Malnutrition

What Are Hunger and Malnutrition?
Everyone feels hungry at times. Hunger is the body's signal that it needs food. Once we've eaten enough food to satisfy our bodies' needs, hunger goes away until our stomachs are empty again.
Malnutrition is not the same thing as hunger, although they often go together. People who are malnourished lack the nutrients needed for proper health and development. Someone can be malnourished for a long or short period of time, and the condition may be mild or severe. People who are malnourished are more likely to get sick and, in severe cases, may even die.
Unfortunately, there are millions of people in the world who don't get enough to eat most of the time and are at risk for malnutrition.
Chronic hunger and malnutrition can cause significant health problems. People who go hungry all the time are likely to be underweight, weighing significantly less than an average person of their size. Their growth may also be stunted, making them much shorter than average. (Of course, people can also be underweight or short because they have an illness or because of their genetic makeup.) Worldwide, as many as 27% of children younger than age 5 are underweight.
What Causes Hunger and Malnutrition?
People who don't get enough food often experience hunger, and hunger can lead to malnutrition over the long term. But someone can become malnourished for reasons that have nothing to do with hunger. Even people who have plenty to eat may be malnourished if they don't eat food that provides the right nutrients, vitamins, and minerals.
Some diseases and conditions prevent people from digesting or absorbing their food properly. For example:
• Someone with celiac disease has intestinal problems that are triggered by a protein called gluten, which is found in wheat, rye, barley, and oats.
• Kids with cystic fibrosis have trouble absorbing nutrients because the disease affects the pancreas, an organ that normally produces enzymes necessary for digestion.
• Kids who are lactose intolerant have difficulty digesting milk and other dairy products. By avoiding dairy products, they're at higher risk of malnutrition because milk and dairy products provide 75% of the calcium in America's food supply.
If a person doesn't get enough of one specific nutrient, that's a form of malnutrition (although it doesn't necessarily mean the person will become seriously ill). The most common form of malnutrition in the world is iron deficiency, which affects up to 80% of the world's population — as many as 4 to 5 billion people. Iron is found in foods like red meat, egg yolks, and fortified flour, bread, and cereal.
Who Is at Risk for Malnutrition?
All over the world, people who are poor or who live in poverty-stricken areas are at the greatest risk for hunger and malnutrition. In poor countries, wars and natural disasters such as droughts and earthquakes may also contribute to hunger and malnutrition by disrupting normal food production and distribution.
In the United States, food manufacturers fortify some common foods with vitamins and minerals to prevent certain nutritional deficiencies. For example, the addition of iodine to salt helps prevent some thyroid gland problems (such as goiter), folic acid added to foods can help prevent certain birth defects, and added iron can help prevent iron-deficiency anemia.
Malnutrition affects people of every age, although infants, children, and adolescents may suffer the most because many nutrients are critical for growth and development. Older people may develop malnutrition because aging, illness, and other factors can lead to a poor appetite, so they may not eat enough.
Alcohol can interfere with nutrient absorption, so alcoholics might not benefit from the vitamins and minerals they consume. People who abuse drugs or alcohol can be malnourished or underweight if they don't eat properly.
Children and teens on special diets — such as vegetarians — need to eat balanced meals and a variety of foods to get the right nutrients. Vegetarians and vegans should make sure they get enough protein and vitamins like B12.
Symptoms and Effects of Malnutrition
Malnutrition harms both the body and the mind. The more malnourished someone is — in other words, the more nutrients that are missing — the more likely he or she is to have physical problems. A child who is slightly to moderately malnourished may show no outward physical symptoms.
Indications of malnutrition depend on which nutritional deficiencies a child has, although they can include:
• fatigue and low energy
• dizziness
• poor immune function (which can hamper the body's ability to fight off infections)
• dry, scaly skin
• swollen and bleeding gums
• decaying teeth
• slowed reaction times and trouble paying attention
• underweight
• poor growth
• muscle weakness
• bloated stomach
• osteoporosis, or fragile bones that break easily
• problems with organ function
If a pregnant woman is malnourished, her child may weigh less at birth and have a lower chance of survival. Vitamin A deficiency from malnutrition is the chief cause of preventable blindness in the developing world, and kids with severe vitamin A deficiency have a greater chance of getting sick or dying from infections such as diarrhea or measles. Iodine deficiency, another form of malnutrition, can cause mental retardation and delayed development. Iron deficiency can make kids less active and less able to concentrate. Teens who are malnourished often have trouble keeping up in school.
