Malnutrition

An estimated two billion people worldwide suffer from different forms of malnutrition.  Malnutrition is a major health concern in developing countries where a large proportion of children suffer from hunger and starvation.

What is Malnutrition?

Malnutrition refers to the imbalance between the nutrients required by the body and the amount of nutrients it gets. A common misconception about malnutrition is that it only refers to undernutrition or being underweight due to deficiencies. However, malnutrition also includes over -nutrition, which refers to the consumption of excessive amounts of calories or other dietary supplements. Hence, malnutrition can refer to both undernutrition and overnutrition.

Since undernutrition is far more common globally, the article shall focus on undernutrition and its implications.

There are two major types of undernutrition:

• Protein-energy malnutrition (caused by deficiencies of any one or all the nutrients)
  Protein-energy malnutrition can be further divided into three groups:
  • Acute malnutrition that lasts for less than 15 days and is rapidly correctable.
  • Chronic malnutrition that lasts for weeks to months and takes longer to correct. Often, the damage done might even be irreversible.
• Micronutrient deficiency diseases
  This is caused due to a deficiency of specific micronutrients such as vitamins and minerals.

The symptoms of malnutrition or undernutrition depend upon the nutritional deficiency. The common and characteristic symptoms of malnutrition in children include:

• Prolonged fatigue.
• Getting tired easily.
• Breathlessness.
• Unexplained dizziness.
• Dry skin.
• Low immunity.
• Bleeding gums.
• Swelling in the gums.
• Tooth decay.
• Weight loss.
• Muscle weakness.
• Bloating.

Mental well-being may also be affected due to malnutrition. Some symptoms of this aspect would be:

• Difficulty in concentrating.
• Learning difficulty.
• Confusion.
• Trouble paying attention.
• Inability to solve simple problems.

Deficiency of specific nutrients can lead to the development of certain characteristic symptoms.

For example, iron deficiency will lead to fatigue and a significantly lower concentration span. Iodine deficiency in children can lead to mental retardation and problems in normal physical development.

Symptoms of malnutrition in adults and adolescents (undernutrition) can be as follows:

• Weight loss
  Weight loss tends to be the most obvious symptom of malnutrition. However, it is possible that a person may have a healthy weight or be overweight and still be malnourished. Unintentional loss of 5-10% of body weight within a time-span of 3 to 6 months could be a symptom of malnutrition. A significantly lower BMI (body mass index) is also indicative of malnutrition.
• Apart from weight loss, other symptoms include:
  • Reduced appetite.
  • Lack of energy.
  • Inability to perform activities which one is normally accustomed to.
  • Poor concentration.
  • Feeling cold all the time.
  • Having mood swings.
  • Having spells of depression.
  • Wounds take a long time to heal.
  • Unexplained lethargy.
  • Falling sick often.
    
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Causes

The most common causes of malnutrition include:

• Poor diet.
• Consumption of low-quality food.
• Inability to digest food properly.
• Problems with absorbing nutrients from the food.

There can be physical and social causes of malnutrition as well. These include:

• A physical disability which prevents one from cooking and consuming food.
• Social isolation.
• Having limited knowledge about food.
• Drug abuse.
• Inadequate breastfeeding (in children).
• Poverty.

There are certain factors which may indirectly contribute to malnutrition.

• The production of food and the availability of food resources is significantly impacted by the climate in many sub-Saharan countries. Changes in environmental factors like rainfall, temperature, and soil fertility may impact the food availability for an entire region/country.
• Increasing food prices also make food a less affordable commodity for the poor and make them more vulnerable to malnutrition (undernutrition). This is more of a problem in developing countries where the percentage of population living under the below poverty line (BPL) is significant.

Risk factors

There are several factors which can increase the risk of developing malnutrition. These include:

Health conditions

• Chronic health conditions such as cancer, liver diseases, or lung diseases can lead to a lack of appetite, nausea, and changes in bowel habits. These symptoms may ultimately lead to decreased intake of food and giving rise to malnutrition.
• Mental health conditions such as depression, schizophrenia, or mental retardation can impact one’s desire to eat. Eating disorders are also a cause of malnutrition. Sometimes, the symptoms of an eating disorder may go undetected. However, eating disorders like anorexia nervosa can have a significant impact on the health and could turn into a life-threatening disorder if not treated on time.
• Health conditions which affect the ability to digest food or absorb nutrients like ulcerative colitis and Crohn’s disease can lead to malnutrition.
• Diseases like dementia can also cause a person to ignore their well-being and eating habits.

Medications

Certain medications may have unpleasant side effects such as loss of appetite, diarrhoea, and nausea. These medications may increase the risk of developing malnutrition.

• To prevent malnutrition, the importance of consuming a healthy and balanced diet should be emphasized. A balanced diet must have adequate amounts of carbohydrates, proteins, vitamins, and fats.
• People who can afford a dietician can have a well-planned diet after consultation.
• Preventing eating disorders is also important to prevent malnutrition in individuals. Eating disorders often stem from body image issues and stress eating. They are far more common in teenagers and women. Hence, looking out for symptoms like changes in eating habits, avoiding eating in public or eating too much when stressed can help in early diagnosis. Being aware of one’s eating habits can also prevent fluctuations in the diet.
• People suffering from inflammatory bowel diseases and malabsorption syndromes can opt for dietary supplements after consultation.
• Providing aid and spreading awareness among the people living in poverty can help in avoiding malnutrition. There are various government schemes such as mid-day meals, which provide food to young children to prevent hunger and malnutrition.
• Special attention must be given to pregnant women. It should be made sure through regular health check-ups that their nutrient intake is optimum.

