malnutrition

(măl'nū-trĭsh'ən, -nyū-)
n.
Poor nutrition because of an insufficient or poorly balanced diet or faulty digestion or utilization of foods.

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belongs firmly to the list of Fowlerian lost causes. 'A word to be avoided,' wrote Fowler in 1926, as often as underfeeding will do the work. Alas for Fowler, underfeeding has not done its work, although the related form underfed is still going strong as an alternative for malnourished. It is interesting, though, that we are so ready to use the technical term in general contexts.

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For more information on malnutrition, visit Britannica.com.

Impaired health caused by a dietary deficiency, excess, or imbalance. To support human life, energy (from fat, carbohydrate, and protein), water, and more than 40 different food substances must be obtained from the diet in appropriate amounts. Malnutrition can result from the chronic intake of any of these substances at levels above, as well as below, ranges that are adequate and safe, but commonly the term refers only to deficient intake.

The number of people throughout the world who suffer from nutritional deficiencies as a result of inadequate dietary intake is uncertain, but even the most conservative estimates place that figure at hundreds of millions; many experts consider the actual number to approach 1 billion. Most malnourished people live in developing countries where income, education, and housing are inadequate to buy, transport, store, and prepare food and where nutritional deficiencies are almost always related to poverty. In industrialized countries, chronic conditions of deficient dietary intake occur far less frequently but are reported occasionally among people who are dieting to lose weight, fasting, or on an unusually restrictive (“fad”) diet. Pregnant women, infants, and children are most at risk for inadequate dietary intake because their nutritional requirements are relatively high.

Nutritional deficiencies also occur as a result of illness, injury, or alcohol or drug abuse that interferes with appetite; the inability to eat; defective digestion, absorption, or metabolism of food molecules; or disease states that increase nutrient losses. Secondary malnutrition has been observed frequently among medical and surgical patients who are treated in hospitals for prolonged periods of time. Regardless of cause, the effects of malnutrition can range from minor symptoms to severe syndromes of starvation, protein-calorie malnutrition, or single-nutrient deficiencies. See also Metabolic disorders.

The chronic intake of energy below the level of expenditure induces rapid losses in body weight and muscle mass accompanied by profound changes in physiology and behavior. Together, these effects cause a starving person to become weak, apathetic, depressed, and unable to work productively and to do whatever is necessary to reverse the malnutrition. The consequences of nutritional deficiencies are seen first in tissues that are growing rapidly. These changes are most evident in the gastrointestinal tract, skin, blood cells, and nervous system as indigestion, malabsorption, skin lesions, anemia, or neurologic and behavior changes. Of special concern is the loss of immune function that accompanies severe malnutrition.

The combined effects of malnutrition and infection in young children are referred to as protein-calorie malnutrition. It classified into two entities, marasmus and kwashiorkor, on the basis of physical appearance and the relative proportions of protein and calories in the diet. Children with the marasmus form appear generally wasted as a result of diets that are chronically deficient in calories as well as protein and other nutrients. Children with kwashiorkor are also very thin but have characteristically bloated bellies due to fluid retention and accumulation of fat in the liver, symptoms attributed to diets relatively deficient in protein. See also Adipose tissue; Protein metabolism.

Deficiency conditions due to lack of a single vitamin or mineral occur rarely and usually reflect the lack of the most limiting nutrient in a generally deficient diet. In industrialized countries, single-nutrient deficiencies are most evident in individuals who abuse alcohol or drugs. Classic conditions of deficiency of niacin (pellagra), thiamine (beriberi), vitamin C (scurvy), and vitamin D (rickets) have virtually disappeared as a result of food fortification programs and the development of food distribution systems that provide fresh fruits and vegetables throughout the year. Iron-deficiency anemia also has declined in prevalence, although children in low-income families remain at risk. In developing countries, however, such conditions are still observed among people whose diets depend on one staple food as the major source of calories. A condition of substantial current public health importance is vitamin A deficiency, which is the principal cause of blindness and a major contributor to illness and death among children in developing countries. See also Anemia; Vitamin.

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Disturbance of form or function arising from deficiency or excess of one or more nutrients. See also cachexia; obesity; protein-energy malnutrition; vitamin toxicity.

Condition caused by an unbalanced diet with certain foods being deficient, in excess, or in the wrong proportions. See also kwashiorkor; marasmus; and obesity.

Definition

Malnutrition is a condition that develops when the body does not get the proper amount of protein, energy (calories), vitamins, and other nutrients it needs to maintain healthy tissues and organ function.