Treating Children Who Are Malnourished
Fortunately, many of the harmful effects of malnutrition can be reversed, especially if a child is only mildly or briefly malnourished.
If you think your child isn't getting enough of the right nutrients, talk to your doctor, who may perform a physical exam and ask about the types and amounts of food your child eats. The doctor may also:
• measure height, weight, and body mass index (BMI) to see if they're within a healthy range for your child's age
• order blood tests to check for abnormalities
• use X-rays or CT scans to look for signs of malnutrition in organs and bones
• check for underlying conditions that could cause malnutrition
Treatment for malnutrition depends on its cause. A doctor or dietitian might recommend specific changes in the types and quantities of foods your child eats, and may prescribe dietary supplements, such as vitamins and minerals. If there's an underlying problem causing the malnutrition, the doctor will help you find ways to ensure your child gets the necessary nutrients.
Can a Picky Eater Become Malnourished?
Parents often worry that kids who seem to live on peanut butter sandwiches or hide at the sight of vegetables might not eat enough to stay healthy. Few kids in the United States and other developed nations experience severe malnutrition like that seen in Third World countries. Even finicky eaters usually get adequate calories and nutrients.
The best way for parents to ensure that kids are properly nourished is to serve a variety of healthy foods and limit unhealthy snacks. If you're concerned that your child's energy level is lagging or that he or she isn't growing as fast as other kids of the same age, share your concerns with your doctor.
Malnutrition
Malnutrition is a major health problem, especially in developing countries. Water supply, sanitation and hygiene, given their direct impact on infectious disease, especially diarrhoea, are important for preventing malnutrition. Both malnutrition and inadequate water supply and sanitation are linked to poverty. The impact of repeated or persistent diarrhoea on nutrition-related poverty and the effect of malnutrition on susceptibility to infectious diarrhoea are reinforcing elements of the same vicious circle, especially amongst children in developing countries.
The disease and how it affects people
Malnutrition essentially means “bad nourishment”. It concerns not enough as well as too much food, the wrong types of food, and the body's response to a wide range of infections that result in malabsorption of nutrients or the inability to use nutrients properly to maintain health. Clinically, malnutrition is characterized by inadequate or excess intake of protein, energy, and micronutrients such as vitamins, and the frequent infections and disorders that result.
People are malnourished if they are unable to utilize fully the food they eat, for example due to diarrhoea or other illnesses (secondary malnutrition), if they consume too many calories (overnutrition), or if their diet does not provide adequate calories and protein for growth and maintenance (undernutrition or protein-energy malnutrition).
Malnutrition in all its forms increases the risk of disease and early death. Protein-energy malnutrition, for example, plays a major role in half of all under-five deaths each year in developing countries (WHO 2000). Severe forms of malnutrition include marasmus (chronic wasting of fat, muscle and other tissues); cretinism and irreversible brain damage due to iodine deficiency; and blindness and increased risk of infection and death from vitamin A deficiency.
Nutritional status is compromised where people are exposed to high levels of infection due to unsafe and insufficient water supply and inadequate sanitation. In secondary malnutrition, people suffering from diarrhoea will not benefit fully from food because frequent stools prevents adequate absorption of nutrients. Moreover, those who are already experiencing protein-energy malnutrition are more susceptible to, and less able to recover from, infectious diseases.
The cause
Individual nutritional status depends on the interaction between food that is eaten, the overall state of health and the physical environment. Malnutrition is both a medical and a social disorder, often rooted in poverty. Combined with poverty, malnutrition contributes to a downward spiral that is fuelled by an increased burden of disease, stunted development and reduced ability to work. Poor water and sanitation are important determinants in this connection, but sometimes improvements do not benefit the entire population, for example where only the wealthy can afford better drinking-water supplies or where irrigation is used to produce export crops. Civil conflicts and wars, by damaging water infrastructure and contaminating supplies, contribute to increased malnutrition.
Scope of the Problem
Chronic food deficits affect about 792 million people in the world (FAO 2000), including 20% of the population in developing countries. Worldwide, malnutrition affects one in three people and each of its major forms dwarfs most other diseases globally (WHO, 2000). Malnutrition affects all age groups, but it is especially common among the poor and those with inadequate access to health education and to clean water and good sanitation. More than 70% of children with protein-energy malnutrition live in Asia, 26% live in Africa, and 4% in Latin America and the Caribbean (WHO 2000).
