Malnutrition

Malnutrition - What is malnutrition?

Malnutrition is a condition which occurs when there is a deficiency of certain vital nutrients in a person’s diet. The deficiency fails to meet the demands of the body leading to effects on the growth, physical health, mood, behaviour and other functions of the body. Malnutrition commonly affects children and the elderly.

Malnutrition also entails conditions where diet does not contain the right balance of nutrients. This might mean a diet high on calories but deficient in vitamins and minerals. These second group of individuals may be overweight or obese but are still considered malnourished. Thus being malnourished does not always mean that the person is underweight or thin. (1-4)

Who is at risk of malnutrition?

Malnutrition affects all age groups but is more common in developing countries and among children, elderly and pregnant women. In the United Kingdom, 2 million people were found to be malnourished in 2009 and a further 3 million people were found to be at risk of becoming malnourished. A quarter of all admissions in the UK are due to malnutrition.

Those at a higher risk are elderly over 65, particularly if they are living at care facilities, those with long term chronic illnesses like those of the liver or kidney, those with cancer or other debilitating infections like AIDS and those who abuse drugs or are alcoholics. Malnutrition is common among the low income and homeless groups.

Worldwide malnutrition is found to be the most important cause of illness and death affecting large populations of children and pregnant women. Malnutrition kills 300,000 individuals worldwide each year and is responsible for about half of all deaths in young children and it raises the risk of infections with diarrhea, malaria, measles and respiratory tract infections in children.

According to the World Health Organization, by 2015 prevalence of malnutrition world-wide will be 17.6% and large number of malnourished population will be from developing countries in southern Asia and sub-Saharan Africa. In addition 29% will have stunted growth due to poor nutrition.

Symptoms of malnutrition

The most common symptom of malnutrition is weight loss. For example, those who lose up to 10% of their body weight in 3 months without dieting are considered to be malnourished. There may be other symptoms like fatigue, lack of energy, lack of strength, breathlessness, anemia, changes of skin, hair and nails etc. in adults with malnutrition.

Children with malnutrition additionally show irritability, inability to concentrate, failure to grow to their expected height, stunted growth etc.

Diagnosis of malnutrition

Diagnosis of malnutrition is made clinically by examining the patient. In addition the BMI or body mass index (weight in kilograms over height in metres squared – Weight/height (in m)2) and mid arm circumference.

Those with a BMI less than 18.5 need to see their health care providers for assessment of malnutrition. Children with growth retardation or stunting need to be assessed as well for signs of malnutrition. Other diagnostic tests include routine blood tests for detection of anemia, chronic infection etc.

Treatment of malnutrition

For those who can eat normally, treatment of malnutrition entails providing a diet plan with extra nutrient content. The diet plan needs to be made balanced so as to allow for weight gain along with provision of vitamins and minerals.

For those who cannot eat normally a feeding tube can be used to provide nutrients directly into the digestive system or nutrients available as injectable preparations could be infused directly into one of the blood vessels.

Symptoms of malnutrition

Malnutrition results from a diet deficient in vital nutrients, vitamins and minerals. Over long term or even over a short term this may lead to severe debility and damage to the vital functions of the body. 1-7

Symptoms of malnutrition are easily distinguishable among both adults and children. They may be outlined as follows.

Symptoms of malnutrition in adults

The most common symptom is a notable weight loss. For example, those who have lost more than 10% of their body weight in the course of three months and are not dieting could be malnourished.

This is usually measured using the body mass index or the BMI. This is calculated by the weight in kilograms divided by the height in metres squared. A healthy BMI for adults usually lies between 18.5 and 24.9.

Those with a BMI between 17 and 18.5 could be mildly malnourished, those with BMIs between 16 and 18 could be moderately malnourished and those with a BMI less than 16 could be severely malnourished.

Other symptoms include:

  • Weakness of muscles and fatigue. The muscles of the body appear to waste away and may be left without adequate strength to carry out daily activities.

