Caballero B. (ed.) Encyclopaedia of Food Science, Food Technology and Nutrition. Ten-Volume Set

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also to facilitate harvesting and all other operations.

In northern Colombia there is a miniature (egg-size)

mango, Azucar, with colorful skin and small seed,

which ought to be adopted for gift-box packing.

Propagation

0007 Improved cultivars are propagated vegetatively by

various techniques of budding or grafting in order to

reproduce the exact characters of the parent. They are

not grown from seed because seedlings grown from

the usual monoembryonic seeds are noted for their

variation. The homeowner may plant a mango seed

and be content with the result, but would be better

advised to purchase a grafted tree which will bear

sooner and provide a crop of predictable quality.

Only polyembyronic mangoes are propagated by

seed for commercial purposes. The majority of these

reproduce ‘true’ to the parent. Of course, plantations

of monoembryonic seedlings are necessary for

research and selection in breeding programs.

Soil and Culture

0008 Mango trees are not particularly sensitive to soil type

and they will prosper even on oolitic limestone, but

they respond well to appropriate fertilization, irriga-

tion, and spraying to control insects and fungus

diseases. In humid climates, the mango is subject to

anthracnose, which attacks the flowers and consider-

ably reduces production. A much more serious prob-

lem is the fungus causing powdery mildew on mango

trees from Florida to India. There are a number of

scale insects which attack the tree and its fruit. Man-

goes to be exported or imported may be subject to

fumigation, hot water, or other treatments to avoid

the spread of fruit flies and the mango seed weevil.

Mango trees may suffer from lack of adequate boron,

copper, iron, manganese, or magnesium, and need

regular attention to these deficiencies.

Yield and Handling

0009 Mango trees are long-lived and the yield varies with

the cultivar but always increases with age. A well-

cared-for, fruitful cultivar will bear 200–300 fruits

per year during the first 10–20 years, and twice that

amount in the next 20–40 years. In the Far East, older

trees of special cultivars have borne up to 5000 fruits

or more in a single season. In Puerto Rico, some

Florida cultivars have yielded roughly 30 000–

60 000 kg of fruits per hectare. However, after its

first 10 years, the mango is noted for being an irregu-

lar bearer, providing a heavy crop one year and a light

crop the next. Certain branches may bear one year

and other branches the following year, and bearing is

strongly influenced by weather conditions. In some

tropical climates, mango trees may be partially in

bloom and partially in fruit throughout the year.

There have been various efforts to enhance pollin-

ation, and promote better fruit-setting by smudging,

girdling, deblossoming, or by spraying with chemicals

to retard vegetative growth, but results are unstable

and discouraging.

0010Mangoes are picked when fully mature but slightly

unripe for domestic use, and allowed to soften at

room temperature. For marketing, they are harvested

earlier and some cultivars are treated with ethylene to

achieve uniform color. In any case, the fruit should be

washed immediately after clipping to remove the

gummy sap that exudes from the stem. Otherwise, it

will ‘burn’ the skin, resulting in black stains which

lead to decay.

0011Fully ripe mangoes keep for several days under

home refrigeration. They can be frozen whole for

future use but must be eaten immediately after

thawing. Sliced mango flesh in sugar syrup, with

added lime juice to prevent discoloration, is easily

frozen in leakproof, sealed plastic bags.

0012Keeping quality varies with the cultivar. The best

storage treatment for each must be worked out by

experimentation. But all mangoes are subject to

chilling injury, which generally occurs at storage tem-

peratures below 15



C. Trials in India with the high-

quality Alphonso cultivar demonstrated that the

freshly picked fruit can endure 2 weeks of storage at



C and subsequent ripening at 30



C, but longer

refrigeration brings on ‘low-temperature break-

down’. Ripening of Tommy Atkins and Kent mangoes

has been successfully delayed for 3 weeks at 13



90–100% relative humidity, and atmospheric pres-

sure of 76–152 mmHg, and the fruits have thereafter

ripened satisfactorily. (See Controlled-atmosphere

Storage: Applications for Bulk Storage of Foodstuffs;

Ripening of Fruit; Storage Stability: Mechanisms of

Degradation.)

0013In general, spoilage has been retarded or reduced

by prestorage dipping in hot water, or a solution

of maleic hydrazide, benomyl, or calcium chloride.

Plastic wraps reduce weight loss but do not retard

decay. Waxing is beneficial in delaying ripening, but

it has the undesirable effect of preventing full

coloring.

