A diagnosis of PEM must identify the type present. Individuals affected by maramus present with decreased anthropometric measurements, loss of muscle mass and body weight. There is also a decline in body temperature, pulse and metabolic rate. Serum protein levels are often low but can be normal. Children suffering from PEM have reduced rates of growth and are shorter, particularly in marasmus, compared with their normal counterparts. This can be easily assessed using charts of growth rates (Figure 10.37). They also have an impaired immune system, because of reduced protein synthesis in particular of immunoglobulins, and, as a consequence, infections such as measles that a child would normally be expected to survive are common causes of death in severe cases. A diagnosis of kwashiorkor is made following a thorough physical examination together with a medical and dietary history. Patients affected with kwashiorkor have the characteristic swollen abdomen, show hypoalbuminemia and a reduced lymphocyte count or lymphopenia.