Interventions
Interventions that contribute to preventing malnutrition include :
• Improved water supply, sanitation and hygiene.
• Health education for a healthy diet.
• Improved access, by the poor, to adequate amounts of healthy food.
• Ensuring that industrial and agricultural development do not result in increased malnutrition.
References
WHO. Turning the tide of malnutrition: responding to the challenge of the 21st century. Geneva: WHO, 2000 (WHO/NHD/00.7)
FAO. The state of food insecurity in the world 2000 (FAO, Rome)
See also WHO web site on nutrition
Prepared for World Water Day 2001. Reviewed by staff and experts from the Department of Nutrition for Health and Development and the Water, Sanitation and Health Unit, World Health Organization (WHO).
Rome/New York, June 2, 2008
As heads-of-state and nearly 20 key United Nations officials meet in Rome this week to design a plan to tackle the current global food crisis, the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) is urging the adoption and rapid scale-up of specific nutritional strategies that target children under two years of age.
Simply expanding existing interventions, which were already not able to address the ongoing malnutrition crisis, will certainly not protect the young children who are most vulnerable to rising food prices, MSF said.
“There is a dangerous double standard in which current food aid and nutrition programs are driven more by cost considerations than by the specific nutritional needs of young children,” said Daniel Berman, deputy director of MSF’s Access Campaign. “The nutrient-rich food that growing children need will only reach them if new approaches backed by increased resources are adopted.”
Rapidly growing children have specific nutritional needs and small stomachs. They require food dense in energy and diverse in nutrients, which is best achieved by providing them animal-source foods such as dairy, eggs, meat or fish. Quality of food is as important as quantity, and therefore policy makers must ensure nutrition security and not only food security. Soaring food prices will exacerbate malnutrition, with families not able to afford food nutritious enough for young children to grow and both avoid and overcome disease.
For regions with long-standing malnutrition problems, conventional food aid does not include specific foods for young children. Milk powder was removed from relief food targeted at children in the late 1980s when milk surpluses subsided. Since then, children have been receiving fortified blended flours that contain no animal-source food – a diet which pediatricians do not recommend for children under two.
“We need leaders to open their eyes to the needs of young children who are most vulnerable right now, and for whom more of the same could put them at risk,” said Dr. Susan Shepherd, nutrition advisor at MSF. “One critical question this week is: will donors change the rules so that appropriate food for young children is added to food aid and nutrition programs?”
MSF is calling for food aid to change and for an energy-dense and nutrient-rich diet to be made available to at-risk children. There are new and innovative ways of delivering all the nutrients children need to recover from or to prevent malnutrition and MSF has been able to reach far greater numbers of children in its field projects with new strategies.
The World Health Organization estimates there are 178 million children that are malnourished across the globe, and at any given moment, 20 million suffering from the most severe form of malnutrition. Malnutrition contributes to between 3.5 and 5 million annual deaths of children under five years of age.
According to MSF estimates only 3 percent of the 20 million children suffering from severe acute malnutrition receive the UN-recommended treatment they need. MSF treated more than 150,000 children in 2006 and 2007 in 22 countries with nutrient-rich therapeutic and supplemental food.
MSF Malnutrition Fact Sheet
FAO World Food Summit Rome
June 3-5, 2008
• The food price crisis has aggravated the chronic crisis of child malnutrition. Malnutrition accounts for 11 percent of the global burden of disease yet this is a crisis that the international community has neglected.
• Malnutrition is an issue of food quality as much as quantity. Rapidly growing children have specific nutritional needs and thus specific nutritional and food aid interventions are needed. In terms of food aid, more of the same will not be enough. Grains, pulses and fortified flours are not sufficient to address the nutrition crisis.
• According to MSF estimates, only 3 percent of the 20 million children suffering from severe acute malnutrition each year receive the treatment they need. MSF has successfully used therapeutic ready-to-use food (RUF) to treat severe acute malnutrition and has pilot programs underway with supplemental RUF.
• MSF believes that it is important that both food aid and nutrition programming include interventions that assure the nutrient security of young children in order to avoid malnutrition in the first place.
• Fortified blended flours (FBF) based on wheat or corn plus soya were initially developed in the 1960s with young children’s nutritional needs in mind, and therefore contained dry milk powder. This ingredient was dropped from these flours in the 1980s for reasons that were primarily economic: the end of milk surpluses. FBFs as currently formulated are not found on the market in developed nations because soya flour is an inappropriate food for young children. It contains poor quality protein and far too many anti-nutrient factors that inhibit absorption of essential minerals such as zinc. This is a deadly double standard driven by minimum cost rather than the imperative to meet minimum nutritional standards.