Preparation for Serving and Various Food

Uses

0014As mentioned earlier, ‘freestone’ mangoes can be cut

through to the stone and then the two halves are

held in the palms of the hands and gently twisted to

3694 MANGOES

separate them from the stone. Ordinary, somewhat

fibrous mangoes, can be served ‘in the half-shell’ by

cutting off both plump sides. The center slab is then

peeled and the flesh cut from the stone. Otherwise,

the whole fruit may be peeled and the flesh sliced for

whatever use: eating as dessert, adding to icecream,

milkshake, using as pie filling, stewing as sauce, or

making into preserves. Of course, if the flesh is

fibrous, it should be pressed through a sieve.

0015In the tropics, there are many seedling mangoes so

fibrous that they cannot be sliced. Children and

adults will bruise the fruit by massaging it between

the hands, then make a hole in the stem end and suck

out the juice. This should not be done by anyone who

is sensitive to the irritant in the mango peel.

0016Many immature mangoes are blown down by

spring winds. These are usually salvaged by peeling,

slicing, and cooking as a substitute for apple in pie.

They may also be cooked as a sauce, or used with

tamarind pulp and spices in preparing green mango

chutney. In India, thin slices of unripe mango are

sprinkled with turmeric, then dried and powdered

for use as seasoning.

0017Mango nectars and peeled, seeded, ripe mangoes,

halved or sliced, are commonly canned in Latin

America and South-east Asia and these products

find a good market abroad. However, more attention

must be given to the thorough coating of the inside of

the metal can, to avoid off-flavors and spoilage.

0018In India, the juicy pulp strained from ultrafibrous

ripe mangoes has been dehydrated and utilized as

‘cereal flakes.’ Mango juice powder was developed

in the Philippines years ago and technologists in

Puerto Rico, Hawaii, and elsewhere are developing

uses for the great numbers of mangoes that are out of

tbl0001 Table 1 Food value of mangoes (raw)

Nutrientsand units Meanamount per kg, edible portion

Proximate (g)

Water 817.10

Food energy (kcal) 650

(kJ) 2730

Protein (N  6.25) 5.10

Total lipid (fat) 2.70

Carbohydrate, total 170.0

Fiber

8.40

Ash 5.00

Minerals (mg)

Calcium 100

Iron 1.30

Magnesium 90

Phosphorus 110

Potassium 1560

Sodium 20

Zinc 0.40

Copper 1.10

Manganese 0.27

Vitamins (mg)

Ascorbic acid 277.0

a-Tocopherol 11.2

Thiamin 0.58

Riboflavin 0.57

Niacin 5.84

Pantothenic acid 1.60

Vitamin B

1.34

Folacin (mg)

Vitamin B

(mg) 0

Vitamin A (RE) 389

(IU) 3894

Lipids (g)

Fatty acids

Saturated, total 0.660

4:0

6:0

8:0

10:0

12:0 0.010

14:0 0.090

16:0 0.520

18:0 0.030

Monounsaturated, total 1.010

16:1 0.480

18:1 0.540

20:1

22:1

Polyunsaturated, total 0.510

18:2 0.140

18:3 0.370

18:4

20:4

20:5

22:5

22:6

Cholesterol (mg) 0

Phytosterols (mg)

Amino acids (g)

Tryptophan 0.080

Threonine 0.190

Isoleucine 0.180

Leucine 0.310

Lysine 0.410

Methionine 0.50

Cystine

Phenylalanine 0.170

Tyrosine 0.100

Valine 0.260

Arginine 0.190

Histidine 0.120

Alanine 0.510

Aspartic acid 0.420

Glutamic acid 0.600

Glycine 0.210

Proline 0.180

Serine 0.220

With refuse ¼ 300 g.

Insoluble dietary fiber as determined by the neutral detergent fiber

method (1.08 g per 100 g).

RE, retinol equivalents; IU, international units.

Reproduced from Gebhardt SE, Cutrufelli R and Matthews RH (1982)

Composition of Foods: Fruit and Fruit Juices, Raw, Processed, Prepared.

Agriculture Handbook no. 8–9, p. 168. Washington, DC: Consumer Nutrition

Center, United States Department of Agriculture, Human Nutrition

Information Service.

MANGOES 3695

reach of markets or do not meet fresh-market or

export specifications. Canadian scientists have proved

osmotic dehydration feasible. Solar drying is giving

good results in underdeveloped tropical countries.

(See Drying: Drying Using Natural Radiation.)

Utilization of Mango Waste

0019 In India, mango peel has been found to be a useful

source of pectin equal to that derived from the apple.

The seed kernel contains 11% fat usable in food

industries, and the residual starch has been used to

extend conventional flour stocks during times of food

shortage in South-east Asia.

Food Values

0020 The chemical constituents of the ripe mango, espe-

cially sugars (sucrose, glucose, and fructose) and

acids, vary considerably with the cultivar (Table 1).

