problem solving approach in protein energy malnutrition

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Protein-Energy Malnutrition

Protein-energy malnutrition (PEM) is classically described as 1 of 2 syndromes, marasmus and kwashiorkor, depending on the presence or absence of edema. Each type may be classified as acute or chronic. Additionally, marasmus can precede kwashiorkor. Many patients exhibit symptoms of both disease states.

Marasmus , or PEM without edema , is defined as inadequate intake of all nutrients, but especially energy. Its extreme form is characterized by muscle wasting and depletion of body fat stores. Other findings may include hypothermia, bradycardia, hypotension, decreased metabolic rate, loss of skin turgor, and constipation.

Kwashiorkor , or PEM with edema , is characterized by muscle atrophy, maintenance or gain of body fat, and peripheral edema. Other characteristics include anasarca (generalized edema), hepatomegaly, dry and peeling skin, anorexia, hypothermia, and apathy.

The exact pathogenesis of kwashiorkor is unknown. [1] Derived from an African term meaning “the disease that occurs when the next baby is born,” kwashiorkor was initially thought to result from a diet high in calories (mainly carbohydrates, such as maize) yet deficient in protein; however, recent evidence points away from dietary protein deficiency as the primary cause. While many of these patients exhibit hypoalbuminemia, this is thought to be a consequence of the disease and not a trigger. Aflatoxin poisoning, oxidative stress, immune system dysfunction, and the gut microbiota may play causative roles. [2] [3] [4] [5]

Mixed marasmus-kwashiorkor (edematous malnutrition) can occur in those who have inadequate dietary intake of all nutrients. This condition is typically triggered by an infection or inflammatory state.

PEM affects multiple organ systems and therefore places affected individuals at increased risk of severe illness and death by increasing the likelihood of micronutrient deficiencies, dehydration, infection, and sepsis.

PEM is primarily a problem in resource-limited countries. Worldwide, PEM is a leading cause of death in children under the age of 5, with the highest prevalence in Africa and Southeast Asia. [6] PEM is also found in developed countries under various circumstances, including anorexia nervosa, cancer, hemodialysis, dementia, and severe chronic disease states. The condition has also been found in infants placed on severely restricted diets and in 5% of a population of patients who underwent Roux-en-Y gastric bypass surgery to control obesity. [7] [8] [9]

Diagnosis of PEM is based on a variety of factors. While it was once thought that serum albumin levels were indicative of nutrition status, new guidelines indicate this measure does not take into account the complexity of hepatic protein synthesis. Altered serum albumin and pre-albumin levels can be accounted for by a number of factors, including the acute-phase response, hydration status, disease state, clinical condition, albumin leakage from intra- to extra-vascular spaces, and severe zinc deficiency. [10]

In lieu of albumin levels, the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition have established new standards to diagnose malnutrition in adults. Rather than a single parameter, the recommendations are based on a set of measurable characteristics indicative of nutrition status. To be diagnosed with PEM, patients must meet at least 2 out of the following 6 characteristics: insufficient energy intake, significant weight loss, loss of muscle, loss of subcutaneous fat, fluid accumulation unrelated to hypervolemia, and reduced hand-grip strength. [9]

Treatment for PEM varies based on the severity and etiology of the problem. Patients suffering from eating disorders will need an appropriate dietary intervention in conjunction with mental health support. Malnutrition due to social/environmental reasons or food insecurity may require a case-management consultation to help the patient connect with resources. For hospitalized patients, a team approach that includes the doctor, nurse, dietitian, and other clinicians is recommended to implement an appropriate nutrition care plan. Patients with malnutrition may benefit from oral nutrition supplements and, in some cases, parenteral or enteral nutrition to help improve nutrition status. Lastly, regardless of etiology, nutrition education is essential for long-term health of a patient with malnutrition. [11]

Some individuals treated for PEM are at risk for refeeding syndrome, in which hypophosphatemia, hypokalemia, and hypomagnesemia may lead to disturbances in the cardiac, neurologic, gastrointestinal, respiratory, hematologic, skeletal, and endocrine systems. The World Health Organization has developed guidelines to help prevent these complications and to establish a transition to normalcy. Treatment consists of 3 phases: stabilization, rehabilitation, and follow-up. [12]

The initial (stabilization) phase proceeds from days 1-7. It consists of treatment and prevention of hypoglycemia, hypothermia, dehydration, and infection; correction of electrolyte imbalance and micronutrient deficiencies; and a cautious feeding regimen. A rehabilitation phase proceeds from weeks 2-6, and consists of achievement of catch-up growth, provision of sensory stimulation, and emotional support.

Follow-up is necessary, as some patients relapse. Provision of nutritional supplements is recommended for those of all ages affected by PEM to prevent malnutrition from recurring. Furthermore, education on the benefits of breastfeeding and hygiene have also been found to be helpful interventions in the pediatric population. [5]

• Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc . 2004;104(8):1258-64.   [PMID:15281044]
• Hendrickse RG. Of sick turkeys, kwashiorkor, malaria, perinatal mortality, heroin addicts and food poisoning: research on the influence of aflatoxins on child health in the tropics. Ann Trop Med Parasitol . 1997;91(7):787-93.   [PMID:9625935]
• Sive AA, Dempster WS, Malan H, et al. Plasma free iron: a possible cause of oedema in kwashiorkor. Arch Dis Child . 1997;76(1):54-6.   [PMID:9059163]
• GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet . 2020;396(10258):1204-1222.   [PMID:33069326]
• Kuhl J, Davis MD, Kalaaji AN, et al. Skin signs as the presenting manifestation of severe nutritional deficiency: report of 2 cases. Arch Dermatol . 2004;140(5):521-4.   [PMID:15148094]
• Carvalho NF, Kenney RD, Carrington PH, et al. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics . 2001;107(4):E46.   [PMID:11335767]
• Faintuch J, Matsuda M, Cruz ME, et al. Severe protein-calorie malnutrition after bariatric procedures. Obes Surg . 2004;14(2):175-81.   [PMID:15018745]
• Marcason W. Should Albumin and Prealbumin Be Used as Indicators for Malnutrition? J Acad Nutr Diet . 2017;117(7):1144.   [PMID:28648265]
• Tappenden KA, Quatrara B, Parkhurst ML, et al. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet . 2013;113(9):1219-37.   [PMID:23871528]

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Home > Books > Malnutrition

Malnutrition: Current Challenges and Future Perspectives

Submitted: 03 September 2019 Reviewed: 05 March 2020 Published: 11 November 2020

DOI: 10.5772/intechopen.92007

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Malnutrition

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Achievement of good nutrition is important in Universal Healthcare; hence, all stakeholders should be updated regarding management of malnutrition and challenges encountered, especially in resource-constrained societies of the world. Coexistence of multiple predisposing factors of malnutrition therefore compounds its diagnosis and management. It is of paramount importance therefore that the vulnerable population should be provided with adequate knowledge to alleviate the nutritional challenges they encounter. Capacity building of the healthcare personnel that are entrusted to serve such vulnerable societies should be improved appropriately. Healthy nutrition policy makers, implementers, and evaluators in all healthcare sectors should be conversant with new developments in management of malnutrition and challenges including those encountered in case studies, such as one recently encountered in Kenya, during the management of isoniazid induced pellagra (IPT) in a TB patient also on antiretroviral therapy. Food fortification, nixtamalization, provision of ready-to-use therapy foods (RUTFs), and innovative lipid-based nutrient supplements are relatively new areas whose nutrition policy makers, implementers, and evaluators should be well updated in. As part of nutrition optimization among those at risk, the nonadherence to exclusive breastfeeding for at least 6 months, which globally remains unacceptably high (59%), should urgently be addressed through appropriate and widespread counseling.

• breastfeeding
• fortification
• innovative lipid-based nutrient supplements
• malnutrition
• nixtamalization
• optimization
• universal healthcare

Author Information

Joseph kiprop choge *.

• Department of Clinical Medicine, University of Kabianga, Kenya

*Address all correspondence to: [email protected]

1. Introduction

Malnutrition has been clearly described by the World Health Organization, among other entities dealing with the professional aspects of the subject matter [ 1 , 2 ]. The nutritional imbalance can be classified in various ways, especially for purposes of proper and adequate management. Currently, the categories of malnutrition include undernutrition, overweight, and obesity, among others that will be substantiated shortly. The study of malnutrition, especially in developing countries, will remain important for a long time to come. This is because vulnerable communities, families, and/or individuals therein are likely to be adversely affected, with consequences of morbidity and mortality. Significantly large proportions (about 50%) of children aged five and below die from malnutrition and its complications, including infections. The severity, prevalence, and incidence of such infections may delay recuperation. Stunted growth and impaired cognitive and other aspects of child development may adversely affect learning of children during their first few years (more so the first 1000 days of life).