• Severe and long-term malnutrition can easily be diagnosed by the doctor based on the physical appearance of the person with undernutrition. Visible signs such as weight loss, the presence of wounds or dry and patchy skin can be the indicators of undernutrition. After an initial physical examination, the doctor will inquire about the diet and eating habits of the person.
• The doctor may inquire about one’s ability to prepare food, the number of members in the family, use of drugs or alcohol, and the mental well being of the person.
• In the case of psychiatric disorders like depression and eating disorder, the doctor may further refer you to a professional counsellor for proper diagnosis. It is important to note that eating disorders can show different symptoms of malnutrition. There are two main types of eating disorders namely, anorexia nervosa and bulimia nervosa. In the case of anorexia nervosa, the main symptom would be rapid weight loss. However, in bulimia nervosa, the symptoms could differ. A bulimic individual may appear overweight due to frequent episodes of binge-eating or may also seem to have a normal body weight. In such cases, close monitoring of the eating patterns becomes crucial in order to make the correct diagnosis.

The physical examination may include:

• Measuring the height and weight.
• Determining the body mass index (BMI).
• Estimating the amount of body fat.
• Noting changes in the skin, nails, and hair.
• Looking out for such signs and symptoms will also help in determining how severe the malnourishment is.

The Malnutrition Universal Screening Tool (MUST) tool has been created to diagnose adults and the elderly with malnourishment. It consists of 5 steps:

• Measuring the height, weight and determining the body mass index.
• Noting the percentage of unplanned weight loss and assigning a score to it.
• Identifying any underlying mental and physical health condition and assigning a score to it.
• Adding the scores obtained to calculate the risk score.
• Following the guidelines provided to develop a care plan.

There are also a set of lab tests which can be helpful in uncovering the deficiency of specific nutrients:

• Iron tests.
• Albumin tests.
• Celiac disease antibody tests.
• Complete blood count.
• Comprehensive metabolic panel.

The treatment for malnutrition depends upon its cause and severity. A person may be treated at home for malnutrition. In some cases, one may need to go to the hospital. The primary aim of the treatment is to reduce the risk of developing any complications.

Treatment at home

• If the treatment is going to take place at home, then the health care provider will outline the diet changes you must make in order to be healthy again. You may also be provided with a nutritional care plan, which will be developed after taking inputs from you, as well as, the family.
• A gradual increase in the intake of nutrients such as carbohydrates, proteins, and fats may be recommended. In the case of a deficiency of a particular nutrient, a supplement may also be recommended. If one is unable to consume the amount of food required, then an artificial method such as the feeding tube may be used. These tubes are fitted in the hospitals but can be also used at home.

Treatment at the hospital may include

• Constant supervision by the doctor.
• Presence of a dietician.
• Presence of a counsellor.
• Presence of a social worker.
• A person’s ability to eat and digest the food may be assessed. If necessary, a feeding tube may be used. The feeding tube is inserted down from the nose into the stomach or it can be surgically placed directly into the stomach through the abdomen. The person is usually discharged after proper assessment. However, one may need to come back every week to track the health progress and to make sure the current diet plan is working.
• Parenteral nutrition
  Parenteral nutrition makes use of a drip which can deliver nutrition directly into the vein. It allows one to receive the nutrients that cannot be obtained through eating. The solution passing through the drip may contain certain nutrients and electrolytes depending upon one’s needs.    

Lifestyle management

Several lifestyle changes that can help in overcoming malnourishment have been discussed below:

• Eat small meals every few hours. Have at least three healthy meals daily with some snacks in between. This will also help to improve the energy level.
• Have meals with an adequate amount of carbohydrates, proteins, fats, vitamins and minerals.
• Drink water a few minutes after consuming a meal. Having too much water before a meal can make one feel full.
• Reduce alcohol intake.
• Reduce caffeine intake, especially if you are underweight.
• Have a protein-rich breakfast to keep your energy levels high throughout the day.
• Avoid sugary treats.
• Consume more fruits and raw vegetables to improve your nutrition level. Fruits can be very helpful in satisfying a sweet tooth, while vegetables contain plenty of minerals and vitamins to speed the recovery. Try to have fruits in between your meals as these are not high in proteins or calories.
• Consume nuts as snacks and avoid processed food.
• Opt for dairy food items such as eggs, milk, curd, and cheese if you are trying to put on weight.
• Consume carbohydrate-rich foods such as potatoes and rice to get instant energy.
• When going out, carry fluids like juices, water, and oral rehydration salts to prevent dehydration. Avoid having energy drinks. These contain caffeine and sugar which can cause a fluctuation in your blood glucose level.
• Exercise daily to increase your appetite naturally.
• If you are struggling with an eating disorder, support groups can be helpful in sharing experiences with different people and building a positive body image.
• It is also essential to have regular health check-ups to ensure that your condition is improving.

Prognosis

Malnourishment is a major health concern affecting a large number of people worldwide. People with a poor socio-economic background are worst affected by this condition. Since malnourishment has multiple causes including social factors, the treatment approach should be multi-dimensional in order to overcome all the factors which indirectly lead to malnutrition. The treatment, however, is very direct. A balanced diet will ensure a speedy recovery provided that the diagnosis is made before any serious damage has been done to the body.

Complications

Complications of malnutrition in children and adults include::

• Marasmus- protein-energy malnutrition causing loss of muscle and weight, weakness, and hair loss.
• Kwashiorkar- severe protein-energy malnutrition causing swelling in the limbs, flaking of skin, increase in weight due to the accumulation of fluid in the body, and muscle wasting.
• Severe vomiting.
• Severe dehydration.
• Fever.
• Shortness of breath.
• Skin lesions.
• Developmental disability.
• Permanent brain damage
• Convulsions.
• Severe anaemia.
• Jaundice.
• Internal bleeding.
• Death (in severe cases).