Total sugars may be 11.20–16.80%. Ascorbic acid,

according to analyses in Central America, ranges

from 41.8 to 172.0 mg per 100 g. In India, ascorbic

acid values may be as low as 13 mg per 100 g. Carot-

ene ranges from 0.283 to 1.872 mg per 100 g. The

mango is a poor source of calcium, phosphorus, and

iron. Refer to individual nutrients.

Toxicity

0021 It should be kept in mind that the mango is a member

of the plant family Anacardiaceae, to which belong

poison ivy, poison sumac, the marking nut, and other

well-known sources of severe dermatitis. Mango

propagators, making cuttings of budwood or other

grafting material and rootstocks, may suffer chronic

skin reactions, and some have to give up such work or

wear protective plastic disposable gloves, or barrier

creams. Those who wash and pack mangoes for ship-

ping should also be gloved.

0022 The sap of the tree is irritant, as is that of the

fruit stem and, to a lesser extent, the peel of the fruit,

especially before complete ripening. The fruit flesh

can be contaminated by being sliced with the same

knife that has been used to peel the fruit. Sensitive

people (especially those who have been previously

sensitized by the tree’s sap or by contact with poison

ivy or some other member of the family) may be able

to eat the flesh of the mango if someone else does the

peeling, provided that a fresh, clean knife is utilized to

cut the flesh. Excessive contact with the peel, as in

peeling a number of mangoes for making preserves,

can induce a rash and blisters on the hands of

someone not normally affected by handling whole

mangoes.

0023When the mango tree is in bloom it does not dis-

perse airborne pollen, but the flowers on the tree

exhale an irritant chemical into the atmosphere

which is a common source of itching ears, swelling

of the eyelids, and respiratory irritation.

See also: Controlled-atmosphere Storage: Applications

for Bulk Storage of Foodstuffs; Drying: Drying Using

Natural Radiation; Fruits of Tropical Climates:

Commercial and Dietary Importance; Ripening of Fruit;

Storage Stability: Mechanisms of Degradation

Further Reading

Gebhardt SE, Cutrufelli R and Matthews RH (1982)

Composition of Foods: Fruit and Fruit Juices, Raw,

Processed, Prepared. Agriculture Handbook no. 8–9,

p. 168. Washington, DC: Consumer Nutrition Center,

United States Department of Agriculture, Human Nutri-

tion Information Service.

Gonzalez-Agailar GA, Wang CY and Buta JG (2000)

Maintaining quality of fresh-cut mangoes using anti-

browning agents and modified atmosphere packaging.

Journal of Agricultural Food Chemistry 48(9): 4204–

4208.

Krishnamurthy S and Joshi SS (1989) Studies on low tem-

perature storage of Alphonso mango. Journal of Food

Science and Technology 26(4): 177–180.

Kulkarni VJ and Rameshwar A (1989) Effect of deblossom-

ing and defruiting on off-season flowering and fruiting

in mango (Mangifera indicia L.). Scientia Horticulturae

39: 143–184.

Morton JF (1987) Fruits of Warm Climates. Distributed by

Creative Resource Systems, Winterville, North Carolina.

Rankins J, Hopkinson S and Diop M (1989) Palatability

and nutritional significance of solar dried mangoes for

Senegal. Ecology of Food and Nutrition 23: 131–140.

Singh LB (1960) The Mango – Botany, Cultivation and

Utilization. London: Leonard Hill (Books).

Manihot See Cassava: The Nature of the Tuber

3696 MANGOES

Manufacturing See Biscuits, Cookies, and Crackers: Methods of Manufacture; Brandy and Cognac:

Armagnac, Brandy, and Cognac and their Manufacture; Butter: The Product and its Manufacture; Cakes: Methods

of Manufacture; Canning: Cans and their Manufacture; Caramel: Methods of Manufacture; Casein and

Caseinates: Methods of Manufacture; Cheeses: Manufacture of Extra-hard Cheeses; Manufacture of Hard and

Semi-hard Varieties of Cheese; Cider (Cyder; Hard Cider): The Product and its Manufacture; Dressings and

Mayonnaise: The Products and Their Manufacture; Gin: The Product and its Manufacture; Ice Cream: Methods of

Manufacture; Jams and Preserves: Methods of Manufacture; Chemistry of Manufacture; Low-fat Foods: Types

and Manufacture; Margarine: Methods of Manufacture; Pasta and Macaroni: Methods of Manufacture; Port: The

Product and its Manufacture; Sherry: The Product and its Manufacture; Whisky, Whiskey, and Bourbon: Products

and Manufacture; Yogurt: The Product and its Manufacture

Maples See Sugar: Palms and Maples

MARASMUS

P Codon

er-Franch and V Valls Belle

s, Universidad

de Valencia, Valencia, Spain

Introduction

0001 Marasmus is the most prevalent severe form of mal-

nutrition and the most important nutritional disease

in developing countries. Deficiency of energy-giving

foods predominates over protein deficiency. Its origin

may be primary, due to insufficient food intake, often

associated with infectious or parasitic diseases, or

secondary, due to other conditions that interfere

with the absorption or assimilation of nutrients. It

contributes significantly to high rates of morbidity

and mortality in childhood. It is now recognized as

a public health problem, and action to reduce its

extent is the responsibility of government nutrition

policies and health personnel.