2. Worrying global prevalence trends of malnutrition

According to 2019 statistics from the World Health Organization and UNICEF [ 1 , 2 , 3 ], malnutrition is cosmopolitan, and its prevalence remains unacceptably high, consequently impacting negatively on the lives of the affected children. Approximately one third of women of reproductive age had anemia, while obesity affected a slightly higher proportion (39%) of the world’s adult population. Underweight babies constitute a further 20 million, despite a noted slow decline in stunted growth. In 2018, just over a fifth (21.9%) of the world’s children aged five had stunted growth, despite its overall global prevalence decline from 32.5% during the period between the years 2000 and 2018. During the same period, the population of stunted children decreased in terms of millions (from 198.2 to 149.0). Of this proportion, nearly 40% lived in South Asia, and a similar proportion lived in Africa south of Sahara (SSA), although an alarming proportional increase has been noted from west and central Africa (22.4 million to 28.9 million). Earlier in 2010, 49 million children aged five and below were wasted, while a further 17 million suffered from severe wasting thus translating to 7.3 and 2.4%, respectively. One worrying global trend is the fact that about 45% of mortality among children aged five and below is linked to malnutrition, the bulk of these occurring in low- and middle-income countries. A further global trend is that 528 million (29%) of reproductive-age women are vulnerable to anemia occasioned by inadequate dietary iron supplementation. In the low and middle - income Countries, the rates of childhood obesity and overweight were on the rise, estimated to nearly threefold rise in prevalence during the period between the years 2000 and 2018 alone, in Eastern Europe, Central Asia, the Middle East, and Northern Africa. The prevalence in these regions ranges between 8.8 and 11.2%, respectively. Eastern and south-east Asia, the Pacific, and northern Africa account for more than a third of the world’s overweight children. The gender distribution of these statistics tends to show higher stunting rates among boys than girls. This is thought to be due to the fact that boys have relatively higher risk of low birth weight and preterm birth than girls. These disparities were noted to be prevalent in Latin America, South-ease Asia, and the Caribbean. More attention should then be placed on these regions by those dealing with intervention measures. WHO [ 3 ] report also cites that those who are at risk of malnutrition include infants, children, women, and adolescents and that optimization of nutrition early in life (specifically within the first 1000 days of life) will ensure the child gets the best possible start in life with its life-long benefits. Unfortunately, the nonadherence to the recommended prevalence of breastfeeding practices among many societies of the world remains relatively low and worrying, since only 41% (hence 59% non-compliance) of infants aged 6 months or less were exclusively breastfed and only 45% were continually breastfed for at most 2 years in 2017 [ 4 ].

3. Factors contributing to good nutrition

Before we consider the factors that predispose to malnutrition, let us first discuss the factors that contribute to good nutrition. These factors play an important role, especially in places where the resources are inadequate for the affected society and/or families [ 5 ]. Many of these factors are intertwined, especially in developing countries, where small-scale subsistence farming is practiced. The most notable of these are good agricultural practices, good and vibrant economy, healthy enabling environment, healthy social and family life, good antenatal and perinatal care, and early screening and control of preventable diseases. We shall now revisit each of these factors.

3.1 Good agricultural practices

Parents and household heads need to take responsibility in ensuring good agricultural practices (especially clearing farm land at the right time, planting sufficient good crops, using irrigation and fertilizer where necessary, getting appropriate advice from agricultural extension workers, harvesting at the right time, and safe storing the food to avoid losses through pests, a good transport and distribution system to get enough good food to all regions) are done appropriately. Chronic and irresponsible alcoholism by those charged with providing for the family, for example, may lead to poor (or inadequately productive) agricultural practices that will lead to loss of family income, poverty, and family neglect and may lead to malnutrition, among other health challenges in the family. Improvement of nutrition and prevention of malnutrition require energetic and cooperative efforts directed toward all these factors.

3.2 Good and vibrant economy

Those in influential leadership and governance of societies should on priority basis ensure there is a good economy in place. This should guarantee sufficient resources allocated to support adequate food and fuel/energy, health and education, and good education, among other society needs. Unfortunately, this is not always the case in many parts of the world, especially in developing countries.

3.3 Healthy enabling environment

Each country should ensure there is equitable availability and distribution of safe and sufficient water for drinking, cooking, cleaning, and other uses. Environmental sanitation and sewage treatment and management should also be appropriate. If this kind of environment is lacking, then the affected society will be vulnerable to many health problems, including related nutrition challenges.

3.4 Good education

Provision of appropriate and adequate knowledge on good nutrition and child health to the societies is critical. In most developing countries, this can effectively be done by those charged with the responsibility of disseminating such knowledge to schools, families, and any other modes of communication to large populations. Through good health education, the right attitudes and practices that promote good nutrition to the most vulnerable groups (especially children and mothers) will be guaranteed.

3.5 Healthy social and family life

Dissemination of adequate knowledge on family planning matters, at the right time to the right audience, is important. The right size of and the availability of adequate resources to the family and the presence of a health social environment in a family are paramount. This will ensure adequacy of food and attention to the whole family, especially younger children who usually need more care. Arrangements to ensure adequate resources for food, shelter, and other needs are maintained even if either or both parents have to work and a caretaker has to look after the children in their absence. Good supervision to ensure children get adequate and appropriate food should be in place at all times (at home, in day-care centers, and other such places); otherwise, some children might become malnourished. Care for children from broken or incomplete families directly affects nutritional status, especially if the social integration and communal care are lacking.

3.6 Good antenatal and perinatal care

Pregnant mothers require good antenatal care, especially to ensure good nutrition during pregnancy in order to avoid giving birth to low birth weight babies and to prevent intrauterine growth retardation and prematurity.

3.7 Early screening and control of preventable diseases

Immunization and vaccinations done appropriately at the right time to the right people will ensure early detection and prevention of diseases. Early screening for congenital malformations that interfere with child’s eating or food utilization (such as cleft lip/palate, congenital hypertrophic pyloric stenosis) can alleviate related health problems and their management.

4. Factors predisposing to malnutrition

Globally, inadequate food intake is the most common cause of malnutrition: [ 5 , 6 ]. In developing countries, inadequate food intake may be due to poverty, insufficient, or inappropriate food supplies or early weaning and premature stopping of breastfeeding. Ignorance about the need to have a balanced diet (and lack of adequate knowledge about the appropriate food and the right quantities needed by each family member) and ignorance about the importance of breastfeeding may be important contributing factor(s) in some places, especially if those endowed with the responsibility of disseminating the right knowledge fail to do it appropriately. Psychosocial issues, such as premature death of a breastfeeding mother, deliberate maternal deprivation from whatever reason may also contribute to childhood malnutrition. Single mothers (due to death of a spouse, separation, or divorce) may also face the challenge of premature stoppage of breastfeeding, owing to the fact that such mothers have to constantly provide food and other needs for the family, without the help of a spouse. This challenge might also contribute to maternal deprivation of adequate food to the baby, abuse of the rights toward the baby, especially if the baby was born out of unplanned pregnancy. The introduction of breast milk banks has alleviated this problem in certain places, but adequate health education of the safety and convenience of this approach has not yet been fully embraced culturally by many societies. The fear of disease transmission through breast milk remains a hindrance of new approaches of providing breast milk to babies whose mothers are missing or are not able to produce enough breast milk. In some areas, cultural and religious food customs may play a role. For example, ignorance of what constitutes a balanced diet can contribute to malnutrition. Consequently, certain families might sell most food sources they produce and actually need for the family, in order to buy larger quantities of food supplies they do not actually need. Poor family planning is a major problem in some cultures, especially where polygamy and bearing many children are encouraged, without due regard to limited available resources to support the families. Poor personal and environmental hygiene, due to inadequate sanitation, may aggravate situation by encouraging food contamination during food handling, preparation, and consumption. Consequently, the affected individuals will suffer from inherent risks of dangerous infectious diseases that will increase nutritional losses and/or altered metabolic demands. This scenario is likely to lead to repeated infections if the infrastructure lacks well-maintained sewage and sanitation facilities and/or supply of adequate clean water. Constant or frequent exposure to infection/infestation with intestinal and other worms such as hook worms and fish tape worms, among others will also predispose to nutritional iron deficiency anemia. Many people living under deplorable health conditions will also be exposed to many other parasites, including ascariasis, which contribute to food deprivation.

Chronic disease conditions and illnesses are important etiological factors of malnutrition: [ 5 , 6 ]. This is especially more so in developed countries. People with chronic illnesses (especially children) are at relatively higher risk of nutritional problems. Some of the contributing factors include the following: chronic illnesses are frequently associated with loss of appetite and therefore intake of inadequate food. Some chronic illnesses are also associated with increased metabolic demands, hence increasing caloric needs. Any chronic illness that adversely affects the liver, pancreas, or intestines has the potential of adversely impairing food digestion and absorption. Other chronic illnesses that are associated with malnutrition include surgical diseases (such as cleft lip and/or palate, chronic hypertrophic pyloric stenosis), malignancies, congenital heart diseases, chronic renal failure, chronic bowel inflammatory diseases (such as ulcerative colitis), neuromuscular diseases, and cystic fibrosis, among others. Furthermore, risk of nutritional deficiency may be due to prematurity, failure to thrive for whatever cause, and exposure to toxins in utero (e.g., alcohol intake during pregnancy).

