Marasmus is a severe malnutrition condition resulting from a lack of total energy intake. Balancing macronutrients in the treatment of marasmus is a crucial yet complex task. Deviating from the required amounts, whether more or less, can lead to serious consequences, including impaired bodily functions and even death.

Understanding marasmus 

Definition

Marasmus is a form of severe malnutrition related to protein-energy insufficiency. This is a result of total calorie loss, resulting in a deficiency of adipose tissue and muscles.¹

Causes 

The underlying causes of reduced total energy intake differ between children and adults. These reasons can be broadly categorised into social and biological factors.

For children, a primary social cause is poverty, which directly leads to food insecurity and unsanitary living conditions, often resulting in diarrhoea. Additionally, maternal education plays a crucial role in effective childcare. Biologically, infections are a significant cause in children. Diseases such as HIV and malaria are closely linked to poor growth in children.¹

In adults, ageing can lead to anorexia, characterised by reduced appetite and decreased gastric emptying. Malnutrition can also result from malabsorption due to gastric diseases such as celiac disease and pancreatic insufficiency. Additionally, depression, particularly among elderly individuals living in care centres, is another significant cause of reduced energy intake.¹

Importance of proper nutrition in recovery

Nutrition, especially macronutrients, supplied in the proper amount is the main key to tackling the problem. In the short-term, organ failure, including heart, kidney, gastric and immune system will appear. Over a long period, children can not grow normally, which will affect their abilities to be active in social life, leading to a lower economy and education.¹

What are macronutrients?

Macronutrients are nutrients required in large amounts by the body that can provide energy in the unit of calories. These include carbohydrates, proteins and fats.² The requirement for each component varies depending on the goals of individuals. The balance of these compounds is essential for recovery from conditions like marasmus.²

Recognizing marasmus

Symptoms of marasmus present according to the severity and duration of the condition. Children, the elderly and people associated with other nutrient deficiencies tend to express more clinical presentation.³

Symptoms and signs 

Extreme weight loss

This is the most common and easily noticeable symptom. Children will lose more than 40% of their normal weight for age. Despite this, their weight for height might remain within the normal range, as the condition primarily impairs growth.¹

Muscle and fat wasting

Initially, muscle loss occurs in the groin and axilla areas, followed by the buttocks, face, and thighs. Loss of facial fat leads to a distinctive appearance known as "old man" syndrome.¹ The skin becomes loose, dry, and wrinkled due to the significant fat loss.³

Micronutrient deficiency signs

Marasmus is characterised by a total nutrient deficiency, leading to observable signs of reduced vitamins and minerals. A deficiency in vitamin A can cause dry eyes, while a lack of iron can result in anaemia and spoon-shaped nails. Moreover, long exposure to insufficient vitamin D and calcium can lead to various bone diseases.¹

How it's diagnosed

The anthropometric index is essential for diagnosing marasmus, yet accurate body measurement tools may be unavailable in low-income countries. Marasmus is diagnosed when the middle-upper arm circumference <115 mm or the weight-for-height Z-score is more than three standard deviations below the mean.¹

Additionally, blood tests may be necessary to assess anaemia, while serum albumin levels can indicate the extent of protein loss. Testing for parasites and viruses is also recommended to identify potential associated complications.¹

Treatment

The treatment of marasmus includes 3 phases: Resuscitation and stabilisation, nutritional rehabilitation, follow up and prevention of recurrence.¹

Resuscitation and stabilisation

In the initial phase, the primary focus is on rehydration, preventing infections, and avoiding complications. This phase typically lasts about one week. A critical risk during this period is refeeding syndrome, which occurs when severely malnourished individuals are rapidly overfed, causing electrolyte imbalances and potentially sudden death. To prevent refeeding syndrome, the introduction of macronutrients should be gradual, with caloric intake reaching only 60-80% of the required amount.³,⁷ Providing small, frequent meals and supplementing with thiamine can help mitigate this risk and support the patient’s recovery.¹

Nutritional rehabilitation

Once the electrolyte index is normal, nutritional rehabilitation can start. Caloric intake can now be 120 - 140% of the requirement to regain normal growth. This phase can last for 2 to 6 weeks.¹

Follow-up and prevention

Once the condition is treated, patients should continue consuming balanced and nutrient-dense meals. Educating parents, patients, and relatives is important to prevent relapse. Additionally, ensuring access to sufficient food and clean water is crucial.¹

Role of macronutrients in treatment

Carbohydrate

1. Provide carbohydrate cautiously

Although carbohydrates are usually the main energy source, their use in marasmic patients is highly restricted in the initial stage of treatment.³ High carbohydrate intake stimulates insulin production. Insulin helps move glucose into cells but also affects the balance of electrolytes like potassium, magnesium, and phosphate. In marasmic patients, whose electrolyte stores are already low, increased insulin levels can push these electrolytes into cells, causing dangerously low levels in the blood and disrupting normal bodily functions.⁷

2. Children

Children with marasmus have significantly reduced glucose absorption.⁵ They are at risk of glucose intolerance, which can lead to diarrhoea and worsen malnutrition.⁷ Due to these high risks, marasmic children should be taken to a care centre as soon as possible for careful examination, rather than attempting self-treatment.