0002 Malnutrition or undesirable physical or disease

conditions related to nutrition can be caused by

eating too little, too much, or by an unbalanced diet

that does not contain all nutrients necessary for good

nutritional status. Undernutrition is a lack of ad-

equate energy, protein, and micronutrients to meet

basic requirements for body maintenance, growth,

and development. Today, the more comprehensive

term of protein-energy (or protein-calorie) malnutri-

tion (PEM) is universally accepted for describing

undernutrition. PEM is really a term describing

different types of clinical disorders resulting from

several combinations and degrees of protein and

energy deficiency. It includes a wide spectrum of clin-

ical manifestations conditioned by the relative inten-

sity and duration of protein and energy deficits. Its

severity ranges from weight loss or growth retard-

ation to distinct clinical syndromes. It is the most

important nutritional disease in the developing coun-

tries; this accounts for its high prevalence and its

relationship with child mortality rates, impaired

physical growth, and inadequate social and economic

development.

0003Dietary energy and protein deficiencies usually

occur together, and are frequently associated with

deficiencies of minerals and vitamins. Sometimes

one predominates and, if severe enough, may lead to

the major forms of PEM: marasmus, in which the

deficiency is primarily of energy-giving foods, and

kwashiorkor, with predominant protein deficiency.

Frequently there are mixed pictures, with a combin-

ation of energy deficiency and chronic or acute

protein deficit – marasmic kwashiorkor.

0004These conditions are diagnosed mainly on the basis

of anthropometric measurements, especially weight

and height. The two severe forms of malnutrition

present very different appearences and clinical fea-

tures; the overriding feature of nutritional marasmus

is severe underweight. The degree of malnutrition is

almost always based on the child’s percentage of

standard weight-for-age, and the weight in marasmus

is 60% of that expected for a child of that age

(Table 1).

0005Today a cut-off point using standard deviations

(SD) with respect to the mean weight-for-height is

considered more appropriate, and expert clinicians

MARASMUS 3697

diagnose marasmus using a constellation of clinical

findings (visible severe wasting), and very low weight-

for-height Z-score (3). Low weight-for-height is

identified as the indicator of choice for screening

severely malnourished children who are at increased

risk of dying.

Epidemiology

0006 The global magnitude of PEM is difficult to estimate

with precision because many patients had not been

recorded or had not received medical attention.

0007 PEM young children is the most important nutri-

tional problem in nonindustrialized countries. The

World Declaration on Nutrition produced by the

Food and Agriculture Organization (FAO) and

World Health Organization (WHO) International

Conference on Nutrition (ICN) held in Rome in

1992 states that about 780 million people in develop-

ing countries still do not have access to enough food

to meet their basic daily needs for nutritional well-

being. An estimated 50 million preschool children

were wasting in 1995. Wasting rates change rapidly,

however, especially in situations of emergency food

shortage and population displacement.

0008 It is especially distressing that there is such a high

prevalence and increasing numbers of malnourished

children under 5 years of age in different parts of

Africa, Asia, Latin America, and the Caribbean. Mal-

nutrition causes more than half of the mortality in

children of this age; thus, 55% (or more than 6 mil-

lion) preschool children died annually as a result of

preventable diseases (12 million) which had a direct

or indirect relationship with undernutrition. It has a

potentiating effect on mortality, rather than acting in

a simple additive fashion, and multipled the numbers

of deaths caused by infectious diseases (Table 2).

0009 It was recognized that nutritional marasmus is

more prevalent than kwashiorkor and that these two

serious clinical forms of PEM constitute the small tip

of an iceberg of all malnourished children. They are

relatively easy to detect by their clinical manifest-

ations, and children with moderate or mild malnutri-

tion can remain undiagnosed because often they do

not have clear manifestations of malnutrition; rather,

they are shorter (stunted) and/or thinner than would

be expected for their age. Thus, energy deficiency

plays a more important part than protein deficiency

in global malnutrition.

Causes

0010The etiology can be complex and three factors con-

tribute principally to undernutrition:

0011Inadequate intake of food, with chronic insuffi-

ciency of nutrients.

0012Nutrient losses because of improper digestion and

absorption, or infections that also hinder nutrient

absorption and utilization.

0013Incremental requirements in physiologic circum-

stances (growth, gestation, lactation).