People with multiple food allergies (especially children) may become malnourished, due to challenges of dietary restrictions: [ 5 , 6 ]. People with active allergic symptoms may have increased calorie and protein needs. This is partly because their state of morbidity predisposes them to lack of appetite during the time of ill-health and therefore without extra dietary supplements they might become malnourished. Furthermore, the allergy to certain foods denies them the benefit of the nutrients found in the food they are allergic to. If there is lack of appropriate dietary substitute, then the affected individuals will become malnourished with time.

5. Classification of malnutrition

Malnutrition can be classified into different categories [ 3 , 7 ], namely, undernutrition, overnutrition, micronutrient-related malnutrition, severe acute (SAM), moderate acute (MAM), and global acute malnutrition (GAM), respectively. The assessment of body mass index (BMI) is one of the major ways of differentiating some of these categories. Details of BMI will be given later in the chapter.

Undernutrition consists of stunting, wasting, underweight, and micronutrient deficiencies. Stunting refers to a situation whereby children have a lower than normal height-for-age. Wasting refers to lower than normal weight-for-height, while underweight refers to lower than normal weight-for-age. Micronutrient deficiency refers to inadequate intake of vitamins and minerals. In more technical terms, the World Health Organization [ 3 ] defines these terms as follows. Underweight is defined as weight for age < −2 standard deviations (SD) of the WHO Child Growth Standards median. Stunting is defined as height for age < −2 SD of the WHO Child Growth Standards median. Wasting is defined as weight for height < −2 SD of the WHO Child Growth Standards median. The predisposing factors to some of these are known. Low birth weight is associated with intrauterine growth retardation or restriction, prematurity, or both. This situation is likely to ultimately predispose to poor health in the vulnerable societies. These situations, in addition to aggravating growth and cognitive and chronic disease development in adulthood, also predispose to morbidity and mortality, especially of neonates. Low-birth-weight infants are 20 times more likely to die of these than healthier infants.

Overnutrition comprises obesity and overweight. These are important because they are increasingly associated with lifestyle disorders, notably diabetes mellitus and cardiovascular diseases capable of complicating to stroke and even cancer that are responsible for morbidity and mortality from noncommunicable diseases. In more technical terms, overweight is defined as weight for height > +2 SD of the WHO Child Growth Standards median. Whereas undernutrition is prevalent among societies with inadequate food and the other predisposing factors already described, overnutrition is conversely associated with more affluent societies who tend to live more sedentary lives and can afford more palatable and fast-prepared junk food. These types of food stuffs are relatively cheap and readily available to a large section of the world population. No wonder the upsurge in related nutritional disorders. Variations in nutritional status may also be seen in individual families in a given community.

Micronutrient-related malnutrition occurs due to inadequate intake of vitamins and minerals. Micronutrients enable the body to produce enzymes, hormones, and other essential substances needed for proper growth and development of the human body. Among the micronutrients most essential are iodine, vitamin A, and iron. The deficiency of these micronutrients paused major health threats especially among children and pregnant women from low socioeconomic status.

The following categories are mainly for purposes of management of malnutrition [ 8 ]. Moderate acute malnutrition (MAM) refers to weight-for-height z -score (WHZ) between −2 and −3 or mid-upper arm circumference (MUAC) between 115 and <125 mm. Severe acute malnutrition (SAM) refers to WHZ < −3 or MUAC <115 mm, or the presence of bilateral pitting edema, or both. Global acute malnutrition (GAM) refers to the combination of MAM and SAM and is used as a measurement of nutritional status at a population level and as an indicator of the severity of an emergency situation. The prevalence thresholds for severity of malnutrition among children aged five and below are described elsewhere [ 5 , 9 , 10 , 11 ].

6. Historical background and importance of classifying malnutrition

Part of the documented historical background of the classifications of malnutrition dates back to 1956, when Gómez and Galvan studied the factors they thought were associated with death among malnourished children Mexico City [ 12 ]. Initially, this classification was based on first, second, and third degrees, respectively [ 13 ]. The degrees were based on weight below a specified percentage of median weight for age [ 9 ] According to this classification, the risk of death increases with increasing degree of malnutrition [ 13 ]. An adaptation of Gomez’s original classification is still used today. Whereas this modification provides a way of comparing malnutrition within and between populations, this classification has been criticized as too arbitrary and does not consider overweight as a classification of malnutrition, apart from the fact that 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 [ 14 ]. Nevertheless, the criticism led to the establishment of a new classification of malnutrition by John Conrad Waterlow [ 15 ]. Waterlow classification therefore combines weight-for-height (indicating acute episodes of malnutrition) with height-for-age to show the stunting that results from chronic malnutrition [ 16 ]. One advantage of the Waterlow classification over the Gomez classification is the fact that weight for height can be examined even if ages are not known [ 15 ]. The World Health Organization has since modified some of these classifications [ 9 ].

7. Importance of malnutrition classification in children

Stunting, wasting, underweight, and overweight indicators are important for assessing nutritional imbalance resulting in undernutrition among children, according to the World Health Organization [ 12 ]. As far as child growth is concerned, it is internationally recognized as an important indicator of health in populations. It is also important as indicator for nutritional status. The cumulative effects of malnutrition and the consequent complications among children are reflected by the percentages of children with stunting (low height for age) from and even before birth. The degree of stunting can therefore be interpreted as an indicator for the existence of poor environmental conditions that have the potential of restricting child growth. The proportion of underweight and/or wasted children also indicates acute weight loss, stunting, or both. Hence, it may be difficult to interpret ‘underweight’ because it is a composite indicator. Thus, underweight, even in its mildest form, indicates increased risk of childhood mortality, and this risk increases among severely underweight children. Inadequate food and recurrent childhood infections also have a tendency to increase the risk of mortality among affected children. Stunting predisposes to poor child performance in school and also to delayed developmental milestones and decreased intellectual development in terms of capacity. Childhood wasting also predisposes to immunosuppression, subsequently leading to increased susceptibility to infections.

Childhood obesity may precede the same in adulthood. Overweight and obesity (especially in adolescence and childhood) increase the risk of developing short- or long-term health problems, notably cardiovascular disorders and diabetes mellitus. Also, among the risks are musculoskeletal disorders (e.g., osteoarthritis) and malignancies of the breast, colon, and/or endometrium. The assessment of nutritional status of a given population is an important indicator for moderate and/or severe malnutrition.

8. Importance of malnutrition classification in women

Chronic malnutrition may adversely affect the growth of bones in girls, such that those affected are likely to have abnormal short stature, with relatively smaller pelvis than women with normal growth. Thus, the affected women may get complications during child birth, which might cause obstructed labor that might be dangerous for the baby, the mother, or both. Other birth-related complications of such mothers include the birth of babies with lower weight than normal (low birth weight babies), retarded intrauterine growth, and short stature later in adult life. Their likely general maternal morbidity may also adversely affect quality of healthcare of the mother and baby during pregnancy.

8.1 Anthropometric measurements

The major mode of assessment of nutritional status of gravid women and children is by the use of anthropometry (the process by which anthropometric measurements are serially taken). The measurements have been developed and improved over time. These measurements taken quantitatively and involve measurements of muscle girth, bulk, and sometimes muscle power and tone if other inherent nervous system problems are suspected. Bone length and density as well as quantity of adipose tissue may also be measured. However, the main anthropometric measurements are those of weight and height, and from these two, the body mass index (BMI) may be calculated. Also important are the measurements of head circumference, waist, hip, and limb circumferences as well as the thickness of skin folds. As already discussed in the previous section, such measurements are important in assessing the nutritional status of children and pregnant mothers. For children, the individual measurements done, respectively, determine whether or not each child is normally growing, is stunted, is wasted, or is underweight. For pregnant women, the measurements will determine timely interventions of correcting the malnutrition and even the mode of delivery (normal or assisted vaginal delivery or by Cesarean section). The measurement will therefore also determine the place and cost of delivery if specialists may be required during and after delivery. The type of nutritional follow up will also be determined by the serial quantitative anthropometric measurements. In more sophisticated healthcare set-ups such as in developed countries [ 17 , 18 , 19 ], anthropometry is not only vital for timely and appropriate diagnosis of abnormalities such as microcephaly, macrocephaly, anencephaly, diabetes mellitus, hypertension, and other lifestyle-related illnesses, but it also enables early diagnosis of metabolic syndrome and dyslipidemia, among others. Furthermore, the measurements are helpful in initial assessment and progress of physical fitness of athletes and even the general population [ 18 , 19 ] and for monitoring of nutritional status of children and pregnant mothers [ 20 , 21 ] by the use of newer scientific methods in comparison to conventional ones.

However, there are situations whereby such measurements are discouraged. These include individuals who have undergone limb amputation or those with Plaster of Paris. Anthropometric measurements may be erroneous for those with gross abdominal obesity because of difficulties of locating important reference bony landmarks. Inexperienced personnel taking the measurements may also increase the chances of erroneous measurements.