Description

Poor eating habits or lack of available food may lead to malnutrition. Malnutrition occurs in children who are either undernourished or overnourished. Children who are overnourished may become overweight or obese, which may lead to long-term health problems and social stress.

Undernutrition

Undernutrition is a consequence of consuming little energy and other essential nutrients, or using or excreting them more rapidly than they can be replaced. This state of malnutrition is often characterized by infections and disease. Malnutrition intensifies the effect of every disease. Severe malnutrition is most often found in developing countries. Rarely in the United States do children suffer from severe malnutrition that is not related to severe chronic illness. Deficiency in one nutrient occurs less often than deficiency in several nutrients. A child suffering from malnutrition is usually deficient in a variety of nutrients.

The leading cause of death in children in developing countries is protein-energy malnutrition. This type of malnutrition is the result of inadequate intake of protein and energy. Children who are already undernourished can suffer from protein-energy malnutrition when rapid growth, infection, or disease increases the need for protein and essential nutrients.

Overnutrition

In the United States, nutritional deficiencies have generally been replaced by dietary imbalances or excesses associated with many of the leading causes of death and disability. Overnutrition results from eating too much, eating too many of the wrong foods, not exercising enough, or taking too many vitamins or other dietary replacements.

Risk of overnutrition is also increased by being more than 20 percent overweight, consuming a diet high in fat and salt, and taking high doses of:

• nicotinic acid (niacin) to lower elevated cholesterol levels
• vitamin B₆ to relieve premenstrual syndrome
• vitamin A to clear up skin problems
• iron or other trace minerals not prescribed by a doctor

Nutritional disorders can affect any system in the body and the senses of sight, taste, and smell. Malnutrition begins with changes in nutrient levels in blood and tissues. Alterations in enzyme levels, tissue abnormalities, and organ malfunction may be followed by illness and death.

Complications

Poorly nourished children often have weakened immune systems, thus increasing their chances of illness. Underweight, malnourished teenagers (such as those with an eating disorder) have an increased risk of osteoporosis and may not have menstrual periods. They may have heart and other organ problems with severe malnutrition. Malnutrition, if left untreated, can lead to physical or mental disability, or even death.

Children who are overweight have an increased risk for long-term conditions and diseases, including cardiovascular disease, high cholesterol, high blood pressure, type 2 diabetes, asthma, sleep apnea, and certain cancers. Health consequences range from a higher risk of premature death to chronic conditions that reduce a person's quality of life.

Demographics

Malnutrition is a major cause of illness and death throughout the world. Throughout the developing world, malnutrition affects almost 800 million people, or 20 percent of the population. Approximately half of the 10.4 million children who die each year are malnourished. It often causes disease and disability in the children who survive. Diarrheal diseases are also a major world health problem, and may be a cause of malnutrition. Nearly all of these deaths occur in impoverished parts of Africa and Asia, where they often result from contamination of the water supply by animal and human feces.

Worldwide, the most common form of malnutrition is iron deficiency, affecting up to 80 percent of the population, as many as four or five billion people.

In contrast, children in many parts of the world are becoming increasingly overweight. What was thought of as a problem for industrialized nations only until recently, is now affecting children in developing countries. Approximately 25–30 percent of school-age children in the United States are overweight.

Causes and Symptoms

Worldwide, poverty and lack of food are the primary reasons why malnutrition occurs. Families of low-income households do not always have enough healthy food to eat. When there is a household food shortage, children are the most vulnerable to malnutrition because of their high energy needs.

There is an increased risk of malnutrition associated with chronic diseases, especially disease of the intestinal tract, kidneys, and liver. Children with chronic diseases like cancer, cystic fibrosis, AIDS, celiac disease, and intestinal disorders may lose weight rapidly and become susceptible to malnutrition because they cannot absorb valuable vitamins, iron, and other necessary nutrients. Children who are lactose intolerant have difficulty digesting milk and milk products, and may be at risk for malnutrition, particularly a calcium deficiency.

Symptoms of malnutrition vary, depending on what nutrients are deficient in the body. Unintentionally losing weight may be a sign of malnutrition. Children who are malnourished may be skinny or bloated and may be short for their age (stunted). Their skin is pale, thick, dry, and easily bruised. Rashes and changes in pigmentation are common.

Hair is thin, tightly curled, and easily pulled out. Joints ache and bones are soft and tender. The gums bleed. The tongue may be swollen, or shriveled and cracked. Visual disturbances include night blindness and increased sensitivity to light and glare.