• Nutrition programs have not received the political will and funding required to scale up effective interventions, particularly in food insecure regions. The Lancet Malnutrition Series article 5 states: “Annual funding for basic nutrition programming amounts to at most US $250-300 million per year. Even if this amount were perfectly targeted to the children under two living in the 20 countries that account for 80% of stunting, this would amount to $2 per child whereas effective large scale community nutrition programs are estimated to cost $5-10/child.” This costing does not even include the provision of food. No community education-based nutrition programs have been shown to be effective in food insecure regions.
• In the 2006 publication “Ending Child Hunger and Malnutrition Initiative”, WFP and UNICEF estimate the cost of effectively addressing malnutrition at US $80/family, or US $8 billion for 100 million families. This estimate includes not only health promotion interventions such as clean water and breastfeeding, but also supplementary and therapeutic feeding.
• MSF does not dispute that food aid needs to be supplemented with medium and long term development programing to stimulate economic and agricultural development through national, bilateral, and multilateral agreements and policies, but it urges that these programs should not be implemented at the expense of targeted and immediate solutions.
• Malnutrition is a medical emergency that contributes to at least 3.5 million deaths in children under five each year. The World Health Organization estimates there are 178 million children that are malnourished across the globe, and at any given moment, 20 million suffering from the most severe form. MSF treated over 150,000 children in 2006 and 2007 in 22 countries with therapeutic and supplemental therapeutic food. (document rev. 1 June 2008)

What MSF is calling for:• Ministries of Health and those that support them need to address the critical issues that prevent 97% of children suffering from severe acute malnutrition from getting life-saving treatment.
• Donors need to review the quality of food aid addressed towards malnutrition in children under the age of three, and refocus their efforts away from fortified blended foods towards providing RUF with superior nutrient value, ease-of-use and effectiveness.
• UNICEF and WFP must ensure RUF is available in adequate supplies; this will mean both fundraising and finding solutions for sustainable production.
• WHO must support countries to implement their new growth standards, develop recommendations for effectively treating non-severe malnutrition and promote controlled and operational research to replicate and expand on promising experiences of RUF.
• Ministries of Health, academic nutritionists and other organisations working on malnutrition must implement projects to further document the benefits of therapeutic RUF beyond the treatment for severe malnutrition.
• Researchers, producers and users of RUF must work together to develop new products, adapted for use in the early treatment and prevention of child malnutrition, but also, for other uses such as for maternal nutrition to prevent low birth weight.


Malnutrition getting worse in India
By Damian Grammaticas
BBC News, Madhya Pradesh


Lying on a bed is a tiny malnourished child. Her limbs wasted, her stomach bloated, her hair thinning and falling out. Her name is Roshni.
She stares, wide-eyed, blankly at the ceiling. Roshni is six months old. She should weigh 4.5kg. But when she is placed on a set of scales they settle at just 2.9kg.
Roshni is suffering from severe acute malnutrition, defined by the World Health Organisation as weighing less than 60% of the ideal median weight for her height.
There are 40 beds in this centre. On every one is a similar child. All are acutely malnourished. Wailing, painful, plaintive cries fill the air. This is the Nutrition Rehabilitation Centre in the town of Shivpuri.
You might think we are somewhere in Africa. But this is the central Indian state of Madhya Pradesh - modern India, a land of booming growth.
"The situation in our village is very bad," says Roshni's mother, Kapuri.
"Sometimes we get work, sometimes we don't. Together with our children we are dying from hunger. What can we poor people do? Nothing."
Typical symptoms
The lunchtime meal of boiled eggs, milk and porridge is handed out.
Another mother is cradling her daughter, trying to feed her. The girl's name is Kajal. She is two-and-a-half years old and so weak she can hardly eat.
Her mother tries to spoon some milk into her mouth. It dribbles down her chin. Kajal barely even opens her eyes.
Kajal's skin is pale. Her breath comes sharp, shallow and fast. She too is suffering from severe acute malnutrition. Her weight is 6.7kg.
The nutrition centre here was set up by the United Nations Children's Fund (Unicef).
Doctor Vandana Agarwal, Unicef's nutrition specialist for Madhya Pradesh state, points to Kajal's swollen little feet.
"There is oedema on both the feet, scaly skin on her legs, even her respiration rate is high," Dr Agarwal says.
