Studies On Kwashiorkor And Marasmus In Ibadan

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M.R. Osei & M.A. Hussain DepartmentPreventive and Social Medicine. and Department of Nutrition.
University of Ibadan, Ibadan. Nigeria
The natural dietary evolution of 77 kwashiorkor, 73 marasmus and 100agE:a' nd sex matched controls were studied at three points in timE:'by interviewing the mothers retrospectively. The informations included (a) usual diet after weaning (b) dlE:'tone week before the illness and (c) diet one day before the interview immediately after recruitment into the study. Quantity of food intake was estimated with the help of standardised vessels and. supplimented with actual observations.
No significant increase in eneru and protein intakes Were found in e INTRODUCTION
Most of th.e dietary evidence on which the classical hypothesis of PEMwas based in early sixties were qualitative. And because of difficulties in conducting weighed foed intake studiE:'s in children remarkably little information has been pubished in the literature since then (Church. 1979, Waterlow and Rutishauser. 1979). In Nigeria quantitative data on the dietary intake in kwashiorkor and marasmus is very scarce ana to the best of our knowledge studies cn the natural histc ry of dietary evolution - - _..~-.Correspondence to : M.A. Hussain


JuNE, 1980

in severe PEM have never been reported. These studies are,however, essential for formulating any effective strategy fa their control. In the present paper we describe the dietary intake in kwashiorkor and marasmus children and the natural history of the dietary evolution.

The Children and their mothers
Mothers of '77 kwashiorkor and 73 marasmus chidren VIho attl'nded the general cut patient department ofthe University College Hospital, Ibadan. between November, 1978 and February, 1979 were interviewed without selection. Mothers of 100age and sex matched apparently healthy controls (wei~hing 80% or oVer of standard weit,ht for age) selected from the same family compound were studied as controls.

Assessment of dietary intake
In order to elucidate the natural history of dietary evolution of kwashiorkor and marasmus the diet of the children were studied at three points in time -(3) the usual diet after weaning (b) diet. one week before the sickness (according to the judgement of the mother) and (c) diet one day before the date of interiew.
Dietary information were collected from the mothers by 24 hour recall inteniew in their homes in two parts:
(I) The frl'quency of intake of various foods consumed by the children were first listed. Thl' quantity of each food item was then estimated with the help of standardised plastic bowl~, cups and spoons of different SiZES2nd known WE'ightsby asking thl', mother to equate her feeding vessels at home with those of the interviewer and supplimenting with actual observation of feedirg ..essels. For such food as boiled yam and fried plantain the interviewers also visually cbserved the slices and estimated the quantity. Wherever applicabll' the mothers Wl're asked to give the equivalent price in the market for the quantitil's offood they gave to their children. This helped in validitating the quantities of food given by the mothers and also to obtain corrl'ct weight for analysisl Paps of different consistencies as described by the mothers were prepared and dried in the oven to determine the moisture content. Cooker gari (cassavaflour), fried plantain, boiled yam, cooked ricl', beans, amala (maize flc.ur) and moinmoin (steamed bean cake) were also bought from t.he same market where mothers buy these foods and dried in the oven for estimating their moisture content. Foods containing more than one ingreclient were broken down into its various components according to recipie provided by mother or vendor. Food tables for use in Africa (FAO, 1968) and composition of local food a'v2ilable in the Department of Human Nutrition, University c.f IbadCln,were

~ is

TABLE-I Qualitative groupings of the dietof kwashiorkor. marasmus and control children after weaning. one week before the illness and one day before the Interview.

.U sualdiet after weaning
Kwashiorkor Marasmus Control

..Dieta week before Illness
Kwashiorkor Marasmus

-Diet a day before interview Kwashiorkor Marasmus Control

Freq % Freq % Freq %
Body building 20 24.0 19 25.7 65 50.0

Freq % Freq %
12 15.0 16 19.8


Freq % Freq % Freq % C!

16 20.0 18 21.9 55 44.0

.I.:.:'. rn


Energy giving 56 67.6 45 60.8 45 34.6

65 81.3 58 71.6

60 75.0 54 65.9 40 32.0

Protective food Total

7 8.4 83 leo

10 13.5 20 15.4 74 100 130 100

3 3.7 7 8.6 80 100 81 100

4 5.0

10 122 302 4.0


8 100 82 100 125 100 0

· Marasmus vs Control x2 - 14.22P <'0.01, Kwashiorkorvs Control x2=21.98 P <0.01.
.. Kwashiorkor vs Marasmus x2 = 1.25 p> 0.05
Marasmus vs washiorkor x2 = 2.56 P> 0.05
... Marasmus vs Control x2 ::z:: 22.89 P <0.01 Kwashiorkor vs Control x2 = 37.22 P <0.01
Marasmus vs Kwashiorkor x2 = 2.98 P> 0.05

cen: t>f)