Other symptoms of malnutrition include:

• fatigue
• dizziness
• anemia
• diarrhea
• disorientation
• goiter (enlarged thyroid gland)
• loss of reflexes and lack of coordination
• muscle twitches
• decreased immune response
• scaling and cracking of the lips and mouth

Children who are overnourished are visibly overweight or obese, and consume more food than their bodies need (or expend too little energy through physical activity).

When to Call the Doctor

Parents who worry about malnutrition can discuss their concerns with a doctor, registered dietitian, or other health care provider. Though not an exhaustive list, treatment should be sought for a child if:

• there is a change in bodily functions (impairment)
• the child is not growing
• the child faints
• the child rapidly loses hair
• a girl at puberty stops menstruating or is underweight and fails to start menstruating

Diagnosis

Overall appearance, behavior, body-fat distribution, and organ function can alert a family physician, internist, or nutrition specialist to the presence of malnutrition. Parents may be asked to record what a child eats during a specific period. X rays or a CT scan can determine bone density and reveal gastrointestinal disturbances, as well as heart and lung damage.

Blood and urine tests are used to measure levels of vitamins, minerals, and waste products. Nutritional status can also be determined by:

• comparing a child's weight to standardized charts
• calculating body mass index (BMI) according to a formula that divides height into weight
• measuring skin-fold thickness or the circumference of the upper arm

Treatment

Normalizing nutritional status starts with a nutritional assessment. This process enables a registered dietitian or nutritionist to confirm the presence of malnutrition, assess the effects of the disorder, and formulate a diet that will restore adequate nutrition. For children suffering malnutrition due to an illness or underlying disorder, the condition should be treated concurrently.

Nutritional Concerns

Children who cannot or will not eat, or who are unable to absorb nutrients taken by mouth, may be fed intravenously (parenteral nutrition) or through a tube inserted into the gastrointestinal tract (enteral nutrition).

Tube feeding is often used to provide nutrients to children who have burns, inflammatory bowel disease, or other long-term conditions that cause chronic malnutrition or malabsorption (e.g. cystic fibrosis or AIDS), and interfere with the ability to take in enough calories. This procedure involves inserting a thin tube through the nose and carefully guiding it along the throat until it reaches the stomach or small intestine. If long-term tube feeding is necessary, the tube may be placed directly into the stomach or small intestine through an incision in the abdomen.

Tube feeding cannot always deliver adequate nutrients to children who:

• are severely malnourished
• require surgery
• are undergoing chemotherapy or radiation treatments
• have been seriously burned
• have persistent diarrhea or vomiting
• have a gastrointestinal tract that is not functional

Intravenous feeding can also supply some or all of the nutrients these children need.

Doctors or registered dietitians can help parents can monitor overweight or obese children. These professionals may suggest a weight loss program if the child is more than 40 percent overweight. Keeping weight gain under control can be accomplished by changing eating habits, lowering fat intake, and increasing physical activity.

Prognosis

Some children with protein-energy malnutrition recover completely. Others have many health problems throughout life, including mental disabilities and the inability to absorb nutrients through the intestinal tract. Prognosis is dependent on age and the length and severity of the malnutrition, with young children having the highest rate of long-term complications and death. Death usually results from heart failure, electrolyte imbalance, or low body temperature. Children with semiconsciousness, persistent diarrhea, jaundice, or low blood sodium levels have a poorer prognosis.

A good prognosis exists for overweight children who make lifestyle changes and adhere to a diet and exercise program.

Prevention

Every child admitted to the hospital for poor weight gain or malnutrition should be screened for the presence of illnesses and conditions that could lead to protein-energy malnutrition. Children with higher-than-average risk for malnutrition should be more closely assessed, and evaluated often.

Nutritional Concerns

Proper nutrition is required to ensure optimal health. Consumption of a wide variety of foods, with adequate vitamin and mineral intake, is the basis of a healthy diet. Researchers state that no single nutrient is the key to good health, but that optimum nutrition is derived from eating a diverse diet, including a variety of fruits and vegetables. Because foods such as fruits and vegetables provide many more nutrients than vitamin supplements, food is the best source for acquiring needed vitamins and minerals.

Breastfeeding a baby for at least six months is considered the best way to prevent early-childhood malnutrition. The United States Department of Agriculture and Health and Human Services recommends that all Americans over the age of two:

• consume plenty of fruits, grains, and vegetables
• eat a variety of foods that are low in fats and cholesterol, and contain only moderate amounts of salt, sugars, and sodium
• engage in moderate physical activity for at least 30 minutes, at least several times a week
• achieve or maintain their ideal weight
• use alcohol sparingly or avoid it altogether

Iron deficiency can be prevented by consuming red meat, egg yolks, and fortified breads, flour, and cereals.