The origin of PEM can be primary, when it is the result

of inadequate food intake and is almost always linked

to conditions such as poverty, ignorance, infectious

diseases, and low food availability. The PEM may be

secondary, when it is the result of other diseases that

lead to low food ingestion because of poor appetite or

an inadequate digestion, absorption, or utilization of

nutrients or conditions that result in increased nutri-

tional requirements. This form of malnutrition is seen

in malignancies, acquired immune deficiency syn-

drome (AIDS) or tuberculosis, and eating disorders

such as anorexia nervosa. Primary malnutrition is

most prevalent in developing countries and in disad-

vantaged groups (immigrants, refugees) who live in

similar conditions in the developed world.

0014Therefore inadequate dietary intake and disease

are immediate causes of malnutrition but the factors

that contribute are related to the host, the agent

(diet), and the environment. Availability of food,

however, is just part of the picture. It is now recog-

nized that malnutrition is only the overt sign, or

symptom, of much deeper problems in society.

tbl0001 Table 1 Wellcome classification of types of protein-energy

malnutrition (PEM)

Percentage

of standard

weight for age

Edema

Present Absent

60–80 Kwashiorkor Undernourishment

<60 Marasmic kwashiorkor Nutritional marasmus

tbl0002Table 2 Prevalence and number of wasted preschool children,

1998

UN regions and subregions Prevalence

of wasting

< 5 years (%)

Population

< 5years

(thousands)

Number

wasted

< 5years

Sub-Saharan Africa 9 100 036 9 003 240

Northern Africa 8 42 576 3 406 080

Meridional Asia 18 163 209 29 377 620

Latin America and 3

the Caribbean 54 841 1 645 230

Central/West Europe 5

Baltic States 31 712 1 585 600

Developing

countries

11 536 905 58 971 150

World 11 603 449 66 379 390

Data from UNICEF (2000) The State of the World’s Children. New York: Oxford

University Press.

3698 MARASMUS

0015 PEM is not confined to children but is much more

prevalent during early childhood, mainly affecting

infants and preschool children because of the young

child’s high needs for both energy and protein per

kilogram and the impossibility for children to obtain

food by their own means. Most descriptions of the

condition concentrate on this age group.

0016 The chronic intake of insufficient food can result in

marasmus that develops gradually over several

months or years. This process allows a series of meta-

bolic adjustments that result in decreased nutrient

demands and a nutritional balance compatible with

a lower level of cellular nutrient availability. In mar-

asmus there is a metabolically dynamic state change

to which the affected person adapts to survive in a

compensated manner. The cost of this adaptation

includes functional limitations and metabolic adjust-

ments are more stable when the situation develops

slowly.

Hormonal and Metabolic Changes in

Severe Malnutrition (Figure 1)

0017 Hormones play important roles in the adaptive pro-

cesses of energy and protein metabolism in severe

PEM. Metabolic adaptation in wasting is associated

with a decline in insulin and a rise in glucagon

concentrations which results in increased rates of

gluconeogenesis. During early starvation, protein

catabolism is increased to provide amino acids for

gluconeogenesis; decreased plasma insulin concentra-

tions also allow for a decrease in glucose use by

peripheral tissues. If the situation is prolonged, meta-

bolic adjustments are made to spare muscle protein

such as increased reliance by the central nervous

system on ketone bodies as an oxidative fuel, thereby

decreasing the need for increased rates of gluconeo-

genesis. Insulin decrease enhances lipolysis and

results in increased conversion of free fatty acids

(FFA) to ketone bodies.

0018Malnutrition frequently coexists with infection.

Infection can stimulate the production of gluco-

corticoids that increase the release of gluconeogenic

precursors, that is, amino acids from peripheral

tissues, and accounts for increased proteolysis in this

situation.

0019In the liver the synthesis of insulin-like growth

factors (IGF) is decreased. This results in an alteration

in the feedback for growth hormone (GH) and the

increase of this hormone that contributes to lipolysis,

mediated by direct catabolic effects on glucose and

lipid metabolism.

0020The active thyroid hormone triiodothyronine (T

)

is decreased owing to deficient capturing of iodine by

the gland and alteration in thyroxine (T

) conversion.

This produces a reduced thermogenesis and a spare in

oxygen consumption. This metabolic adaptation

leads to reduced metabolic cost.

Clinical Features

Growth Failure

0021A child’s body responds to malnutrition with a decel-

eration or cessation of growth. In all cases the child

fails to grow properly and presents a marked retard-

ation in length or height-for-age. Maintenance of a

satisfactory growth rate in the child depends on an

adequate supply of energy. Subnormal intakes lead to

a decline in growth velocity. Somatomedin C (IGF-1)

is synthesized by the liver and other tissues in re-

sponse to stimulation by GH. One of the major effects

of GH is the promotion of linear growth and skeletal

maturation. Somatomedin C is responsible for these

effects and for increased synthesis of DNA, RNA, and

protein in fibroblasts and chondrocytes. It also in-

creases the rates of protein synthesis and cell prolifer-

ation in other tissues. Both adequate dietary protein

and total energy contents are necessary for mainten-

ance of somatomedin concentrations.

