"Underfeeding" redirects here. For the concept in metalworking, see Underfeeder.
Malnourishment, undernourishment |
A malnourished child in an MSF treatment tent in Dolo Ado. |
Critical care medicine |
Problems with physical or mental development; poor energy levels; hair loss; swollen legs and abdomen[1][2] |
Eating a diet with too few or too many nutrients; malabsorption[3][4] |
Lack of breastfeeding; gastroenteritis; pneumonia; malaria; measles; poverty; homelessness[5] |
Improving agricultural practices; reducing poverty; improving sanitation |
Improved nutrition; supplementation; ready-to-use therapeutic foods; treating the underlying cause[6][7][8] |
821 million undernourished / 11% of the population [2017][9] |
406,000 from nutritional deficiencies [2015][10] |
Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems.[11] Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues and form.[12]
Malnutrition is a category of diseases that includes undernutrition and overnutrition.[13] Undernutrition is a lack of nutrients, which can result in stunted growth, wasting, and underweight. A surplus of nutrients causes overnutrition, which can result in obesity. In some developing countries, overnutrition in the form of obesity is beginning to appear within the same communities as undernutrition.[14]
Most clinical studies use the term 'malnutrition' to refer to undernutrition. However, the use of 'malnutrition' instead of 'undernutrition' makes it impossible to distinguish between undernutrition and overnutrition, a less acknowledged form of malnutrition.[12][15] Accordingly, a 2019 report by The Lancet Commission suggested expanding the definition of malnutrition to include "all its forms, including obesity, undernutrition, and other dietary risks."[16] The World Health Organization[17] and The Lancet Commission have also identified "[t]he double burden of malnutrition," which occurs from "the coexistence of overnutrition [overweight and obesity] alongside undernutrition [stunted growth and wasting]."[18][19]
Prevalence[edit]
It is estimated that nearly one in three persons globally has at least one form of malnutrition: wasting, stunting, vitamin or mineral deficiency, overweight, obesity, or diet-related noncommunicable diseases.[20] Undernutrition is more common in developing countries.[21] Stunting is more prevalent in urban slums than in rural areas.[22] Studies on malnutrition have the population categorised into different groups including infants, under-five children, children, adolescents, pregnant women, adults and the elderly population. The use of different growth references in different studies leads to variances in the undernutrition prevalence reported in different studies. Some of the growth references used in studies include the National Center for Health Statistics [NCHS] growth charts, WHO reference 2007, Centers for Disease Control and Prevention [CDC] growth charts, National Health and Nutrition Examination Survey [NHANES], WHO reference 1995, Obesity Task Force [IOTF] criteria and Indian Academy of Pediatrics [IAP] growth charts.[23]
In children[edit]
The prevalence of undernutrition is highest among children under five.[22] In 2020, 149 million children under five years old were stunted, 45 million were wasted, and 38.9 million were overweight or obese.[24] The following year, an estimated 45% of deaths in children were linked to undernutrition.[24][5] The prevalence of wasting among children under five in South Asia was reported to be 16% moderately or severely wasted.[22] In Asia, India has one of the highest burden of wasting with over 20% wasted children.[25] However, the burden of undernutrition among under-five children in African countries is much higher. A pooled analysis of the prevalence of chronic undernutrition among under-five children in East Africa was identified to be 33.3%. This prevalence of undernutrition among under-five children ranged from 21.9% in Kenya to 53% in Burundi.[26] In Tanzania, the prevalence of stunting, among children under five varied from 41% in lowland and 64.5% in highland areas. Undernutrition by underweight and wasting was 11.5% and 2.5% in lowland and 22.% and 1.4% in the highland areas of Tanzania respectively.[27] In South Sudan, the prevalence of undernutrition explained by stunting, underweight and wasting in under-five children were 23.8%, 4.8% and 2.3% respectively.[28]