3. Adults

In adults, during the first stage, patients are restricted to 150-200g of dextrose per day.⁴ In the rehabilitation phase, patients can normally absorb food high in carbohydrates to compensate for energy. People should opt for high-quality carbohydrate food packed with rich sources of other vitamins, such as starchy vegetables and legumes.

Protein

1. The importance of protein

Protein is essential for patients with marasmus at every stage of treatment.⁴ A study compared high-carbohydrate, high-fat, and high-protein diets with equal calorie content in children with marasmus. It concluded that a high-protein diet was well tolerated by all children, whereas the effectiveness of the high-carbohydrate and high-fat diets reached only 60% of the cases.³ A high protein diet is also associated with an overall improvement of absorption status, and a decrease in gastric bacteria.³

2. Children

According to WHO recommendations, children in the initial stage of treatment should receive a low-protein milk-based formula diet. Once metabolic abnormalities are adequately addressed, a transition to protein-rich milk can be introduced gradually.

3. Adults

Guidelines from the Society of Critical Care Medicine stated that protein should be used at 1.5g/kg/day.⁴ For individuals recovering, it is essential to incorporate high-quality protein sources into their diet to support tissue repair, muscle regeneration, and overall recovery. Patients should opt for a wide variety of proteins to provide all essential amino acids. 

Fat

1. The importance of fat

Fat plays a crucial role for children and adults with marasmus throughout all stages, as it sustains energy levels and accelerates recovery from malnutrition. Research has demonstrated that higher fat levels are linked to quicker rehabilitation in individuals with marasmus.⁶

2. Children

The WHO recommends lipid-based formula milk for children with marasmus, during both stabilisation and rehabilitation stages.

3. Adults

Animal-based fats, like those present in fatty fish and dairy products, provide essential fatty acids and nutrients crucial for recovery. Incorporating plant-based fats, such as nut butter or avocado, into daily diets or smoothies is also beneficial for increasing energy intake in individuals recovering from malnutrition.

Differential diagnosis

Kwashiorkor

This condition differs from marasmus as it results from sufficient calorie intake but inadequate protein consumption. Normal growth may occur, with the most typical symptom being oedema.¹

HIV wasting syndrome

This syndrome is characterised by unintentional weight loss >10%, associated with diarrhoea and weakness.³ These manifestations typically result from reduced oral intake.¹

Chronic pancreatitis

Chronic pancreatitis can result in protein-energy malnutrition due to malabsorption caused by insufficient pancreatic enzymes. This condition may lead to a decreased supply of calories despite adequate oral intake.¹,³

FAQ’s

What are the signs that someone with marasmus is improving?

Signs that someone with marasmus is improving include gradual weight gain, increased energy levels, and a reduction in visible signs of malnutrition like muscle wasting and skin changes. Improved appetite, tolerance of nutrient-dense foods, and normalisation of electrolyte levels also indicate recovery progress.

Are there any supplements that can help in marasmus recovery?

Several supplements can aid in marasmus recovery. These include multivitamins and minerals to replenish depleted stores, protein supplements for those needing additional protein, omega-3 fatty acids for inflammation reduction, probiotics to support gut health, and specific vitamin supplements such as iron or vitamin D depending on individual deficiencies.

How can I ensure my child gets enough nutrients during marasmus recovery?

Ensuring a child gets enough nutrients during marasmus recovery involves providing a balanced diet with nutrient-dense foods like fruits, vegetables, lean proteins, whole grains, and healthy fats. Parents should seek guidance from dietitians to ensure their child receives adequate calorie and nutrient intake without overwhelming their digestive system

Summary

In conclusion, the careful management and balance of macronutrients—carbohydrates, proteins, and fats—are crucial for effectively treating marasmus. These nutrients play essential roles in restoring health, supporting recovery, and preventing complications, making their proper incorporation into dietary plans paramount for successful outcomes in patients with severe malnutrition.