0022Undernutrition retards growth and this is true for

all different parts of the body. Some parts are affected

more than others; adipose tissue loses its fat, and

muscle and liver lose some of their protein. If the

undernutrition is severe, the adipocytes become

unrecognizable as cells and the spaces between them

are occupied by extracellular material. There is less

change in the composition of the kidneys and heart,

and the brain is the least affected of all.

0023If undernutrition is imposed early in life, when

growth is faster, then complete recovery in size may

never be possible. If, at the stage of development

when the cells are dividing rapidly, cell division is

hindered, the cell divisions lost during the period

of undernutrtion will never be regained, even after

Deficient food intake

Low plasma glucose − low plasma amino acids

Insulin IGF-1 T

Proteolysis

Lipolysis

Wasting

Growth Basal

metabolism

FFA Ketone bodies

fig0001 Figure 1 Endocrine changes in marasmus. IGF-1, insulin-like

growth factor-1; T

, triiodothyronine; FFA, free fatty acids.

MARASMUS 3699

rehabilitation. The result is a child shorter than

normal (stunting).

0024 In severe malnutrition there is a relative increase in

body water and decrease in body potassium. The

extracellular fluid volume is better preserved than

cell mass; the shrunken cells retain their fluid cover-

ing. The noncollagen proteins are reduced to about

one-half and the collagen protein do not change

significantly. Skin and bone account for about 70%

of total body collagen. The child appears to be ‘skin

and bones.’

Wasting

0025 Loss of tissue mass during starvation involves oxida-

tion of endogenous fuel stores in order to generate

energy required for life-sustaining metabolic activ-

ities. A decrease in energy intake is quickly followed

by a decrease in energy expenditure. When the de-

crease in energy expenditure cannot compensate for

the insufficient intake, body fat is mobilized with a

decrease in adiposity and weight loss. Lean body mass

diminishes at a slower rate, mainly as a consequence of

muscle protein catabolism with major flow of amino

acids, primarily alanine, that contributes to energy

sources. As the cumulative energy deficit becomes

more severe, subcutaneous fat is markedly reduced,

and protein catabolism leads to muscular wasting.

0026 Clinically, the muscles are always extremely wasted

and loss of subcutaneous fat makes the ribs promin-

ent. The loss of flesh is obvious, with little or no

remaining subcutaneous fat. In contrast to the rest

of the body, the belly is sometimes relatively protuber-

ant. The skin, particularly over the buttocks, hangs in

wrinkles. There may be pressure sores over bony

prominences. These features and the sunken cheeks

caused by disappearance of the Bichat fat pads give

the marasmic child’s face the appearance of a monkey

or an old person (Figure 2).

Hair Changes

0027 The hair usually shows changes. There is more fre-

quently a change of texture and it becomes sparse,

thin, and dry, without its normal sheen. It is easily

pulled out without causing pain.

Appetite

0028 Some children are anorexic while others may be rav-

enously hungry; they often violently suck their hands

or make sucking noies, but they seldom tolerate large

amounts of food and vomit easily.

Mental and Physical State

0029 The child’s mood may be anxious rather than apa-

thetic. Marasmic children have a rather wide-awake

appearance and cry easily, with an expression of

misery and sadness (Figure 3). There is a marked

weakness and the child frequently cannot stand with-

out help.

Vital Constants

0030Heart rate, blood pressure, and body temperature

may be low.

Biochemical and Metabolic Features

0031In severe PEM all the processes of the body show a

reductive adaptation to current nutritional conditions

that is better if harmonic changes in the metabolism

of proteins, energy, and other nutrients occur.

0032Hemoglobin and hematocrit are usually moder-

ately low. The serum iron may be normal, but iron

body stores are usually depleted. Following nutri-

tional rehabilitation there may be an additional

decrease in iron stores because of the increased re-

quirements for tissue synthesis and the greater needs

for hematopoietic factors. If iron is not available, the

patient is prone to develop severe anemia. Plasma

ferritin is increased because of concurrent infections.

fig0002Figure 2 Marasmic infant, Rwanda 1997. Courtesy of Dr

M Gracia.

3700 MARASMUS

0033 Serum concentrations of total proteins are normal

or moderately low, and the ratio of nonessential to

essential amino acids in plasma is usually normal.

0034 Excretion of hydroxyproline, 3-methylhistidine,

creatinine, and urea nitrogen in urine is reduced.

0035 Prealbumin and retinol-binding protein, two pro-

teins with a short mean life (< 2 days) whose synthesis

is energy-dependent, are decreased.

