Malnutrition Awareness: A Global Health Equity Crisis

Malnutrition Awareness: A Global Health Equity Crisis

by Bridget Storm, MA, RD, LDN, CNSC

Malnutrition, in its simplest form, refers to deficiencies, excesses, or imbalances in a person's intake of energy and nutrients. It remains one of the most pressing global health issues, contributing significantly to morbidity and mortality, particularly in children under the age of five. Though often associated with undernutrition in developing countries, malnutrition can also manifest as overnutrition, leading to obesity and related health complications. This blog will explore the causes, consequences, and potential solutions to malnutrition.

Malnutrition Globally Defined

Malnutrition can be categorized into two broad types:

1. Undernutrition: This occurs when the body doesn't get enough nutrients, leading to conditions such as:
• Stunting: Short height for age due to chronic undernutrition.
• Wasting: Low weight for height, often associated with acute malnutrition.
• Micronutrient Deficiencies: Lack of essential vitamins and minerals, such as iron, iodine, and vitamin A.
2. Overnutrition: A condition often associated with excessive intake of nutrients, especially calories, leading to obesity and an increased risk of diseases like diabetes, heart disease, and certain cancers.

Causes of Malnutrition

Malnutrition arises from a complex interplay of various factors, including:

• Poverty and Food Insecurity: Poverty is the primary driver of malnutrition globally. Limited income restricts access to nutritious food, resulting in diets that lack essential nutrients.
• Poor Dietary Practices: Lack of knowledge about nutrition or cultural practices can lead to unbalanced diets, especially in vulnerable populations. In some cultures, certain groups, such as women or children, may have limited access to nutritious food.
• Health Conditions: Many chronic health conditions impact nutrient requirements or the body's ability to absorb nutrients, leading to malnutrition. Some examples include: cancer, HIV/AIDS, substance misuse, GI malabsorptive disorders, and bariatric surgery.
• Agricultural and Food Systems: The shift from traditional to modern agricultural systems often results in the loss of dietary diversity. Globalization has increased the availability of cheap, processed foods high in sugars and fats, contributing to malnutrition, especially overnutrition.
• Conflicts and Displacement: Wars and civil conflicts disrupt food production, supply chains, food economics, and healthcare systems, often leaving affected populations malnourished.

Malnutrition and Food Insecurity

According to 2018 HCUP (Healthcare Cost and Utilization Project) data, 749,405 patients with diagnosed malnutrition came from low income communities.

• Food insecurity often leads to the consumption of calorie-dense but nutrient-poor foods, causing both obesity and malnutrition simultaneously (the “double burden” of malnutrition).
• Low income communities are often characterized as food deserts – areas where residents have limited access to affordable, nutritious food, particularly fresh fruits and vegetables, due to a lack of nearby grocery stores or supermarkets or inability to access markets due to lack of transportation.
• Limited access to fruits, vegetables, and fortified foods increases the risk of deficiencies in vitamins and minerals, contributing to malnutrition.
• Food insecurity, often linked to poverty, exacerbates malnutrition, which in turn limits educational and economic opportunities, perpetuating the cycle of food insecurity.

Malnutrition Diagnosis: AAIM or GLIM

Malnutrition, particularly in hospitalized and clinical settings, is a key factor impacting patient outcomes. Over the years, different organizations have developed criteria to diagnose and classify malnutrition. Two prominent approaches are the AAIM (Academy of Nutrition and Dietetics and American Society of Parenteral and Enteral Nutrition Indicators for Malnutrition) and the GLIM (Global Leadership Initiative on Malnutrition) criteria. Both provide frameworks for identifying malnutrition but differ in methodology and application.  Within the US, 89% of hospitals surveyed in 2022 report using AAIM for malnutrition diagnosis.

	AAIM	GLIM
Application	Primarily U.S., hospital-focused	Global use, adaptable to various healthcare systems
Diagnostic Criteria	Inadequate intake, unintentional weight loss, loss of muscle mass, body fat depletion, fluid accumulation, reduced handgrip strength and/or functional capacity	Phenotypic Criteria: unintentional weight loss, loss of muscle mass, low BMI
Etiology	Acute illness/inflammation, chronic illness, or social/environmental circumstances	Etiologic Criteria: Inadequate intake, disease burden/inflammation (acute or chronic)
Severity	Moderate or Severe (adults); Mild severity only applicable to infants and children	Moderate or Severe
Complete Diagnosis (adults)	(Severity) Malnutrition due to (Etiology) as evidenced by (2 or more diagnostic criteria)	Requires at least 1 etiologic and at least 1 phenotypic criterion