Vitamin A deficiency affects one third of children under age 5 around the world,[29] leading to 670,000 deaths and 250,000–500,000 cases of blindness.[30]
In adults[edit]
As of June 2021, 1.9 billion adults were overweight or obese, and 462 million adults were underweight.[24] Globally, two billion people had iodine deficiency in 2017.[31] In 2020, 900 million women and children had anemia, which is often caused by iron deficiency.[32]
Certain groups have higher rates of undernutrition, including elderly people and women [in particular while pregnant or breastfeeding children under five years of age]. Undernutrition is an increasing health problem in people aged over 65 years, even in developed countries, especially among nursing home residents and in acute care hospitals.[33] In the elderly, undernutrition is more commonly due to physical, psychological, and social factors, not a lack of food.[34] Age-related reduced dietary intake due to chewing and swallowing problems, sensory decline, depression, imbalanced gut microbiome, poverty and loneliness are major contributors to undernutrition in the elderly population.[35]
Recent increase[edit]
There has been an increase in world hunger over the past decade. In 2015, 795 million people [about one in ten people on earth] had undernutrition.[9][36] In 2020, one in nine people in the world—or 820 million people worldwide—was hungry.[37]
These increases are partially related to the ongoing COVID-19 pandemic, which continues to highlight the weaknesses of current food and health systems. It has contributed to food insecurity, increasing hunger worldwide; meanwhile, lower physical activity during lockdowns has contributed to increases in overweight and obesity.[38] In 2020, experts estimated that by the end of the year, the pandemic could double the number of people at risk of suffering acute hunger.[39] Similarly, experts estimate that the prevalence of moderate and severe wasting could increase by 14% due to COVID-19; coupled with reductions in nutrition and health services coverage, this could result in over 128,000 additional deaths among children under 5 in 2020 alone.[38] Although COVID-19 is less severe in children than in adults, the risk of severe disease increases with undernutrition.[40]
Other major causes of hunger include manmade conflicts, climate changes, and economic downturns.[41]
Definitions[edit]
Undernutrition[edit]
Undernutrition can occur either due to protein-energy wasting or as a result of micronutrient deficiencies.[2][42][24][1][3][43][44] It adversely affects physical and mental functioning, and causes changes in body composition and body cell mass.[45][46] Undernutrition is a major health problem, causing the highest mortality rate in children, and is responsible for long-lasting physiologic effects.[47] It is a barrier to the complete physical and mental development of children.[44]
Undernutrition can manifest as stunting, wasting, and underweight. If undernutrition occurs during pregnancy, or before two years of age, it may result in permanent problems with physical and mental development.[1][43] Extreme undernutrition can cause starvation, chronic hunger, Severe Acute Malnutrition [SAM], and/or Moderate Acute Malnutrition [MAM].
The signs and symptoms of micronutrient deficiencies depend on which micronutrient is lacking.[2] However, undernourished people are often thin and short, with very poor energy levels; and swelling in the legs and abdomen is also common.[1][2][43] People who are undernourished often get infections and frequently feel cold.[2]
Micronutrient malnutrition[edit]
Micronutrient malnutrition results from inadequate intake of vitamins and minerals.[24] Worldwide, deficiencies in iodine, Vitamin A, and iron are the most common. Children and pregnant women in low-income countries are at especially high risk for micronutrient deficiencies.[24][43]
Anemia is most commonly caused by iron deficiency, but can also result from other micronutrient deficiencies and diseases. This condition can have major health consequences.[48]
It is possible to have overnutrition simultaneously with micronutrient deficiencies; this condition is termed the double burden of malnutrition.