The body mass index (BMI, which is the weight in kilograms divided by the square of the height in meters—kg/m 2 ) is helpful in determining the classification of obesity, overweight, or underweight in both children and adults. The range of measurements calculated in this manner, in relation to given limits for the normal and abnormal values, will determine whether or not an individual is healthy in terms of BMI. Normal weight BMI range is generally between 18.5 and 24.9. Moderate to severe thinness in adults is indicated by BMI < 17.0, whereas a BMI < 18.5 is an indication of underweight. Individuals considered overweight are those with BMI ≥ 25.0, while those considered obese have BMI ≥ 30.0. The health implications of underweight, obesity, and overweight have already been discussed in the previous section. Generally, overweight and obesity predispose to a wide range of noncommunicable diseases. Among these are malignancies of various types, musculoskeletal and respiratory disorders, gallbladder diseases, ischemic (coronary) heart disease, and associated complications such as heart attack and stroke, among others. Some of these drastically reduce the lifespan and/or quality of life of affected individuals. The significance and implications of BMI are therefore of paramount importance in public health, which cannot be anymore overemphasized.

8.2 Pathophysiology of malnutrition

Malnutrition and its complications may affect virtually part of the human body basically because the energy provided by various biomolecules, vitamins, and micronutrients is essential for all physiological and biochemical functions in the body [ 6 , 22 ]. Dietary deficiency of these nutrients therefore adversely affects the functioning of the body. Digestion of protein to produce amino acids is required for metabolism, enzymatic functions, and antibody production, among others. Micronutrients are required as cofactors for various metabolic functions essential for the body. When nutritional deficiency occurs, the body is forced to readjust its hormonal secretion and metabolic functions (a process known as reductive adaptation) in order to economize on the available nutrients for survival.

Among the adjustments are reduced thyroxine and insulin productions to minimize metabolic rate and increase glucose availability for generation of energy, respectively. Consequently, protein deficiency leads to impaired/arrested or failed physical growth and/or cognitive development. Immunity may also be suppressed due to relatively reduced antibody production occasioned by protein deficiency. Other immune response changes include decreased complement system and certain cytokine functioning, impaired phagocytosis due to decreased T-lymphocyte levels, loss of delayed hypersensitivity, and decreased secretion of immunoglobulin A (IgA). These are subsequently associated with increased susceptibility to a wide variety of infections. Diarrhea from the infections may further aggravate the situation by causing anorexia, decreased nutrient absorption (also due to villous atrophy that occurs especially in kwashiorkor), and direct nutrient losses, among other changes requiring increased metabolic needs of the body. In order for the body to meet its energy demands, the body resorts to breaking down stored fat and muscles, resulting in body wasting seen especially in marasmus. Other pathological changes within the brain that have been confirmed in various studies, include reduced myelination, brain neurons, weight and growth rate, thinning of the cerebral cortex, and changes in the dendritic spines in severely malnourished infants. Fatty degeneration of the liver and the heart coupled by small bowel atrophy and decreased intravascular volume may result in secondary hyper-aldosteronism in some. A differential diagnosis of these changes is severe mental retardation [ 22 ].

8.3 Clinical presentation of malnutrition

Protein energy malnutrition (PEM), sometimes synonymously described as undernutrition, commonly presents with a myriad of clinical symptoms and signs [ 6 ]. The complaints elicited during history taking typically include poor weight gain, slowing of linear growth, behavioral changes such as apathy (lack of interest in surroundings), irritability, anxiety, impaired social responsiveness, and some deficits in attention. Oedema, apathy, hair and skin changes, and reduction of subcutaneous tissue are frequently observable in patients with PEM [ 23 ], and the most affected are the face, arms, legs, and buttocks. It is not unusual to find coexistence of PEM with deficiency of micronutrients, especially in developing countries. The micronutrient-deficient individuals may actually present with features resembling those of PEM. Kwashiorkor and marasmus are two forms of PEM that commonly coexist (hence known as marasmic-kwashiorkor) or may be distinct as separate clinical entities [ 24 ]. PEM may cause cognitive impairment, especially if the nutritional deficiency occurs between the third trimester of pregnancy and the first 2 years of life [ 25 ]. Iron deficiency anemia in children aged 2 years and below is likely to affect brain function as an acute and probably also as a chronic occurrence. Similarly, the deficiency of folic acid has also been associated with defective development of neural tubes.

‘Kwashiorkor’, which is a Ghanaian term that means ‘the sickness the older one gets when the next sibling is born’, is caused by inadequate consumption of dietary protein [ 24 ]. The descriptive definition rightly identifies the fact that the older sibling is deprived of breast feeding and instead is weaned on a diet composed largely of carbohydrates and devoid of proteins [ 26 ], thus rendering the older sibling malnourished. The clinical presentation of kwashiorkor mainly includes but exclusive to oedema, apathy, failure to thrive, underweight, and hair changes. Oedema occurs due to hypoalbuminemia following decreased oncotic pressure and consequent fluid extravasation to tissues. Oedema affects the face and the upper and lower extremities and may be slight or gross (anasarca), depending on the degree of protein deficiency. The presence of ascites and pleural effusion suggests the existence of peritoneal infection with tuberculosis (TB peritonitis). Failure to thrive (underweight, usually between 60 and 80% of expected body weight or failed growth) commonly occurs and may be masked by oedema, especially in lower extremities. Unlike in marasmus, kwashiorkor presents with muscle wasting (but with retention of subcutaneous tissue). Wasting of muscles is especially seen on chest, upper arms, and gluteal area. Children with high intake of carbohydrates (hence known as ‘sugar babies’) but with coexisting kwashiorkor tend to have generalized puffiness and much subcutaneous fat but no skin changes. Those affected also frequently have very low albumin levels. Close observation of an affected child will typically reveal apathy (due to mental changes, making the child apathetic and miserable; hence, the child may sit the whole day without interest in food or surroundings). This is in contrast with marasmus whereby the child is extremely wasted and hungry but may even be playful and interested in surroundings. Hair changes (altered texture, loss of luster, fine, straight, soft, scarce, and easily plucked hair with color changes ranging from brown, and reddish, to gray blond or white) are observable. Skin changes are also common, depicting pigmentation or depigmentation, desquamation (flunky-paint or irregular dermatoses), or ulceration. In severe cases of kwashiorkor, the skin may resemble extensive burns over the child’s legs, buttocks, and perineum. Severe cases are prone to potentially fatal hypothermia, due to decreased basal metabolic rate (BMR); hence, the skin cannot respond to a fall in environmental temperature. Hypothermia victims may die especially at night when temperature is very low. Changes in mucous membranes include angular stomatitis, cheilosis, smooth tongue, perianal ulceration, and papillar atrophy. Hepatomegaly may occur due to fatty infiltration of the liver and also may occasion by profound but potentially fatal hypoglycemia. Gastrointestinal changes include anorexia, nausea, and vomiting. Diarrhea is nearly always profused and may result in dehydration and electrolyte imbalance. Dehydration is more chemical than infective in origin. If chemical (malabsorptive) diarrhea occurs, it causes decrease in enzymes, secondarily associated with villous atrophy (the atrophied portions are the tips where lactose is absorbed, hence resulting in lactose intolerance), low proteins, and pancreatic atrophy. Lactose intolerance may also occur and may be due to failure to absorb lactose, resulting in osmotic diarrhea. Lactose in the gut also predisposes to fermentation by normal gut flora, resulting in lactic acid formation, hypoperistalsis that may aggravate diarrhea. Anemia is frequently present and tends to display dimorphic (microcytic/macrocytic hypochromic) picture. If purpura and thrombocytopenia occur, they unfortunately indicate guarded/severe prognosis if no urgent management intervention is instituted.

‘Marasmus’ (which means ‘to waste away’) is caused by combined inadequate intake of protein and energy, which causes gaunt expression, severe wasting, leaving little or no edema, minimal subcutaneous fat, severe muscle wasting, and abnormally low serum albumin levels. Metabolism in such a child is adapted to prolonged survival [ 24 , 27 ]. In contrast to the situation in kwashiorkor, muscle wasting in marasmus is associated with loss of subcutaneous tissue. Marasmus in some semiliterate societies is sometimes described as ‘a child with an appearance of an old man wearing an oversized coat’, for lack of better description to make it better understood by those very ignorant of the dangerous situation the child is in and requiring urgent intervention. The child’s interest in surroundings and playful nature is therefore deceptive. Marasmus is typically seen in places with severe famine, conflict or war-torn areas with significant food restriction, or more severe cases of anorexia [ 24 ]. A child with marasmus may be anemic, but less so than kwashiorkor and hair changes are also fewer than in kwashiorkor. Tuberculosis and other secondary coinfections may occur and should therefore be sought carefully.

Complications of malnutrition include infections, hypothermia, hypoglycemia, anemia, dehydration, electrolyte imbalance, growth retardation/failure to thrive, and thrombocytopenia/disseminated intravascular coagulopathy (DIC), among others.