0036 Blood glucose concentration remains normal,

mainly at the expense of gluconeogenic amino acids

and fats. Hypoglycemia is present especially after

prolonged fasting or when malnutrition is compli-

cated by serious infections.

0037 Concentrations of cholesterol and triglycerides are

low.

0038 There is a deficiency in essential fatty acids and

a imbalance between the n-3 and n-6 families that

accounts for adverse effects (phospholipid deficiency

in the retina).

Fluid and Electrolyte Disturbances

0039 There is water and electrolyte characteristics in severe

PEM, namely:

0040Intracellular potassium depletion, as body potas-

sium is almost entirely stored within the lean

tissues and muscle makes up most of the lean tissue.

0041Mild to moderate metabolic acidosis: due to rising

circulating levels of ketone bodies in response to a

change from a glucose-based to a lipid-based (FFA

and ketone bodies) energy supply to minimize

protein catabolism in skeletal muscle by reducing

the need for amino acid-derived gluconeogenesis.

0042Decreased body magnesium, with or without

hypomagnesemia.

Changes in Body Systems and Organs

0043In the gastrointestinal tract it is common that villi are

flattened and atrophic, and the amount of almost all

digestive enzymes is reduced. This condition leads to

poor digestion and absorption and may contribute to

diarrhea. Severely malnourished children are prone

to diarrhea because of these alterations and possibly

also because of irregular intestinal motility and gas-

trointestinal bacterial overgrowth. There is an alter-

ation in pancreatic function, with a decrease of lipase

and consequent steatorrhea.

0044Myocardial changes produced by atrophy of the

cardiac muscle may lead to reduced cardiac output

and electrocardiographic changes. Cardiac work de-

creases as does the function.

0045Renal function may be abnormal. Renal plasma

flow and glomerular filtration rates may be reduced

as a consequence of the decreased cardiac output, but

water clearence and the ability to concentrate and

acidify urine appear unimpaired.

Effect of Malnutrition on Immune

Responses

0046Deficiencies in the immune system explain the high

susceptibility of severely malnourished patients to

infections and a greater predisposition to severe com-

plications of otherwise less important infectious dis-

eases. There is a marked impairment of both humoral

and cell-mediated immune functions.

0047Severe thymic atrophy, tonsils, and other lymph

tissues smaller in size than normal account for a

T-cell deficiency that is particularly common in

undernourished children. A depression of T-helper

cells and possibly an increase in T-suppressor cell

can also occur. There is decreased killer-cell activity

because of reduced leukocytosis, lowered phagocytic

activity of neutrophils, poor antibody formation, and

decreased production of interferon and complement.

0048Reduced levels of secretory immunoglobulin A in

secretions could be responsible for the compromised

resistance to organisms that cause respiratory or

fig0003 Figure 3 (see color plate 103) Expression of sadness in a

marasmic person. Courtesy of Cruz Roja Espan

MARASMUS 3701

gastrointestinal infections. Atrophy of gut-associated

lymphoid tissue contributes to diarrheal diseases.

0049 Concomitant infections may lead to an increased

concentration of serum immunoglobulins.

0050 Although marasmus is a macronutrient deficiency

due to insufficient food intake, and energy deficiency

is more important and frequent than protein defi-

ciency, it is usually complicated by multiple simultan-

eous nutrient deficiencies (vitamin and minerals) that

also contribute to the effects and all the features can

also be worsened by infection, thus establishing a

vicious circle.

Treatment

0051 Treatment strategies can be divided into three stages;

0052 Resolving serious complications

0053 Nutrient repletion

0054 Ensuring nutritional rehabilitation

Resolving serious complications

0055 Nutritional rehabilitation can be delayed until life-

threatening conditions are solved. The most frequent

conditions are described below.

0056 Dehydration and electrolyte disturbance These chil-

dren need careful attention and can usually be treated

by appropriate oral fluids rather than by intravenous

therapy. Rehydration can be achieved using the WHO

standard oral rehydration solution (ORS) by mouth or

by nasogastric tube. Intravenous fluids must be used in

severe dehydration with hypovolemia, impending

shock, frequent vomiting, and persistent abdominal

distention. Careful attention must be displayed be-

cause cardiac failure may develop during or after ad-

ministration of intravenous fluids. These may be the

result of impaired cardiac function, sudden expansion

of the intravascular fluid volume, severe anemia, or

impaired membrane function.

0057 Infections Infections are so common in severely

malnourished children that antibiotics are often rou-

tinely recommended when an infection is suspected.

Appropriate antibiotic therapy must be started, even

before obtaining the results of microbiologic cultures.

A broad-spectrum antibiotic or a combination, such

as ampicillin and gentamicin, is usually given intra-

venously.

0058 Treatment for intestinal parasites is rarely urgent

and can be deferred until nutritional rehabilitation is

under way.