Protein-energy malnutrition[edit]
'Undernutrition' sometimes refers specifically to protein–energy malnutrition [PEM].[2][49] This condition involves both micronutrient deficiencies and an imbalance of protein intake and energy expenditure.[42] It differs from calorie restriction in that calorie restriction may not result in negative health effects. Hypoalimentation [underfeeding] is one cause of undernutrition.[50]
Two forms of PEM are kwashiorkor and marasmus; both commonly coexist.[11]
Kwashiorkor is primarily caused by inadequate protein intake.[11] Its symptoms include edema, wasting, liver enlargement, hypoalbuminaemia, and steatosis; the condition may also cause depigmentation of skin and hair.[11] The disorder is further identified by a characteristic swelling of the belly, which disguises the patient's undernourished condition.[51] 'Kwashiorkor' means 'displaced child' and is derived from the Ga language of coastal Ghana in West Africa. It means "the sickness the baby gets when the next baby is born," as it often occurs when the older child is deprived of breastfeeding and weaned to a diet composed largely of carbohydrates.[52]
Marasmus [meaning 'to waste away'] can result from a sustained diet that is deficient in both protein and energy. This causes their metabolism to adapt in order to prolong survival.[11] The primary symptoms are severe wasting, leaving little or no edema; minimal subcutaneous fat; and abnormal serum albumin levels.[11] It is traditionally seen in cases of famine, significant food restriction, or severe anorexia.[11] Conditions are characterized by extreme wasting of the muscles and a gaunt expression.[51]
Overnutrition[edit]
Excessive consumption of energy-dense foods and drinks and limited physical activity causes overnutrition.[53] It causes overweight, defined as a body mass index [BMI] of 25 or more, and can lead to obesity [a BMI of 30 or more].[24][2] Obesity has become a major health issue worldwide.[54] Overnutrition is linked to chronic non-communicable diseases like diabetes, certain cancers, and cardiovascular diseases. Hence identifying and addressing the immediate risk factors has become a major health priority.[55] The recent evidence on the impact of diet-induced obesity in fathers and mothers around the time of conception is identified to negatively program the health outcomes of multiple generations.[56]
Classifying malnutrition[edit]
Definition by Gomez & Galvan[edit]
In 1956, Gómez and Galvan studied factors associated with death in a group of undernourished children in a hospital in Mexico City, Mexico. They defined three categories of malnutrition: first, second, and third degree.[57] The degree of malnutrition is calculated based on a child's body size compared to the median weight for their age.[58] The risk of death increases with increasing degrees of malnutrition.[57]
An adaptation of Gomez's original classification is still used today. While it provides a way to compare malnutrition within and between populations, this classification system has been criticized for being "arbitrary" and for not considering overweight as a form of malnutrition. Also, height alone may not be the best indicator of malnutrition; children who are born prematurely may be considered short for their age even if they have good nutrition.[59]
Normal | 90–100% | |||||||||||||||||||||||||||||||||||||||||
Mild: Grade I [1st degree] | 75–89% | |||||||||||||||||||||||||||||||||||||||||
Moderate: Grade II [2nd degree] | 60–74% | |||||||||||||||||||||||||||||||||||||||||
Severe: Grade III [3rd degree] | 95% | >90% | ||||||||||||||||||||||||||||||||||||||||
Mild: Grade I | 87.5–95% | 80–90% | ||||||||||||||||||||||||||||||||||||||||
Moderate: Grade II | 80–87.5% | 70–80% | ||||||||||||||||||||||||||||||||||||||||
Severe: Grade III | 35.0% No data Disability-adjusted life year for nutritional deficiencies per 100,000 inhabitants in 2004. Nutritional deficiencies included: protein-energy malnutrition, iodine deficiency, vitamin A deficiency, and iron deficiency anaemia.[167]
The figures provided in this section on epidemiology all refer to undernutrition even if the term malnutrition is used which, by definition, could also apply to too much nutrition. The Global Hunger Index [GHI] is a multidimensional statistical tool used to describe the state of countries' hunger situation. The GHI measures progress and failures in the global fight against hunger.[168] The GHI is updated once a year. The data from the 2015 report shows that Hunger levels have dropped 27% since 2000. Fifty two countries remain at serious or alarming levels. In addition to the latest statistics on Hunger and Food Security, the GHI also features different special topics each year. The 2015 report include an article on conflict and food security.[169] People affected[edit]The United Nations estimated that there were 821 million undernourished people in the world in 2017. This is using the UN's definition of 'undernourishment', where it refers to insufficient consumption of raw calories, and so does not necessarily include people who lack micro nutrients.[9] The undernourishment occurred despite the world's farmers producing enough food to feed around 12 billion people—almost double the current world population.[170] Malnutrition, as of 2010, was the cause of 1.4% of all disability adjusted life years.[171] Number of undernourished globally