8.4 Micronutrients (vitamins, minerals, and trace elements) and their toxicities

Micronutrients (vitamins, minerals, and trace elements), in addition to essential fatty acids and amino acids [ 28 , 29 ], are important for health. Fat-soluble vitamins are A, D, E, and K, while B and C are water-soluble vitamins. Fat-soluble vitamins have a higher potential for toxicity than do water-soluble vitamins, owing to their ability to accumulate in the body. The most toxic are those vitamins that contain iron, especially the following acute ingestions by affected children. In the context of nutrition, a mineral is a chemical element required as an essential nutrient by organisms to perform functions necessary for life [ 30 , 31 ]. Since minerals are elements, they cannot be synthesized biochemically by living organisms but are obtained by plants from soil [ 32 ]. Human beings obtain most of their minerals from eating plants and animals or from drinking water [ 32 ]. The five major minerals in the human body are calcium, phosphorus, potassium, sodium, and magnesium [ 30 , 33 ]. The rest of the elements (at least 20 of them) with specific biochemical body functions are sulfur, iron, chlorine, cobalt, copper, zinc, manganese, molybdenum, iodine, and selenium, which serve as structural and functional roles and electrolytes [ 30 , 34 ]. The most abundant elements in the body are oxygen, hydrogen, carbon, and nitrogen. Calcium makes up to 99% of bones and teeth and making up about 1.5% of body weight. Phosphorus makes up about two thirds of calcium and about 1% of a person’s body weight, while the other major minerals (sodium, potassium, chlorine, sulfur, and magnesium) constitute about 0.85% of the body weight. Overall, the 11 chemical elements (H, C, N, O, Ca, P, K, Na, Cl, S, and Mg) constitute 99.85% of the human body, with the rest forming only 0.15% of the human body [ 33 ]. The main sources and clinical presentation of micronutrient deficiencies and toxicities are hereby tabulated ( Table 1 ).

Deficiencies and toxicities of micronutrients, including vitamins, minerals, and trace elements.

8.5 Useful investigations

Laboratory studies are done based on information from a complete history and physical examination [ 6 ]. The most helpful laboratory studies in assessing malnutrition in a child are hematological studies and laboratory studies evaluating protein status. Hematological studies should include a complete blood count (CBC) with red blood cell (RBC) indices, serum electrolytes, sedimentation rate, urinalysis, culture, and a peripheral smear. The blood tests help to exclude anemia from various nutritional deficiencies, including iron, folic acid, and vitamin B-12 deficiencies, which are measured by assessing serum albumin, retinol-binding protein, prealbumin, transferrin, creatinine, and BUN levels. Others include retinol-binding protein, prealbumin, and transferrin determinations that are much better short-term indicators of protein status than albumin. A better parameter to use in the field is serum albumin, since it has a longer half-life. In children who have a history of adequate food intake and signs/symptoms of malnutrition, focus is made toward identifying the cause of malnutrition. Stool specimens should be obtained if the child has a history suggestive of presence of worms or other parasites or circumstances that predispose to malnutrition. Other useful tests include thyroid functions or sweat chloride tests, liver function and triglyceride tests (for suspected liver disease), zinc levels (especially if chronic diarrhea is present), blood and urine sugar levels (to rule out diabetes mellitus), and coeliac serology tests, among other tests, depending on suspected cause(s). Nutritional assessment parameters such as height and weight (for BMI), MUAC, head circumference in children aged three and below, and others that are recognized according to the WHO standards are also done.

8.6 Treatment and management principles and prevention of malnutrition

The principles laid down for the management of malnutrition are generally applied [ 6 ]. These include the need for multi-disciplinary professional approach for specific, supportive, and preventive management. Specific and supportive treatments will largely depend on the classification of malnutrition encountered, while preventive measures will also depend on avoiding the prevalent cause and the predisposing factors encountered by those affected. Specific treatments will focus on the actual cause(s) of the malnutrition diagnosed after thorough evaluation of history, physical examination, and various investigations. These include provision of specific dietary food measured out depending on their preparation or manufacture, in addition to appropriate food supplements that may be fortified or not, depending on the prevailing cultural and socioeconomic practices encountered. Supportive management entails the need to initially manage life-threatening anemia, hypoglycemia, and/or hypothermia if these are found. Zinc [ 60 , 61 ], folic acid, iodine, and vitamins A and D, among other supplements may also be given if indicated. Any other micronutrient deficiencies must be corrected, especially for children who still require to growth and development. Prevention measures largely address the need to avoid the predisposing factors of malnutrition from recurring in future, through appropriate health education and follow-up assessment schedules and programs. Promotion of breastfeeding, appropriate weaning practices, and age-appropriate nutritional counseling are strongly recommended in developing countries where there are major challenges in getting safe alternatives for human milk. The need to address emerging trends of food fortification, Ready-to-Use Therapeutic Foods (RUFT) [ 62 ], and other related issues is also important. Supplementations that are beneficial for pregnant mothers worldwide need special appropriate attention [ 63 , 64 ]. Nutritional researches, with a view to addressing emerging and/or re-emerging nutritional challenges, such as those associated with antiretroviral and pellagra (IPT) [ 65 ] should also be encouraged.

8.7 Food fortification and nixtamalization

Food fortification [ 66 ], described as the supplementation of one or more components to improve the benefits from the natural or artificial food products [ 67 ], has received much professional and cosmopolitan attention. Food fortification is either voluntary or mandatory. Voluntary fortification gives food manufacturers the option to add minerals, vitamins, or both, to the food to be fortified, provided there is compliance with the laid down rules and regulations by Food and Drug Administration (FDA). On the other hand, mandatory fortification provides no option to do the same, in order to ensure that the significant public health need(s) is/are addressed adequately. Some of the mandatory fortifications achieved in the past include that of global iodized salt, vitamins A and D, zinc, folic acid, and iron and fortification of several B vitamins (thiamin, riboflavin, and niacin) to baking flour in certain countries, such as the United States during the 1940s onward, among many others. Such approaches by the FDA have successfully seen the reduction of neural tube defects (by 1998) among other problems. Food fortification as the major approach to the treatment of malnutrition is considered more cost effective and enables improvement of health achievable over a relatively shorter time than other forms of food aid. Many countries continue to identify their own fortification requirements and the approaches to address them; hence, fortification programs should be developed in this manner to address other common nutritional deficiencies. Iron deficiency, among many others, still needs to be addressed locally and globally. Despite the progress in food fortification, there are still major challenges to be overcome to ensure that malnutrition is well managed. However, precautions need to be taken to avoid over-fortification, by ensuring that minimum and maximum daily dietary requirements for fortification are met for each type of fortification. To achieve these, global authorities, including the World Health Organization among others that adhere to evidence-based data for such important decisions, should lead the way.

Although nixtamalization (the process for the preparation of maize/corn or other grain, by soaking and cooking them in an alkaline solution—usually lime water or wood ash lye then washed and hulled to soften them) is an ancient practice of improving the nutritional value of maize and other grains such as sorghum, some of its benefits (e.g., the ability to remove between 97 and 100% of aflatoxin from contaminated maize) [ 66 ] may continue to encourage the practice in places where maize is the staple food. The fact that pellagra was in the past found to be endemic in poor populations that used maize in southern parts of the United States during the early period of the twentieth century [ 68 ] does not rule out the possibility of the same happening in contemporary times within the developing world. It is encouraging to note that pellagra was nearly eliminated in the developed world after fortification of wheat flour was achieved [ 69 ]. However, it might remain a challenge in places where such fortification has not been fully achieved, a likely scenario in many developing countries. The fact is that case studies such as the one described in Kenya recently (although this was a patient on antiretroviral therapy and prone to drug induced pellagra on treatment for tuberculosis) [ 65 ] may suggest the need to explore the possibility of existing pellagra due to niacin deficiency and in the absence of nixtamalization—a process that is rarely practiced in some societies, despite the need for it in some. In this regard perhaps, nixtamalization may still have a place in modern societies, especially in the developing world, and may need to be explored and improved. This has in the past been done with some benefits of reducing pellagra, improving availability of dietary calcium, copper, and zinc and removal of mycotoxins (aflatoxin) that is produced by Fusarium proliferatum and Fusarium verticillioides in certain places [ 70 ]. However, other unexplored effects (beneficial and adverse) may need to be investigated through further research.

8.8 Innovative lipid-based nutrient supplements and ready-to-use therapeutic foods (RUTF)

In addition to food fortification already described, innovative lipid-based nutrient supplements have also been introduced to alleviate undernutrition in vulnerable populations (notably infants, lactating mothers, and pregnant women). The project has already been piloted in several countries, including Burkina Faso, Ghana, and Malawi, among others. Some of their products had already been fortified by 2011 [ 71 ], namely, micronutrient powder (MNP) and lipid-based nutrient supplements (LNS); these are effective in reducing anemia and iron deficiency. Both are designed to be easily consumable by infants (thus advantageous over the pill forms commonly prepared as micronutrient pill supplements). However, an evaluation study [ 72 ] suggested that the micronutrients constituted in it may alone be insufficient to stimulate linear growth. Many studies (especially on LNS) applicable to different cultural settings are ongoing, despite challenges associated with adding micronutrients into the product.