0059 Severely malnourished children not infrequently

have tuberculosis or AIDS and should be examined.

If the disease is found to be present, specific treatment

is needed. In areas where malaria is prevalent, an

antimalarial is desirable.

0060Hypothermia/hypoglycemia The seriously mal-

nourished child has difficulty in maintaining normal

body temperature. This may be due to impaired

thermoregulatory mechanisms, reduced fuel substrate

availability, or severe infection.

0061Untreated hypothermia is a common cause of death

in malnourished children. If the child’s temperature is

below 36



C, efforts must be made to warm the child.

The child’s temperature should be checked frequently

as the patient may rapidly become hyperthermic.

0062Body temperature usually rises in the hypothermic

patient shortly after the introduction of glucose-

containing diets.

0063Asymptomatic hypoglycemia can be prevented or

treated by the frequent feeding of small volumes of

glucose-containing diets or solutions. Severe symp-

tomatic hypoglycemia must be treated intravenously.

Nutrient Repletion

0064As recovery begins, restoration of nutritional status

rapidly and safely as possible becomes the principal

consideration. Children with severe nutritional mar-

asmus may consume very high amounts of energy,

and weight gain may be quite rapid.

0065It is best to begin with a liquid formula fed orally or

by nasogastric tube, divided equally into 5–12 feed-

ings per day, depending on the patient’s age and

general condition. If the child is still being breast-

fed, breast-feeding should continue. Initially a mix-

ture providing 120 kcal and 3 g protein per kg body

weight should be provided.

0066In many hospitals in developing countries an aque-

ous mixture containing dried skimmed milk, vege-

table oil, casein, and sugar is used. A marasmic child

during the early part of recovery may be capable of

consuming and utilizing 150–200 kcal and 4–5g of

protein per kilogram of body weight per day. As the

appetite improves and no signs of intolerance or

complications are evident, the energy intake may be

increased to 250 kcal kg

1

body weight.

0067The various regimens must provide a diet that

meets daily maintenance requirements, compensates

for continued losses, and meets the requirements for

growth. Adequate amounts of vitamins and minerals

must be assured. Some evidence now suggests that

zinc supplementation may be beneficial. Extra vita-

min A and iron is often advisable since deficiency can

develop as a result of increased demands when ad-

equate protein and energy feeding begins.

0068In developed countries hydrolyzed milk formulas

are preferred because of their digestibility and better

absorption.

3702 MARASMUS

Ensuring Nutritional Rehabilitation

0069 In all cases it is particularly important that the patient

is not discharged from treatment until follow-up is

assured and adequate feeding is continued. A mixed

diet should gradually be introduced, aimed at provid-

ing the energy, protein, minerals, and vitamins needed

by the child. Emotional and physical stimulation

must be provided.

0070 As a general guideline, vigorous dietary therapy

should continue for 15 days after the marasmic

patientq reaches an adequate weight-for-height and

his or her clinical and overall performance are good.

If he or she continues growing at a normal rate and

has no functional impairments, treatment can be

terminated after 1 month of adequate dietary intake.

Specific treatment of other nutritional problems (iron

deficiency) must sometimes be prolonged.

0071 Instruction about the causes of PEM and nutrition

education about the rational and nutritious use of

foods, personal and environmental hygiene, appro-

priate immunizations, and early treatment of diarrhea

and other diseases are vital for the person who will be

responsible for the child.

Prevention

0072 It is now understood that good nutrition lies in

adequate levels of three factors:

0073 Household food security

0074 Appropriate care and feeding practices

0075 Adequate health care

The prevention of PEM poses a huge challenge.

Various strategies include appropriate nutrition

policies with improving food security and care

practices to insure good nutrition. These measures

should be accompanied by promoting healthy life-

styles, suitable immunizations, growth monitoring,

and early treatment for common diseases as well

as prompt rehydration therapy for diarrhea and regu-

lar deworming. Severe malnutrition is more often

associated with deficient food intake than with

deficient protein intake. Cereal-based diets meet

energy needs and also meet protein needs. Its neces-

sary to pay attention to increasing total food intake,

to protect and promote breast-feeding and sound

weaning, and to encourage higher consumption of

oil and fats that reduce bulk and increase the energy

density of foods.

0076 Severe malnutrition may manifest as a health prob-

lem but health professionals alone cannot solve it.

This problem requires the contribution of agricultural

professionals, educators, and professionals in eco-

nomics, social development, and politics.

See also: Kwashiorkor; Malnutrition: The Problem of

Malnutrition; Malnutrition in Developed Countries;

Nutritional Assessment: Importance of Measuring

Nutritional Status; Anthropometry and Clinical

Examination; Biochemical Tests for Vitamins and

Minerals; Functional Tests