Mortality[edit]Deaths from nutritional deficiencies per million persons in 2012 0–4 5–8 9–13 14–23 24–34 35–56 57–91 92–220 221–365 366–1,207 Mortality due to malnutrition accounted for 58 percent of the total mortality in 2006: "In the world, approximately 62 million people, all causes of death combined, die each year. One in twelve people worldwide is malnourished and according to the Save the Children 2012 report, one in four of the world's children are chronically malnourished.[175] In 2006, more than 36 million died of hunger or diseases due to deficiencies in micronutrients".[176] In 2010 protein-energy malnutrition resulted in 600,000 deaths down from 883,000 deaths in 1990.[177] Other nutritional deficiencies, which include iodine deficiency and iron deficiency anemia, result in another 84,000 deaths.[177] In 2010 malnutrition caused about 1.5 million deaths in women and children.[178] According to the World Health Organization, malnutrition is the biggest contributor to child mortality, present in half of all cases.[179] Six million children die of hunger every year.[180] Underweight births and intrauterine growth restrictions cause 2.2 million child deaths a year. Poor or non-existent breastfeeding causes another 1.4 million. Other deficiencies, such as lack of vitamin A or zinc, for example, account for 1 million. Malnutrition in the first two years is irreversible. Malnourished children grow up with worse health and lower education achievement. Their own children tend to be smaller. Malnutrition was previously[when?] seen as something that exacerbates the problems of diseases such as measles, pneumonia and diarrhea, but malnutrition actually causes diseases, and can be fatal in its own right.[179] History[edit]Hunger has been a perennial human problem. However, until the early 20th century, there was relatively little awareness of the qualitative aspects of malnutrition. Throughout history, various peoples have known the importance of eating certain foods to prevent symptoms now associated with malnutrition. Yet such knowledge appears to have been repeatedly lost and then re-discovered. For example, the ancient Egyptians reportedly knew the symptoms of scurvy. Much later, in the 14th century, Crusaders sometimes used anti-scurvy measures - for example, ensuring that citrus fruits were planted on Mediterranean islands, for use on sea journeys. However, for several centuries, Europeans appear to have forgotten the importance of these measures. They rediscovered this knowledge in the 18th century, and by the early 19th century, the Royal Navy was issuing frequent rations of lemon juice to every crewman on their ships. This massively reduced scurvy deaths among British sailors, which in turn gave the British a significant advantage in the Napoleonic Wars. Later on in the 19th century, the Royal Navy replaced lemons with limes [unaware at the time that lemons are far more effective at preventing scurvy].[181][182] According to historian Michael Worboys, malnutrition was essentially discovered, and the science of nutrition established, between World War I and World War II. Advances built on prior works like Casimir Funk's 1912 formulisation of the concept of vitamins. Scientific study of malnutrition increased in the 1920s and 1930s, and grew even more common after World War II. Non-governmental organizations and United Nations agencies began to devote considerable energy to alleviating malnutrition around the world. The exact methods and priorities for doing this tended to fluctuate over the years, with varying levels of focus on different types of malnutrition like Kwashiorkor or Marasmus; varying levels of concern on protein deficiency compared to vitamins, minerals and lack of raw calories; and varying priorities given to the problem of malnutrition in general compared to other health and development concerns. The green Revolution of the 1950s and 1960s saw considerable improvement in capability to prevent malnutrition.[182][181][183] One of the first official global documents addressing Food security and global malnutrition was the 1948 Universal Declaration of Human Rights[UDHR]. Within this document it stated that access to food was part of an adequate right to a standard of living.[184] The Right to food was asserted in the International Covenant on Economic, Social and Cultural Rights, a treaty adopted by the United Nations General Assembly on December 16, 1966. The Right to food is a human right for people to feed themselves in dignity, be free from hunger, food insecurity, and malnutrition.[185] As of 2018, the treaty has been signed by 166 countries, by signing states agreed to take steps to the maximum of their available resources to achieve the right to adequate food. However, after the 1966 International Covenant the global concern for the access to sufficient food only became more present, leading to the first ever World Food Conference that was held in 1974 in Rome, Italy. The Universal Declaration on the Eradication of Hunger and Malnutrition was a UN resolution adopted November 16, 1974 by all 135 countries that attended the 1974 World Food Conference.