Also introduced for better management of malnutrition are Ready-to-Use Therapeutic Foods (RUTF), which are high-energy lipid-based spreads that are designed to be used for the treatment of severe acute malnutrition (SAM) and in any cultural setting [ 62 , 73 ]. F-75 and F-100 are two commonly available formulations from the World Health Organization (WHO) [ 74 ], which are used for the management of severe acute malnutrition. Their preparation process is elaborate [ 62 ], and the products are highly successful in terms of affordability and availability, in the management of malnutrition in various healthcare settings [ 73 ]. They are recommended by the World Health Organization and should gradually introduce until the child attains normal growth [ 75 , 76 ]. Some have been successfully used in African countries, especially among children aged 5 years and below [ 67 ]. Like all other new formulations, the current and future challenges that RUTF may have should to be considered especially those concerning their safety, reliability, and affordability with short- and/or long-term use.

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29-03:  Protein–Energy Malnutrition

Katherine H. Saunders; Leon I. Igel

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General considerations, pathophysiology.

• CLINICAL FINDINGS
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Decreased intake of energy or protein, increased nutrient losses, or increased nutrient requirements.

Kwashiorkor: caused by protein deficiency.

Marasmus: caused by combined protein and energy deficiency.

Protein loss correlates with weight loss: 35–40% total body weight loss can be fatal.

Protein–energy malnutrition occurs as a result of a relative or absolute deficiency of energy and protein. It may be primary, due to inadequate food intake, or secondary, as a result of other illness. For many developing nations, primary protein–energy malnutrition remains a significant health problem. It occurs in two distinct syndromes. Kwashiorkor, caused by a deficiency of protein in the presence of adequate energy, is typically seen in weaning infants at the birth of a sibling where foods containing protein are insufficient. Marasmus, caused by combined protein and energy deficiency, is seen where adequate quantities of food are not available.

In industrialized societies, protein–energy malnutrition is most often secondary to other diseases. Kwashiorkor-like secondary protein–energy malnutrition occurs primarily in hypermetabolic acute illnesses such as trauma, burns, and sepsis. Marasmus-like secondary protein–energy malnutrition typically results from chronic diseases such as chronic obstructive pulmonary disease (COPD), heart failure, cancer, or AIDS. A substantially greater number of patients have risk factors that could result in them. In both syndromes, protein–energy malnutrition is caused either by decreased intake of energy and protein or by increased nutrient losses related to underlying illness. For example, diminished energy intake may result from poor dentition or various gastrointestinal disorders. Increased nutrient losses may result from malabsorption, diarrhea, and glycosuria. Increased nutrient requirements occur with fever, surgery, neoplasia, and burns.

Protein–energy malnutrition affects every organ system. The most obvious results are loss of body weight, adipose stores, and skeletal muscle mass. Weight losses of 5–10% are usually tolerated without loss of physiologic function; losses of 35–40% of body weight can result in death. Loss of protein from skeletal muscle and internal organs is usually proportionate to weight loss. Protein mass is lost from the liver, gastrointestinal tract, kidneys, and heart.

As protein–energy malnutrition progresses, organ dysfunction develops. Hepatic synthesis of serum proteins decreases, and depressed levels of circulating proteins are observed. Cardiac output and contractility are decreased, and the electrocardiogram (ECG) may show decreased voltage and a rightward axis shift. Autopsies of patients who die with severe undernutrition show myofibrillar atrophy and interstitial edema of the heart.

Respiratory function is affected primarily by weakness and atrophy of the muscles of respiration. Vital capacity and tidal volume are depressed, and mucociliary clearance is abnormal. The gastrointestinal tract is affected by mucosal atrophy and loss of villi of the small intestine, resulting in malabsorption. Intestinal disaccharidase deficiency and mild pancreatic insufficiency also occur.

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Malnutrition in the Elderly pp 59–68 Cite as

Causes of protein-energy malnutrition

• David R. Thomas MD, FACP 2  
• Conference paper

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In developed countries, medical conditions, rather than lack of food, are the main contributors to malnutrition. Undernutrition is especially common in older persons, occurring in 5–12% of community-dwelling older persons, in 30–61% of hospitalized older persons, and in 40–85% of persons in long-term care institutions. The multi-factorial nature of undernutrition in the elderly forces a structured differential diagnostic approach to determine underlying causes. Heightened physician awareness of nutritional problems and prompt risk assessment is imperative to prevent the sequelae of undernutrition. This structured approach to the differential diagnosis is essential to evaluate potentially reversible causes of malnutrition.

• Chronic Obstructive Pulmonary Disease
• Nursing Home
• Anorexia Nervosa
• Nursing Home Resident
• Malabsorption Syndrome

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Thomas, D.R. (1999). Causes of protein-energy malnutrition. In: Seiler, W.O., Stähelin, H.B. (eds) Malnutrition in the Elderly. Steinkopff. https://doi.org/10.1007/978-3-642-47073-8_8

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17 Severe protein–energy malnutrition

• Published: January 1993
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This chapter focuses on severe protein-energy malnutrition (PEM) — now called severe acute malnutrition (SAM) — in children. It explains the cause and signs of the three type of PEM: marasmus, kwashiorkor, and marasmic kwashiorkor. It discusses the dangers of PEM, management of severe malnutrition in children, medical treatment, phases of recovery, and monitoring recovery. Note that there are now new guidelines on the management of SAM.

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• Pan Afr Med J

Malnutrition in Sub – Saharan Africa: burden, causes and prospects

Luchuo engelbert bain.

1 Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Israel - Centre for Population Studies and Health Promotion, CPSHP, BP 7535, Yaoundé, Cameroon

2 Faculty of Arts, Letters and Social Sciences, FALSS, University of Yaoundé I, Cameroon

Paschal Kum Awah

3 Faculty of Science, University of Dschang, Cameroon

Ngia Geraldine

4 Awing District Hospital, Santa Health District, Bamenda, Cameroon

Njem Peter Kindong

Yelena sigal, nsah bernard.

5 Faculty of Health Sciences, University of Buea, Cameroon

Ajime Tom Tanjeko

Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. Contributing to more than half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001. Poverty remains the major contributor to this ill. The vicious cycle of poverty, disease and illness aggravates this situation. Grooming undernourished children causes children to start life at mentally sub optimal levels. This becomes a serious developmental threat. Lack of education especially amongst women disadvantages children, especially as far as healthy practices like breastfeeding and child healthy foods are concerned. Adverse climatic conditions have also played significant roles like droughts, poor soils and deforestation. Sociocultural barriers are major hindrances in some communities, with female children usually being the most affected. Corruption and lack of government interest and investment are key players that must be addressed to solve this problem. A multisectorial approach is vital in tackling this problem. Improvement in government policy, fight against corruption, adopting a horizontal approach in implementing programmes at community level must be recognized. Genetically modified foods to increase food production and to survive adverse climatic conditions could be gateways in solving these problems. Socio cultural peculiarities of each community are an essential base line consideration for the implementation of any nutrition health promotion programs.

Introduction

Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause [ 1 ]. Malnutrition literally means “bad nutrition” and technically includes both over- and under- nutrition. The World Food Programme (WFP) defines malnutrition as “a state in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance process such as growth, pregnancy, lactation, physical work and resisting and recovering from disease”[ 1 ]. Contributing to more than half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001 [ 2 , 3 ]. Protein-energy malnutrition (PEM), first described in the 1920s, is observed most frequently in developing countries but has been described with increasing frequency in hospitalized and chronically ill children in the United States [ 4 ].

Poor environmental conditions may increase insect and protozoan infections and also contribute to environmental deficiencies in micronutrients. Overpopulation, more commonly seen in developing countries, can reduce food adequacy, leading to inadequate food intake or intake of foods of poor nutritional quality and quantity. Conversely, the effects of malnutrition on individuals can create and maintain poverty, which can further hamper economic and social development [ 3 ]. This is explained with children starting life with low intellectual quotients and being impossible later to offer the best of their expected intellectual abilities.

Kwashiorkor and marasmus are two forms of Protein Energy Malnutrition (PEM) that have been described. The distinction between the two forms of PEM is based on the presence of edema (kwashiorkor) or absence of edema (marasmus). Marasmus involves inadequate intake of protein and calories, whereas a child with kwashiorkor has fair-to-normal calorie intake with inadequate protein intake. Although significant clinical differences between kwashiorkor and marasmus are noted, some studies suggest that marasmus represents an adaptation to starvation whereas kwashiorkor represents a dys-adaptation to starvation.

In addition to PEM, children may be affected by micronutrient deficiencies, which also have a detrimental effect on growth and development. The most common and clinically significant micronutrient deficiencies in children and childbearing women throughout the world include deficiencies of iron, iodine, zinc, and vitamin A and are estimated to affect as many as two billion people. Although fortification programs have helped diminish deficiencies of iodine and vitamin A in individuals in the United States, these deficiencies remain a significant cause of morbidity in developing countries, whereas deficiencies of vitamin C, B, and D have improved in recent years. Micronutrient deficiencies and protein and calorie deficiencies must be addressed for optimal growth and development to be attained in these individuals.

