to monitor brain growth in the presence of malnutrition. Brain growth is better spared than either height or weight during malnutrition. To interpret anthropometric data, they must be compared with reference data. The choice of the appropriate reference has been discussed by Johnston and Ouyang. Because well-nourished children in all populations follow similar patterns of growth, reference data need not come from the same population as the children of interest. It is of greater importance that reference data be based on well-defined, large samples, collected in populations that are healthy and adequately nourished. Reference growth charts (Kuczmarski et al., 2002) have been compiled from cross-sectional data collected from population surveys of U.S. children. These have been adopted as international standards by the World Health Organization. Anthropometric is non expensive and requires minim al training. Its limitations are: Inter observers error in measurement Limited Nutritional diagnosis Problems with reference standards Arbitrary statistical cut off levels for abnormality

BIOCHEMICAL OR LABORATORY ASSESSMENT: Laboratory assessment can be categorised as biochemical, haematological and microbiology.Biochemical: serum protein, creatinine/hydroxyprolineHaematological: CBC, iron, vitamin levelsMicrobiology: Parasites/infection

CLINICAL ASSESSMENT:It is useful in severe forms of protein energy malnutrition, based on thorough physical examination for features of Protein Energy Malnutrition and vitamin deficiency. It focuses on skin, eye, hair, mouth and bones. Chronic illness and goiter are excluded.Advantages: Fast and easy to perform Inexpensive Non-invasiveLimitations: Did not detect early cases Trained staff needed

DIETARY ASSESSMENT:Several techniques exist for collecting dietary data with which to estimate nutritional status. Because these techniques vary in cost for data collection, burden on the respondent, and which aspects of diet they are designed to measure, it is important to clearly articulate the goals of dietary assessment of nutritional status before choosing an assessment strategy.The primary consideration in choosing a dietary assessment method is the specific type of data needed. Is the research intended to document intake of "foods" or of "nutrients"? If the answer is foods, the method must take account of the population's foodways. These include variability in food intake patterns (for example, day-today, seasonal, ritual cycles); differences in food consumption by sex, age, and ethnicity; and what items the population considers to be legitimate "food." If the objective is to measure nutrient intake, the method must take into account several additional factors: food preparation techniques, including the addition of condiments and the effects of the technique on nutrient composition of the food; sources of error in the determination of amounts of foods consumed; differentiation distribution of nutrients among foods; and the contribution of "non-food" consumption to total nutrient consumption.Another important consideration is the time period the data are intended to represent. If the period is a relatively discrete one, it may be possible to document diet quite precisely. However, if the interest is in measuring "usual" diet, the methods must allow this abstract concept to be estimated statistically.Population measures of dietary status can be derived either from data describing the entire population or population sub-group, or from data describing samples of individuals. Population-wide data include food availability figures, which allow the assessment of food balancethe amount of food produced or imported by a population less that exported or used as nonhuman food. Dietary assessment include: breast and complementary feeding details, 24hr dietary recall, home visits, calculation of protein and dietary calorie content of children foods, feeding technique and food habits.OVERVIEWProtein energy malnutrition is prominent in developing countries, and many children are affected. A large percentage of the worlds population is found in developing countries. Children commonly affected are victims of dirty water, bad food, poor sanitation, dirty and unkempt environment. Malnutrition is implicated in >50% of deaths of