Consequences of Malnutrition

The impacts of malnutrition are far-reaching and can last a lifetime:

• Impaired Physical and Cognitive Development: In children, malnutrition—especially in the first 1,000 days of life—can lead to stunting, reduced intellectual capacity, and poor academic performance.
• Increased Risk of Disease: Malnourished individuals have weakened immune systems, making them more susceptible to infections and diseases such as pneumonia and malaria.
• In Hospitalized Patients: Malnutrition has been shown to increase mortality, length of stay, ICU length of stay and vent days, infection risk, and overall health care costs. It also results in impaired wound healing, decreased immune function, and more frequent (1.4x) 30-day readmission rates.
• Economic Burden: Malnutrition impairs productivity, both at individual and societal levels. Adults who suffered from malnutrition in childhood may struggle with work capacity, leading to reduced economic output.
• Obesity and Non-Communicable Diseases: Overnutrition, particularly in high-income countries and increasingly in low- and middle-income nations, leads to obesity and an increase in lifestyle-related diseases, including heart disease and type 2 diabetes.

Strategies to Address Malnutrition

Addressing malnutrition requires a multi-faceted approach that includes improvements in policy, healthcare, education, and agricultural practices:

• Nutrition Education: Public health campaigns should aim to educate communities about balanced diets, focusing on the importance of essential nutrients. Targeting schools and communities with information on healthy eating can help prevent both undernutrition and overnutrition.
• Food Fortification: Governments can fortify staple foods with essential vitamins and minerals, such as iodine, iron, and folic acid. For instance, fortifying salt with iodine has been successful in reducing iodine deficiency disorders worldwide.
• Support for Agriculture: Promoting sustainable agricultural practices that emphasize the production of diverse, nutrient-rich foods can help combat malnutrition. Smallholder farmers should be supported to grow a variety of crops, which can improve both their incomes and the nutritional diversity of local markets.
• Social Safety Nets: Policies that provide food assistance, especially to vulnerable populations, can help mitigate food insecurity. Programs such as school feeding initiatives and food vouchers can ensure access to nutritious food for children and low-income families.
• Healthcare Interventions: Improving equitable healthcare access, especially for women and children, is crucial. Immunizations, deworming, and access to prenatal care help protect against diseases that exacerbate malnutrition.

Tackling malnutrition is a global priority and requires coordinated action across sectors, from healthcare and agriculture to education and governance. By understanding the root causes and the long-term impacts of malnutrition, it becomes clear that both undernutrition and overnutrition need to be addressed through sustainable, holistic strategies that prioritize human health and well-being.

Look for more startling stats on food insecurity and malnutrition on my social media (IG handle @storm.nutritionstudysupport & https://www.facebook.com/stormnss) throughout this week in recognition of Malnutrition Awareness Week.

And don’t forget to visit me at https://nutritionstudysupport.com for more resources and valuable insights!

References:

1. World Health Organization. (2021). Malnutrition. Available online at https://www.who.int/health-topics/malnutrition#tab=tab_1.
2. United Nations Children's Fund (UNICEF). (2020). Malnutrition. Available online at https://data.unicef.org/topic/nutrition/malnutrition/#:~:text=The%20global%20prevalence%2Dbased%20estimates,need%20of%20treatment%20that%20year.
3. Global Nutrition Report. (2020). Action on Equity to End Malnutrition. Available online at https://media.globalnutritionreport.org/documents/2020_Global_Nutrition_Report_2hrssKo.pdf.
4. Food and Agriculture Organization (FAO). (2021). The State of Food Security and Nutrition in the World 2021. Available online at https://www.fao.org/publications/home/fao-flagship-publications/the-state-of-food-security-and-nutrition-in-the-world/en.
5. ASPEN Infographic: Malnourished Hospitalized Patients Are Associated with Poorer Outcomes  (2021) 
6. ASPEN Infographic: Malnourished Hospitalized Patients Continue to Rise  (2021)  
7. Gundersen, C., & Ziliak, J.P. (2015). Food Insecurity and Health Outcomes. Health Affairs, 34(11), 1830-1839. doi:10.1377/hlthaff.2015.0645.
8. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.
9. Jensen GL, Cederholm T, Correia ITD, et al. GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community. J Parenter Enteral Nutr. 2019;43(1):32-40.
10. Guenter P, Blackmer A, Malone A, et al. Current nutrition assessment practice: a 2022 survey. Nutr Clin Pract. 2023;38:998-1008.