We searched medical literature in biomedical databases PUBMED, OVID and Google scholar using the following key words: “Malnutrition”, “Burden”, “Determinants”, “Causes”, and “Sub - Saharan Africa”. The search was limited to articles published in and after 1993. The bibliographies of the articles on hand were used to find other references. We also searched through indexes of major journals that publish on malnutrition in Sub-Saharan africa. Of the 267 articles we found only 29 were included in the final review. These were articles that had data on determining factors and burden of malnutrition in Sub-Saharan Africa. A critical analysis that entailed systematic review of these articles in Sub Saharan-Africa, relevant to malnutrition information was done.

Current status of knowledge

Context and rationale.

The impact of malnutrition usually falls mainly on children under five years of age [ 1 ]. Conceptually speaking, malnutrition generally involves nutrition and obesity. Africa is going through a rapid sociodemographic transition, with an alarming increase in incidences of obesity, diabetes mellitus, cardiovascular diseases (stroke and myocardial infarction). Our main focus will be under nutrition. Despite the millennium development goals target to reduce hunger by half by 2015, major failures have been recorded mainly in Africa. Out of the 800 million people still suffering from hunger in the world, over 204 million come from Sub-Saharan Africa. The situation is currently getting worse in this region as it moved from 170.4 million hungry people in 1990 to 204 million in 2002 [ 5 ]. This increase has generally been attributed to poverty, illiteracy, ignorance, big family size, climate change, policy and corruption. Infectious diseases are the major cause of mortality and morbidity in developing countries. PEM is also associated with a number of co morbidities such as lower respiratory tract infections including tuberculosis, diarrhea diseases, malaria and anemia. These co-morbidities may prolong the duration of hospital stay and death among affected children [ 6 , 7 ].

Food security in Sub-Saharan Africa

Food security is said to exist if at all times, people have a physical and economic access to sufficient, safe and nutritious food that meet their dietary and food preferences, for an active and healthy life [ 8 ]. This ongoing condition has been caused by a number of factors including distribution obstacles, global climate change, a lack of successful local agriculture, and an inability or disinterest to act by local officials. The situation has been further complicated by an inefficient and disorganized international response. Excessive food aid without any insistence on guaranteeing sustainability has been cited by some authors as a perpetuating factor of this ill in Sub Saharan Africa. Certain groups are particularly vulnerable to food insecurity, including women (especially low income pregnant and lactating women), victims of conflict, the ill, migrant workers, low-income urban dwellers, the elderly, and children under five [ 10 ] Support for local and regional farming, climate prediction methods, financial aid for development and infrastructure, and a more united aid initiative would lead Sub Saharan Africa towards sustainable and reliable food sources and a more secure future. But more importantly, these solutions would lead to less dependency on foreign food aid and greater reliance on solutions from within Sub Saharan Africa. The establishment of properly functioning economic and political structures would help to lead countries to food security, as well as help to improve the overall wellbeing of the people [ 9 ]. Root causes of malnutrition in Sub - Saharan Africa

Childers et al estimated that some 1.4 billion people now live in absolute poverty, 40% more than 50 years ago. Nearly one of every four human beings alive today exists only on the margins of survival, too poor to obtain the food they need to work, or adequate shelter, or minimal health care, let alone education for their children [ 11 ]. Poverty is unmistakably the driving factor in the lack of resources to purchase or otherwise procure food, but the root causes of poverty are multifaceted. Poverty, combined with other socioeconomic and political problems, create the bulk of food insecurity around the globe [ 10 ]. Food distribution discrepancies happen to be a major driving factor in perpetuating lack of food in most areas of Sub Saharan Africa. Malnutrition in childhood is known to have important long-term effects on the work capacity and intellectual performance of adults. Health consequences of inadequate nutrition are enormous. It was estimated that nearly 30% of infants, children, adolescents, adults and elderly in the developing world are suffering from one or more of the multiple forms of malnutrition, 49% of the 10 million deaths among children less than 5 years old each year in the developing world are associated with malnutrition, another 51% of them associated with infections and other causes [ 12 ]. Fluctuation of prices of foods in the on a global scale is likely to affect these already disadvantaged population. They generally do not have diversified commercial food choices to provide in the world market. Their dependence once upon a time on incomes from commercial crops, almost exclusively in some areas, like Cocoa and Coffee was matched by serious suffering, malnutrition and disease when the prices of these products experienced dramatic drops in the world market [ 13 ]. Focusing on children under the age of five, who are the most affected by malnutrition in Sub Saharan Africa, a vicious cycle has been described to actually exist between poverty and malnutrition. In fact, the World Bank estimates that on average individuals suffering from malnutrition lose 10 per cent of their potential lifetime earnings. This has a much broader impact too; in the same report the World Bank found that countries can lose 2-3 per cent of their GDP because of under nutrition [ 13 ]. Malnutrition has in some instances been actually considered, and generally is considered as a poverty indicator. Malnutrition leads to sub optimal intellectual development. Knowing that children are the future of any society, an unproductive generation shall thus be prone to be poor, completing this poverty malnutrition chain [ 14 ]. Malnourished women usually have malnourished fetuses during pregnancy, delivered generally with low birth weights and consequently growing into physically and mentally stunted children. Stunted adults imply low human capital, low incomes and poverty.

The second problem is the co-existence of under- and over-nutrition in the same household, family or community. This double burden is extended to a double burden of disease. Therefore, as in many other developing countries, the over-nutrition-related diseases emerged before the battle against under-nutrition deficiency diseases has been won. This phenomenon can, at least partially, be explained by the effects of foetal malnutrition and the low quality of staple-food diets (sufficient energy but not enough micronutrients) in poor households. However, the relationship between household food insecurity and the overweight status of mothers and children are not only observed in developing countries. Several authors have found that this phenomenon is also prevalent in the developed world [ 15 ].

Education and malnutrition

Improving the educational status of parents, especially of mothers, on nutrition, sanitation and common disease prevention strategies should logically reduce the malnutrition related mortality and morbidity. It is said that the way to the child's stomach is through the mind of the mother. Quality of food taken, choices and quantity are all at the discretion of the mother or care giver. This problem is very crucial in Sub Saharan Africa, where access to formal education for the girl child in certain communities is still a major burning challenge. The burden of malnutrition has been directly linked to poverty, quality of food intake, excessive disease and poor health status [ 13 ]. The relationship between education and poverty is too close, and virtually integrates into the virtual cycle of Ignorance, disease and poverty. Education could help reduce excessively large family sizes that are usually seen in most regions of Sub Saharan Africa. A poor community of certain cultural beliefs might not actually realize that giving birth to a fewer number of children might actually help them to match their limited resources, and also offer adequate and quality nutrition to the family.

Musgrove et al describes three important ways that ignorance and lack of education contribute to malnutrition. First people may know very little about vitamins or nutrients, and they fail to eat even the cheap and available ones. Secondly, ignorance about causes of disease and its consequences. Treatment and prevention options maybe most of the time very accessible and cheap. Poor hygienic conditions and the inability to control some intestinal parasites (Ascaris Lumbricoides and Hook worms) have serious impacts in competing for nutrients with the host, causing anemia and suppressing appetite. Huge decreases in school performance amongst children infected by these parasites have been reported. Thirdly, some people might be ignorant on how to care for their young children as they might undervalue healthy practices like breastfeeding, offering vitamins and other micronutrient rich foods to their children [ 16 ]. Improvements in women's education have contributed by far the most accounting for 43 per cent of the reduction in child malnutrition between 1970 and 1995 while improvements in per capita food availability contributed about 26 per cent [ 21 ].

Climate change

Increasingly variable rainfall patterns are likely to affect the supply of fresh water. A lack of safe water can compromise hygiene and increase the risk of diarrheal disease, which kills 2.2 million people every year. In extreme cases, water scarcity leads to drought and famine. By the 2090s, climate change is likely to widen the area affected by drought, double the frequency of extreme droughts and increase their average duration six-fold [ 17 ]. According to the World Health Organization, Many of the major killers such as diarrheal diseases, malnutrition, malaria and dengue are highly climate-sensitive and are expected to worsen as the climate changes. The direct damage costs to health (i.e. excluding costs in health-determining sectors such as agriculture, water and sanitation), is estimated to be between US$ 2-4 billion/year by 2030 [ 18 ].

For Sub-Saharan Africa, the Comprehensive Climate Change scenario studies carried out by the International Food Policy Research Institute (IFPRI) predicts consistently higher temperatures and mixed precipitation changes for the 2050 period. Compared to historic climate scenarios, climate change will lead to changes in yield and area growth, higher food prices and therefore lower affordability of food, reduced calorie availability, and growing childhood malnutrition in Sub-Saharan Africa [ 19 ].

Climate change represents a major threat for the coming decades, particularly in Africa which has more climate sensitive economies than any other continent. Some regions in Africa have become drier during the last century (e.g. the Sahel) and it is projected that the continent will experience a stronger temperature increase trend than the global average [ 20 ]. Africa has often been identified as one of the most vulnerable regions to climate variability and change because of multiple stresses and low resilience, arising from endemic poverty, weak institutions, as well as recurrent droughts and associated complex emergencies and conflicts. Climate-related risks have significant impacts on African populations and economies and drive large allocations to emergency resources [ 20 ]. Under nutrition in turn undermines the resilience of vulnerable populations decreasing their ability to cope and adapt to the consequences of climate change and their ability grow economically.