  • Many people complain of tiredness all day and lack of energy. This may also be due to anemia caused by malnutrition.

  • Increased susceptibility to infections.

  • Delayed and prolonged healing of even small wounds and cuts.

  • Irritability and dizziness

  • Skin and hair becomes dry. Skin may appear dry, and flaky and hair may turn dry, lifeless, dull and appear like straw. Nails may appear brittle and break easily.

  • Some patients suffer from persistent diarrhea or long term constipation.

  • Menstruation may be irregular or stop completely in malnourished women.

  • Depression is common in malnutrition. This could be both a cause as well as an effect of malnutrition.

Symptoms of malnutrition in children

Symptoms of malnutrition in children include:

  • Growth failure. This may be manifested as failure to grow at a normal expected rate in terms of weight, height or both

  • Irritability, sluggishness and excessive crying along with behavioral changes like anxiety, attention deficit are common in children with malnutrition.

  • The skin becomes dry and flaky and hair may turn dry, dull and straw like in appearance. In addition, there may be hair loss as well.

  • Muscle wasting and lack of strength in the muscles. Limbs may appear stick like.

  • Swelling of the abdomen and legs. The abdomen is swollen because of lack of strength of the muscles of the abdomen. This causes the contents of the abdomen to bulge out making the abdomen swollen. Legs are swollen due to edema. This is caused due to lack of vital nutrients. These two symptoms are seen in children with severe malnutrition.

  • There are classically two types of protein energy malnutrition (PEM) in children. These are Marasmus and Kwashorkor.

  • In Marasmus there may be obvious weight loss with muscle wasting. There is little or no fat beneath the skin. The skin folds are thin and the face appears pinched like an old man or monkey. Hair is sparse or brittle.

  • In Kwashirkor the child is between 1 and 2 with hair changing color to a listless red, grey or blonde. Face appears round with swollen abdomen and legs. Skin is dry and dark with splits or stretch marks like streaks where stretched.

  • In nutritional dwarfism the patient appears stunted in growth.

Symptoms of a lack of vitamins

Lack of vitamins and minerals – Some patients have a malnutrition with lack of only the vital micronutrients like vitamins and minerals. These are manifested by symptoms such as:

  • Normal BMI

  • Skin and hair problems

  • Swelling of the tongue

  • Sores around the corners of the mouth

  • Poor vision at night or in dimly lit areas

  • Breathlessness

  • Tinnitus or buzzing or ringing in the ears

  • Anemia

  • Pain in the bones and joints

Causes of malnutrition

Malnutrition occurs when a person does not receive adequate nutrients from diet. This causes damage to the vital organs and functions of the body. Lack of food is the most cause of malnutrition in the poorer and developing countries.

However, in developed countries like UK or USA the cause may be more varied. For example, those with a high calorie diet deficient in vital vitamins and minerals are also considered malnourished. This includes the obese and the overweight.

The causes of malnutrition include:

  • Lack of food: this is common among the low income group as well as those who are homeless.

  • Those having difficulty eating due to painful teeth or other painful lesions of the mouth. Those with dysphagia or difficulty swallowing are also at risk of malnutrition. This could be due to a blockage in the throat or mouth or due to sores in the mouth.

  • Loss of appetite. Common causes of loss of appetite include cancers, tumours, depressive illness and other mental illnesses, liver or kidney disease, chronic infections etc.

  • Those with a limited knowledge about nutrition tend to follow an unhealthy diet with not enough nutrients, vitamins and minerals and are at risk of malnutrition.

  • Elderly living alone, disabled persons living alone or young students living on their own often have difficulty cooking healthy balanced meals for themselves and may be at risk of malnutrition.

  • The elderly (over 65 years of age are), especially those living in care facilities are at a higher risk of malnutrition. These individuals have long term illnesses that affect their appetite and ability to absorb nutrients from food and they may also have difficulty feeding themselves. In addition, there may be concomitant mental ailments like depression that affect appetite and food intake.

  • Those who abuse drugs or are chronic alcoholics.