[186] This non-legally binding document set forth certain aspirations for countries to follow to sufficiently take action on the global food problem. Ultimately this document outline and provided guidance as to how the international community as one could work towards fighting and solving the growing global issue of malnutrition and hunger. Adoption of the right to food was included in the Additional Protocol to the American Convention on Human Rights in the area of Economic, Social, and Cultural Rights, this 1978 document was adopted by many countries in the Americas, the purpose of the document is, "to consolidate in this hemisphere, within the framework of democratic institutions, a system of personal liberty and social justice based on respect for the essential rights of man."[187] A later document in the timeline of global inititaves for malnutrition was the 1996 Rome Declaration on World Food Security, organized by the Food and Agriculture Organization. This document reaffirmed the right to have access to safe and nutritious food by everyone, also considering that everyone gets sufficient food, and set the goals for all nations to improve their commitment to food security by halving their amount of undernourished people by 2015.[188] In 2004 the Food and Agriculture Organization adopted the Right to Food Guidelines, which offered states a framework of how to increase the right to food on a national basis. Special populations[edit]Undernutrition is an important determinant of maternal and child health, accounting for more than a third of child deaths and more than 10 percent of the total global disease burden according to 2008 studies.[189] Children[edit]Malnourished children in Niger, during the 2005 famine. Undernutrition adversely affects the cognitive development of children, contributing to poor earning capacity and poverty in adulthood.[190] The development of childhood undernutrition coincides with the introduction of complementary weaning foods which are usually nutrient deficient.[191] The World Health Organization estimates that malnutrition accounts for 54 percent of child mortality worldwide,[49] about 1 million children.[192] There is a strong association between undernutrition and child mortality.[193] Another estimate also by WHO states that childhood underweight is the cause for about 35% of all deaths of children under the age of five years worldwide.[194] Over 90% of the stunted children below five years of age live in sub-Saharan Africa and South Central Asia.[70] Although access to adequate food and improving nutritional intake is an obvious solution to tackling undernutrition in children, the progress in reducing children undernutrition is disappointing.[195] Women[edit]Researchers from the Centre for World Food Studies in 2003 found that the gap between levels of undernutrition in men and women is generally small, but that the gap varies from region to region and from country to country.[196] These small-scale studies showed that female undernutrition prevalence rates exceeded male undernutrition prevalence rates in South/Southeast Asia and Latin America and were lower in Sub-Saharan Africa.[196] Datasets for Ethiopia and Zimbabwe reported undernutrition rates between 1.5 and 2 times higher in men than in women; however, in India and Pakistan, datasets rates of undernutrition were 1.5–2 times higher in women than in men. Intra-country variation also occurs, with frequent high gaps between regional undernutrition rates.[196] Gender inequality in nutrition in some countries such as India is present in all stages of life.[197] Studies on nutrition concerning gender bias within households look at patterns of food allocation, and one study from 2003 suggested that women often receive a lower share of food requirements than men.[196] Gender discrimination, gender roles, and social norms affecting women can lead to early marriage and childbearing, close birth spacing, and undernutrition, all of which contribute to malnourished mothers.[72] Within the household, there may be differences in levels of malnutrition between men and women, and these differences have been shown to vary significantly from one region to another, with problem areas showing relative deprivation of women.[196] Samples of 1000 women in India in 2008 demonstrated that malnutrition in women is associated with poverty, lack of development and awareness, and illiteracy.[197] The same study showed that gender discrimination in households can prevent a woman's access to sufficient food and healthcare.[197] How socialization affects the health of women in Bangladesh, Najma Rivzi explains in an article about a research program on this topic.[198] In some cases, such as in parts of Kenya in 2006, rates of malnutrition in pregnant women were even higher than rates in children.[199] Women in some societies are traditionally given less food than men since men are perceived to have heavier workloads.[200] Household chores and agricultural tasks can in fact be very arduous and require additional energy and nutrients; however, physical activity, which largely determines energy requirements, is difficult to estimate.[196] Physiology[edit]Women have unique nutritional requirements, and in some cases need more nutrients than men; for example, women need twice as much calcium as men.