Climate variability and change considerably influence shocks, trends and seasonality that observed and predicted in Sub-Saharan African countries, and that represent sources of stresses in the lives and livelihoods of exposed communities. Increased temperatures deplete land of its moisture more rapidly and can lead to regional water scarcity, salinization of agricultural lands, and to the destruction of crops. As temperatures increase, precipitation is becoming more variable over most of Africa. For some regions, rainfall variability and unpredictability has been substantial in the past forty to fifty years. According to Boko et al, there has been an overall annual decline in rainfall observed since the end of the 1960s over Africa with some regions experiencing greater declines than others. For instance, the Sahel and Southern Africa have become drier during the twentieth century [ 20 ].

Government policy, political zeal and corruption

Tackling malnutrition is directly related to the achievement of Millennium Development Goal (MDG) 1 (eliminating hunger), MDG 4 (reducing child mortality) and MDG 5 (reducing maternal mortality). In fact, the achievement of many of these goals in human development hinges upon the elimination of malnutrition, as it impacts on health, productivity and educational achievement. However, most African government have either underestimated, undermined or have a lukewarm attitude with respect to investing and ensuring alleviation of malnutrition. Corruption is highest in Sub Saharan regions, with resources concentrated in the hands of a few. The fight against this ill in recent years has produced very insignificant results. Misappropriation of state funds and corruption have led to division amongst peoples, wars with massive killings, spending on expensive war equipment, further impoverishment of the population, aggravating the burden and consequences of malnutrition in this part of the world. The policies of national Governments and international institutions over past decades have neglected SSA's rural and agricultural development. Policies such as structural adjustment programs that aimed to close budget gaps, created large human development deficits, especially among the poor, and skewed allocations of national revenue and foreign aid so that agriculture and nutrition were neglected. The first attempt to address the problem of food insecurity through more than just food aid in SSA was through the “Freedom from Hunger Campaign”, initiated by the FAO and other development agencies. The campaign sought to involve developing countries in analyzing the causes of food crises and malnutrition, and to find sustainable solutions. However, nearly six decades later, that worthy intention has not been fulfilled in all parts of the world. Early attempts by African Governments to tackle the food security situation on the continent, such as the Lagos Plan of Action (1980-1985) and Regional Food Plan for Africa (1978-1990), also failed due to organizational and financial difficulties [ 21 ]. However, with the dawn of the new millennium, many African Governments have committed to increasing public spending on agriculture by signing the Maputo Declaration on Agriculture and Food Security in 2003 [ 22 ]. This however has always been a myth rather than reality, as trends continue predicting bad days with respect to hunger and malnutrition in most areas of the continent. Governments have not actually measured the burden of malnutrition, and consequently fail to consider the fight against malnutrition as a priority. Methods used at times, because of lack of adequate expertise might be outdated and ill adapted to the contexts to meet present day challenges. Genetically modified foods have been adopted in many areas of Africa with interesting results. However, many countries are still not in for it, or have not committed to testing this new method, which could be a possible solution to this ill. Ethical issues still surround the usage of genetically modified foods in most areas of the world, despite outstanding evidence of its safety [ 28 , 29 ].

Other causes

Poor distribution channels and inequalities in global food distribution: countries that have registered the highest improvements in overall malnutrition rates are not the countries that have experienced the highest growth rates, indicating that changes in malnutrition are not proportionate of economic growth. Furthermore, the countries that managed to reduce inequalities the most were not systematically the ones with the highest growth rates either, indicating that policies need to address the constraints of the most vulnerable households for growth to be both nutrition-sensitive and inclusive. Aggregate reduction in child malnutrition across countries should not conceal the fact that not all segments of the population benefit from improvement with the same magnitude. There is a need for policies that address the specific constraints of households left out of progress so that growth can be nutrition-sensitive and inclusive [ 23 ].

"The situation described above takes place in an international context in which enough food is produced so that no child or person in the world dies from lack of food or suffers chronic malnutrition. It is inexcusable that around 1.3 billion tons of foods are annually wasted at the global level. While some 10 million children die every year from malnutrition before reaching age five, inhabitants of developed countries have the luxury of throwing away 95 to115 kg of food per capita. Many of the people living in extreme poverty spend almost 70% of their income in foodstuffs. In addition to the 2 billion people suffering from malnutrition, thousands of millions live on the verge of food insecurity and suffer the effects of increased food prices resulting from the crisis of the global capitalist system that has been imposed on us by major centers of power" Statement by the Cuban delegation at the plenary meeting of the second committee on Agriculture Development and Food Security. New York, 6 November 2012).

Sociocultural and religious factors

Breastfeeding practices and weaning foods are associated to malnutrition. Maternal educational level, maternal age, marital status, availability of pipe borne water and latrines have been reported to be associated to malnutrition [ 24 ]. Childhood malnutrition is accounted for by contextual effects over and above likely compositional effects, that urban-rural differentials are mainly explained by the socioeconomic status of communities and households, that childhood malnutrition occurs more frequently among children from poorer households and/or poorer communities and that living in deprived communities has an independent effect in some instances. Socioeconomic inequalities in childhood malnutrition are more pronounced in urban centers than in rural areas [ 25 ].

Gender and malnutrition

Intra family gender inequalities in food distribution and nutritional status have been observed. For instance, in Bangladesh, 54% of malnourished children are females and have a likelihood of 1.44 times greater to be malnourished than males [ 26 ]. More often than not, the face of malnutrition is female. In households which are vulnerable to food insecurity, women are at greater risk of malnutrition than men. Malnutrition in mothers, especially those who are pregnant or breastfeeding can set up a cycle of deprivation that increases the likelihood of low birth weight, child mortality, serious disease, poor classroom performance and low work productivity [ 27 ]. According to the Food and Agricultural Organization, FAO, vulnerable women and girls are more likely to die of malnutrition than men and boys. Social and economic inequalities between men and women often stand in the way of good nutrition [ 27 ]. This condition is seen in South Asian and African communities, where boys and men are culturally selected to eat more nutritive foods such as eggs [ 26 , 27 ].

Despite extensive global economic growth in recent decades, including in some of the poorest countries in Africa, millions of people remain locked in a vicious cycle of hunger and poverty. Poverty means parents can't feed their families with enough nutritious food, living children malnourished. Malnutrition leads to irreversibly stunted development and shorter, less productive lives. Less productive lives mean no escape from poverty. Many African countries are even becoming more food insecure. The millennium development goal with respect to hunger eradication with respect to Africa has been a failure. Low levels of education especially in women are key perpetuators of poor nutrition practices in this Region of the World. Children under five are the most affected. Male children tend to have better health status than females in certain communities. The problem is further aggravated by adverse climatic conditions, with droughts and floods in some areas. Government policy has not been very successful most of the time, because most governments fail to consider this as a serious issue, and rescue projects from the western world are vertical and do not consider socio cultural realities of target implementation sites. In Africa, funds accorded for fighting malnutrition are often embezzled.

• Improving government policy, increasing political will and application of community adapted strategies in tackling this issue is fundamental. It should be recognized, not only as a public health issue, but as a fundamental human right especially for children to eat. Starting life disadvantaged with adverse consequences from malnutrition (ill health, mental retardation, high malnutrition related morbidity and mortality resulting especially from under-five deaths) is a neglected but serious developmental hindrance to Sub - Saharan Africa.
• The fight against corruption must cease to be lip service but actually get effective.
• The use of modern agricultural techniques to increase food production is very essential. Provision or subsidization of the ministries of Agriculture to provide fertilizers, use genetically modified foods to resist adverse weather conditions and improve yield could be possible solutions to be investigated.
• Improvement of the transport system to give access to locals to sell their local produce to raise incomes for their families is important.
• Base Line surveys to determine and understand sociocultural peculiarities of each community during implementation of particular programs are vital. Avoidance of vertical programs could be of great help.
• The ministry of environments of countries must engage in programs to protect the environment which continues to be degrading. Feasible and sustainable irrigation programs should be scaled up especially in drought affected regions.
• The solution to this problem of malnutrition in developing countries entails a multisectorial approach with well defined and achievable goals. The ministries of health, education, agricultural, environment, universities and research organizations and other non-governmental organizations or international donors must work together if any tangible outcomes are expected.

Further research involving the potential acceptability of new agricultural technologies, modern farming methods and genetically modified foods in a Sub Saharan African context should be undertaken. Understanding the socio cultural peculiarities of the milieu is fundamental. It might be difficult and unproductive implementing some health promotion programs, especially when they are very vertical and culturally inadapted. Implication of the community representatives in the programs from the early planning stages could be key determinants of program ownership, acceptability and sustainability.

Competing interests

The authors declare no competing interests.

Authors’ contributions

All authors participated in the literature search, interpretation and critique of the articles reviewed. Luchuo Engelbert Bain prepared the initial manuscript. All authors have read and approved the final version of the manuscript.