  • Those with eating disorders like anorexia nervosa have difficulty maintaining adequate nutrition.

  • Those with digestive illnesses like ulcerative colitis or Crohn’s disease or malabsorption syndrome have difficulty in assimilating the nutrients from diet and may suffer from malnutrition.

  • Those with diarrhea or persistent nausea or vomiting.

  • Some medications tend to alter the body’s ability to absorb and break down nutrients and taking these may lead to malnutrition.

  • The demand for energy from food exceeds the amount of food taken. This includes those who have suffered a serious injury, burn or after major surgical procedures. This also includes pregnant women and children whose growth and needs for the unborn baby causes increased demand for nutrients and calories that may be deficient in a normal diet.

  • Among children lack of knowledge of adequate feeding among parents is the leading cause of malnutrition worldwide.

  • Premature babies are at a higher risk of malnutrition as are infants at the time of weaning.

  • Childhood cancers, heart defects from birth (congenital heart disease), cystic fibrosis and other major long term diseases in children are the leading cause of malnutrition.

  • Neglected children, orphans and those living in care homes are at risk of malnutrition.

Diagnosis of malnutrition

Malnutrition is diagnosed based on certain factors like duration and precipitating causes if any. Clinical history and symptoms of malnutrition are often the major determinants of malnutrition and there is little role of diagnostic and imaging studies in evaluation of malnutrition.

Diagnostic tests and imaging studies may be needed to rule out deeper causes or illnesses that may have led to the malnourished state. 1-7

Outline of diagnosis of malnutrition includes BMI, routine blood tests and so forth.

Body mass index (BMI)

This is calculated by the weight in kilograms divided by the height in metres squared. A healthy BMI for adults usually lies between 18.5 and 24.9. Those with a BMI between 17 and 18.5 could be mildly malnourished, those with BMIs between 16 and 18 could be moderately malnourished and those with a BMI less than 16 could be severely malnourished.

Those with a history of unintentionally losing weight over the last few months, those who are unable to feed themselves or those with a health condition that caused lack of adequate nutrition or caused increased demands of nutrients that was not met by regular diet are at risk of malnutrition.

These individuals need to be evaluated carefully. Those who have eaten little or nothing for the last five days or are likely to eat little or nothing for five days or longer, those who cannot absorb nutrients from food well like those with ulcerative colitis or Crohn’s disease, may be at risk.

In general all with a BMI less than 18.5 in a course of few months need to be evaluated. Pregnant women, elderly living in care homes and children are at greater risk.

Routine blood tests

This is done to assess anemia and other vitamin and mineral deficiencies. There may be dehydration, low blood sugar and signs of severe infection as is evident by raised while blood cell counts.

Diagnosis of malnutrition in children

In children weight and height is measured and compared with the charts showing the expected average height and weight for a child of that age. Some children are persistently smaller for age and may be genetically so.

What should alarm parents and caregivers is a sudden or significant drop below the expected level for a child as it may indicate malnutrition. Children who show a slower growth may also be malnourished.

Mid-upper arm diameter

Mid upper arm diameter may be used in children. An upper arm circumference of less than 110 mm is also used to define severe malnutrition in children. In children thickness of skin folds is also measured. With malnutrition there is loss of the fat beneath the skin called the subcutaneous fat. This leads to thin skin folds.

Blood tests in children

Routine blood tests in children include those for blood glucose, blood counts, urine for routine examination, stool for parasites and worm infestations (as these may lead to malnutrition in children), blood protein or albumin levels, HIV test and tests for other infections.

Levels of iron in blood, folic acid and vitamin B 12 are also recommended. For protein estimation other tests include Pre-albumin, transferrin, retinol-binding protein.

Other tests for malnutrition

Other tests include:

  • thyroid function tests
  • estimation of the intestine for Crohn’s disease or Coeliac disease
  • levels of Calcium, Phosphate, Zinc and vitamins
  • low levels of cholesterol and albumin (especially in elderly)