"The child is in a lethargic condition, her hair is thin, sparse, lustreless, easily-pluckable. These are the typical symptoms of protein energy malnutrition."
India has some of the highest rates of child malnutrition and mortality in under-fives in the world and Madhya Pradesh state has the highest levels in India.
There are around 10 million children in the state. A decade ago 55% were malnourished. Two years ago the government's own National Family Health Survey put the figure for Madhya Pradesh at around 60%.
So why is it going up?
Compounded
"It's basically inadequate access to food, poor feeding practices, poor childcare practices," says Dr Agarwal.
In Madhya Pradesh the situation is compounded by two significant factors. For four years in a row the rains have failed, so food crops have failed too. And now global food prices have risen, stretching many families beyond breaking point.
"In the past year food prices have increased significantly, but people's incomes haven't improved," says Dr Agarwal. "Like wheat, earlier they used to buy it at eight rupees a kilogram, now it's 12 rupees."
"Because of the increase in food prices a mother cannot buy an adequate quantity of milk, fruits and vegetables. So their staple diet has become wheat chapattis," she explains.
"A child cannot survive on wheat chapattis alone. About 80% of mothers and children are anaemic because they can't get good quality food."
To see why things are so bad, we headed out into the villages around Shivpuri. The drought zone stretches across this part of central India. The land is parched and barren. The air hot and heavy.
The village of Chitori Khurda is a ramshackle collection of 80 stone and mud huts on a rocky plain. The villagers here come from the bottom rung of India's social scale.
Among the lowest of the low in India's caste system are the Scheduled Tribes, just above them come the Other Backward Castes.
Together they make up 95% of the population of Chitori Khurda.
Worst hit
Even here, in this desolate spot, caste matters consign the lowest to the harshest existence.
Chitori Khurda village has no water supply. There are four wells in the fields around, but all belong to higher caste owners who often refuse to let the villagers use them.
So these are the people worst hit by rising food prices. They have little land of their own. What they do have is the least fertile, sometimes far away. Without water they cannot irrigate, so they cannot feed themselves.
And out here there is not much in the way of work either.
The men of Chitori Khurda get odd jobs labouring for higher castes or just play cards all day. The women sit outside their houses sorting green leaves they have gathered into small bundles. The leaves are sold to make local cigarettes. But it does not earn much.
So in almost every home people are going hungry. Unicef says 79% of the children in this village are malnourished.
Siya showed me her house, crouching to get in through the low door, we entered a stifling-hot, single room where the family of six live.
Siya picked up the can where she keeps her flour. It should hold enough for a week's supply. There were just a few cupfuls left.
Her two youngest children, seven-month-old Anjali and two-year-old Aseel, are both severely acutely malnourished. The family can afford to eat only twice a day. The children chewed slowly on a few chapattis flavoured with a tiny bit of onion and ground chillies. It is all they have to eat.
Getting worse
Siya's husband works as a bonded labourer. He is still trying to pay off a loan he took out 15 years ago.
In theory the government provides 30kg of subsidised flour a month to every poor family. But corruption and inefficiency mean the system often does not work.
Even with the full allocation a family like Siya's would have to buy an additional 90kg of flour a month at a cost of more than 1,000 rupees.
Siya says several days a month the family has to go to bed hungry.
"The children cry and create a commotion," she tells me. "I go door-to-door until somebody gives me a little."
Every lunchtime the children of Chitori Khurda gather at the Anganwadi centre in the village. It is where nutrition and health services are provided at village level.
On the day we visited, each child was given two puris (small bread puffs fried in oil) along with some sweet porridge. The allocation is 80g of food a day per child.
The children ate it, then sat hoping for more, but there was none.
Madhya Pradesh is trying hard to tackle the problem of malnutrition, but it is getting worse, not better.
Corruption and inefficiency hamper the system. Some Anganwadi workers skim off food to sell. Others refuse to give food to lower-caste children. Many simply do not turn up as they are not paid much for the job.
Add to that high food prices and the poorest are sliding into hunger.
Back in Shivpuri, two-and-a-half-year-old Kajal had to be transferred to hospital. Her condition was so serious, she was so anaemic and her haemoglobin levels so low that she had to have an emergency blood transfusion.
Lying in her hospital bed Kajal was reviving, slowly. Her mother, anxious, looked on, a pressing question weighing on her mind.
Kajal should survive, but how will she feed her child?
Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/south_asia/7445570.stm

Published: 2008/06/10 11:36:03 GMT

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