[200] Pregnancy and breastfeeding[edit]During pregnancy and breastfeeding, women must ingest enough nutrients for themselves and their child, so they need significantly more protein and calories during these periods, as well as more vitamins and minerals [especially iron, iodine, calcium, folic acid, and vitamins A, C, and K].[200] In 2001 the FAO of the UN reported that iron deficiency affected 43 percent of women in developing countries and increased the risk of death during childbirth.[200] A 2008 review of interventions estimated that universal supplementation with calcium, iron, and folic acid during pregnancy could prevent 105,000 maternal deaths [23.6 percent of all maternal deaths].[201] Malnutrition has been found to affect three quarters of UK women aged 16–49 indicated by them having less folic acid than the WHO recommended levels.[202] Frequent pregnancies with short intervals between them and long periods of breastfeeding add an additional nutritional burden.[196] Educating children[edit]"Action for healthy kids" has created several methods to teach children about nutrition. They introduce 2 different topics, self-awareness which teaches children about taking care of their own health and social awareness, which is how culinary arts vary from culture to culture. As well as its importance when it comes to nutrition. They include eBooks, tips, cooking clubs. including facts about vegetables and fruits.[203] Team Nutrition has created "MyPlate eBooks" this includes 8 different eBooks to download for free. These eBooks contain drawings to color, audio narration, and a large number of characters to make nutrition lessons entertaining for children.[204] According to the FAO, women are often responsible for preparing food and have the chance to educate their children about beneficial food and health habits, giving mothers another chance to improve the nutrition of their children.[200] Elderly[edit]Malnutrition and being underweight are more common in the elderly than in adults of other ages.[205] If elderly people are healthy and active, the aging process alone does not usually cause malnutrition.[206] However, changes in body composition, organ functions, adequate energy intake and ability to eat or access food are associated with aging, and may contribute to malnutrition.[207] Sadness or depression can play a role, causing changes in appetite, digestion, energy level, weight, and well-being.[206] A study on the relationship between malnutrition and other conditions in the elderly found that malnutrition in the elderly can result from gastrointestinal and endocrine system disorders, loss of taste and smell, decreased appetite and inadequate dietary intake.[207] Poor dental health, ill-fitting dentures, or chewing and swallowing problems can make eating difficult.[206] As a result of these factors, malnutrition is seen to develop more easily in the elderly.[208] Rates of malnutrition tend to increase with age with less than 10 percent of the "young" elderly [up to age 75] malnourished, while 30 to 65 percent of the elderly in home care, long-term care facilities, or acute hospitals are malnourished.[209] Many elderly people require assistance in eating, which may contribute to malnutrition.[208] However, the mortality rate due to undernourishment may be reduced.[210] Because of this, one of the main requirements of elderly care is to provide an adequate diet and all essential nutrients.[211] Providing the different nutrients such as protein and energy keeps even small but consistent weight gain.[210] Hospital admissions for malnutrition in the United Kingdom have been related to insufficient social care, where vulnerable people at home or in care homes are not helped to eat.[212] In Australia malnutrition or risk of malnutrition occurs in 80 percent of elderly people presented to hospitals for admission.[213] Malnutrition and weight loss can contribute to sarcopenia with loss of lean body mass and muscle function.[205] Abdominal obesity or weight loss coupled with sarcopenia lead to immobility, skeletal disorders, insulin resistance, hypertension, atherosclerosis, and metabolic disorders.[207] A paper from the Journal of the American Dietetic Association noted that routine nutrition screenings represent one way to detect and therefore decrease the prevalence of malnutrition in the elderly.[206] See also[edit]
References[edit]
External links[edit]
What is the most common type of malnutrition in developing countries?Deficiencies of iron, vitamin A and zinc are ranked among the World Health Organization's [WHO] top 10 leading causes of death through disease in developing countries: Iron deficiency is the most prevalent form of malnutrition //www.wfp.org/nutritionworldwide, affecting millions of people.
Which is the most common cause of childhood malnutrition?Poverty is the number one cause of malnutrition in developing countries. Often times, families living in poverty lack access to fresh fruits and vegetables.
What is the most common form of malnutrition?Obesity-the most prevalent form of malnutrition.
What are the types of malnutrition in children?There are 4 broad sub-forms of undernutrition: wasting, stunting, underweight, and deficiencies in vitamins and minerals.
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