TABLE-II Energy and protein intake of Control, Kwashiorkor and Marasmic children (M :I: SD)

Energy (Kcal)



(n= 100)

I - - -One day

-- {

lOne day

IwAealtnei,ng I'Ifn7oesresek ibntetheferoV,.iew Minmtagkee wAela-wn-ing I'If7noesreseibeinfottehcrevew IAinvtea.kaeg,

-629 -


-645 -14.1 - -15.0 -14.6







Kwashiorkor (n = 77)

-469 :I: 102

-455 :I: III

-483 :I: 106

-469 :I: 106

-9.0 :1:2.5

-9.1 :1:2.5

-8.3 :l: 2.6

-8.5 :1:2.5

Marasmus (n=73)

-392 :I:: 86

-391 :I: 85

-374 :I: 108

-374 :I: 108

-6.8 :1:1.4

-6.7 :1:1.4

6.4' :I: I.7

.6.6 :I: I.6

-Not significantly different between figures in each horizontal raw


III-Energy and Protein intake of Control. Kwashiorkor and Marasmus expressed in terms of per kilogram expected bodyweight cempared to recommended allowance (mean :I: SD)

Control (n= 100) Kwashiorkor (n=77) Marasmus t n= 73)


Energy (Kcal) /kg/day actual intake adequacy



Prctaein (gm)kg/day

Recom- actual intake %






100 36.1:1:8.1


2 0.64:1:0.19


103 33.8:1:8.2


2.2 0.58.:1:0.14 26

Control 'IS Kwashiorkor = P <0.01 ; Contrel vs Marasmus = P <0.01; Marasmus vs
Kwashiorkor = P> 0.05



I Vol. VI, No. 1


then used for calculating the nutritic.nal content of the diet. These methods of collecting oletary information ha\ e been extensively used in the Department c.f Nutrition over the years and have been found to give valid results.


I) Quaiitative groupings of food forming the diet of kwashiorkor. marasmus and control children after weaning, one week before illness and a day before the interview.
The diets of the children Were qualitativel), divided into three food groups-body building. energy giving and protect.ive food. The results presented in table-I tevealed that the diet of the control group was qualitatively (P <0.01) than those of both kwashiorkor and marasmus chidren at.all three points oftime under study.
However. the diets of mar2smus and kwashiorkor groups were not different (P> 0.05).
II) Quantitative intake of energy and protein by malnourished and control children.

The mean energy and protein intakes of marasmus, kwashiorkor and control groups after weaning. one week beforE'the illness and a day before the interview are presented in table-II. The intakes per kg expected and actual body weight compared to their recommended allowances are presented in table 3 and 4. This was done to facilitate comparision between the groups. Table 2 shows that within each group, the mean energy and protein intake did not differ significantly over the specific periods under study.
However, among the groups the marasmic children were taking the least and the control group largest amount of el'\ergy and protein respectiVE'ly. That is to say that the dietary intake did not increase significantly in each of the three groups over the period under study.
On the basis of expected body weight (table-III) energy and protein intake per kg body weight were found to be extremely low compared to teir recommended allowances in all the three groups. The control grcup was, hc,wever, consuming a significantly higher quantity of energy (P <0.01) and protein (P <0.001) than of both kwashiorkor and marasmus. No significant tlifferences (P> 0.05) were fc,und between marasmus and kwashiorkor chidren. Slightly higher but stilllc,w intakes of energy and protein were found when comparisons Were made on the basis of actual body weight (table-IV). The kwashiorkor group was found to be taking significantly lower amount of energy and protein than those of both cntrol (P <0.001) and marasmus group (P <0.001). The control group was also taking significantly (P <0.001) higher amount of protein than marasmus group but their energy intake was not significantly cjifferent (P> 0.05).


JUNE. 191


Energy and Protein Intake of Control, & Kwashiorkor and Marasmus children expressed in terms of per kg actual body weight compared to recommended allowance. (M:!:SD)



-Energy (Kcal) {kg/day Actual intake %adequacy


"Protein (gm)k&Jda Actual intake



75.0:i: 13.6





(n-IOO) Kwashiorkor 100

60.1:1: 13.6



I. I :f:0.32





74.0:i: 17'9


2.2 1.3:i:0.31


- Control vs & kwashlor:kor = P <0.001. Marasmus 'Is KwashiorkQr= P <0.001
Control vs Marasmus = P> 0.05
.. Control 'IS Marasmus= P <0.001. Control vs Kwashiorkor = P <0.001, Marasmul 'IS Kwashiorkor = P> 0.05

In this study we have examined the dietary evidence during the natural evolution of kwashiorkor and marasmus children in Nigeria by providing retrospective data on both qualitative and quantitative Intake of food at three arbitrarily selected points in their life. The data strongly suggests that the intakes of energy and protein did not Increase significantly with the time span under study. This actually meant that intakes of energy and pretein tended to fall compared to requirement as the children grew older, a fact that agreed with the findings of a longitudinal study by Rutishauser (1974) in Uganda.
The extremely low intake of enerty and protein even in the control group indicates a serious subsist~nce level whic!' can be tipped against them by any other precipitating factors like infection and sudden worsening of sociocultural meilu of the family. In other words it means that at the present intake level the chances of a control child to becoming malnourished remains extremely high. The lowest intake of energy and protein in the marasmus group in terms of their expected body weight strongly favour the view that the children were severely underfed.
The substantial improvement that occurred in energy and protein intake of marasmus and kwashiorkor children when comparisons were made in terlT\s of actual body

Vol. VI. No. 1


weight, !s In fact due to seVere loss of body weight In relation to age. This was more marked in case of marasmus but wa.s partly masked by oedema in case of kwashiorkor. The improvement in intakes in control group was not that dra.matic because of little change in weight. This bring out the inherent danger in using actual body weight as base for determining nutl lent requirement in malnourished children.
The prefer ence of carbohydrate rich food by the mothers of the malnourished group Indicates that the bulk of the weaning food in the present series may be the critical factor In the causation PEM in Nigeria. Such a view Is supported by the studies of Rutisal'ser and Frood (1973) in Uganda.

Our results thus generally agree with the findin~s c.f extensive studies by Gopalan (1968) in India. that the diet of children who developed kwashicrkc.r and marasmus were quantitatively and quantitat.lvely similar. Similar findings en the qualit.y c.f t.he diet were reported by Laditan and Reeds (1976) from Ibadan. Waterlow and Rutishauser (1974) after reviewing the existing dietary information from six countries suggested that the primary deficiency is dietary energy and protein deficiency is only secondary. That is to say that the energy and protein need will be met if enough of the same kind of diet is ea.ten by the children. Similar finding have been reported from India (Sukhatene 1970), from Pakistan (Hussain, 1973) and from Bangladesh (Hussain and Ahmed 1977).
The main problem for the dietary solution of kwashiorkor and marasmus in Nigeria thus lie in devising ways and means to improve food intake and energy concentration of the diet of these children. This conclusions are, however. based on a retrospectiVe study which is far from ideal and must be accepted and interpreted with the Inherent limitations that pertains to all retrc.spective studies.


The authors gratefuly acknowledge the help and suggestion made by Prof. Z.A. Ademuwagun during the course of the study. and Prof. Omololu and Prof. A.B.O.O. Oyediran for the facilities.

Mrs. M. R. Osei acknowledges the financial assistance from WHO this work possible.

which made

Church. M.: Dietary factors in mainUtiition. quality and quantity of diet in relation to child development. Proc. Nutr. Soc. 38. 41,1979. F .A.O. Food composition table for use in Africa F.A.O., Rome, Italy, (1968).


JUNE, 1980

Gopalan. C.: Kwashiorkor and marasmus, evolution and distinguishing features. In R. A. McCance and E. M. Widdowson (Eds) Calorie deficiencies and protein deficiencies. j. and A Churchill, London pp. 49-58, 1968.

Hussain. M. A.: A fresh look at the Incldece of protein deficiency In Pakistan. Brit. j. Nutr. 29, 21 I, 1973.

Hussain, M. A. and Ahmad K.: Protein problems in Bangladesh, Ecol. Fd. Nutr. 6,31,1977.

Ladltan A. A. O. and Reed P.j.: A study of age of onset, diet and the Importance of infection in the pattern of severe P. E. M. in Ibadan, Nigeria. Brit. j. Nutr. 36, 411. 1976.

Rutlshauser, I.H.E.: Factors affecting th~ intake of energy and protein by Ugan~an preschool chldren. Ecol Fd. Nutr. 3, 213, 1974.
Rutishauser. I. H. E. and Frood, j.D.L.: The effect of a traditional low-flat diet on energy and protein intake, serum albumin concentration and bodywelght In Uganda preschool chldren, Brit. j. Nutr. 29, 261, 1973.
Sukhatene, P.V.: Incidence of protein deficiency in relation to different diets in India. Brit. j. Nutr. 24, 477, 1970.
Waterlow. j.C. and Rutishauser, I. H. E.: Malnutrition In Man In j. Cravlofo. L. Hambraeusand B.Vahlquist(Eds)Symposiumof the SwedishNutrition FoundationEarly Malnutrition and Mental Development, Almqvist and Wlksell. Stockholm. 1974.


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Studies On Kwashiorkor And Marasmus In Ibadan