Parental Concerns

Infants, young children, and teenagers need additional nutrients to provide for growth requirements. This is also true for women who are pregnant or breastfeeding; a mother's nutritional status affects her baby. Nutrient loss can be accelerated by diarrhea, excessive sweating, heavy bleeding (hemorrhage), or kidney failure. Nutrient intake can be restricted by age-related illnesses and conditions, excessive dieting, severe injury, serious illness, a lengthy hospitalization, or substance abuse.

Children usually eat as much or as little as they need in order to feel satisfied. Children should be allowed to select what they want to eat among healthy food choices; they should be allowed to stop eating when they feel full. An underweight, overweight, or normal weight child should be allowed to decide how much to eat or whether to eat at all, within reason.

Parents must proactively prevent childhood obesity by recognizing weight imbalances when they begin. They can help an overweight child to lose weight (if medically necessary) by being supportive, rather than scolding. Parents should offer their children nutritious food choices and encourage physical activity. With proper intervention, an overweight child is not destined to become an overweight adult, but weight loss goals should be realistic.

Resources

Books

Kleinman, Ronald E., and the American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition Handbook, 5th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2003.

Physicians Committee for Responsible Medicine. HealthyEating for Life for Children. Hoboken, NJ: Wiley, 2002.

Willett, Walter C., and P.J. Skerrett. Eat, Drink, and BeHealthy: The Harvard Medical School Guide to Healthy Eating. New York: Simon & Schuster Source, 2002.

Organizations

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098. (847) 434-4000.

American College of Emergency Physicians. 1125 Executive Circle, Irving, TX 75038-2522. (800) 798-1822.

American College of Nutrition. 300 S. Duncan Ave. Ste. 225, Clearwater, FL 33755. (727) 446-6086.

American Dietetic Association. 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606-6995. (800) 877-1600.

Food and Nutrition Information Center. Agricultural Research Service, USDA, National Agricultural Library, Room 105, 10301 Baltimore Boulevard, Beltsville, MD 20705-2351. Web site: www.nal.usda.gov/fnic/fniccomments.html.

[Article by: Mary K. Fyke Crystal Heather Kaczkowski, MSc.]

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Condition caused by an unbalanced diet with nutrients being deficient, in excess, or in the wrong proportions. Many people, including athletes, suffer from mild malnutrition that adversely affects their physical performance.

The nutritional requirements of the human body reflect the nutritional intake necessary to maintain optimal body function and to meet the body's daily energy needs. Malnutrition (literally, "bad nutrition") is defined as "inadequate nutrition," and while most people interpret this as undernutrition, falling short of daily nutritional requirements, it can also mean overnutrition, meaning intake in excess of what the body uses. However, undernutrition affects more than one-third of the world's children, and nearly 30 percent of people of all ages in the developing world, making this the most damaging form of malnutrition worldwide.

The etiology of malnutrition includes factors such as poor food availability and preparation, recurrent infections, and lack of nutritional education. Each of these factors is also impacted by political instability and war, lack of sanitation, poor food distribution, economic downturns, erratic health care provision, and by factors at the community/regional level.

People at Risk
Certain people are more susceptible to malnutrition than others. For example, individuals in rapid periods of growth, such as infants, adolescents, and pregnant women, have higher nutritional needs than others, and are therefore more susceptible to the effects of poor nutrition. Those living in deprived socioeconomic circumstances or that lack adequate sanitation, education, or the means to procure food are also at risk. Most importantly, individuals at risk for systemic infections (particularly gastrointestinal) and those who suffer with a chronic disease are at greatly increased risk because they require additional energy to support their immune system and often have decreased absorption of nutrients.

In fact, the relationship between malnutrition and infection is cyclical—infection predisposes one to malnutrition, and malnutrition, which impairs all immune defenses, predisposes one to infection. The World Health Organization (WHO) identifies malnutrition as "the single most important risk factor for disease" (WHO). Some research has identified malnourished children as being more likely to suffer episodes of infectious disease, as well as episodes of longer duration and greater severity, than other children. In particular, hookworm, malaria, and chronic diarrhea have been linked with malnutrition. These conditions are more prevalent in the developing world than in the industrialized world, though malnutrition exists worldwide, particularly in areas of poverty and among patients with chronic disease or who are hospitalized and on enteric feeding.

Necessary Nutrients
The WHO's Department of Nutrition for Health and Development is responsible for formulating dietary and nutritional guidelines for international use. Adequate total nutrition includes the following nutrients: protein, energy (calories), vitamin A and carotene, vitamin D, vitamin E, vitamin K, thiamine, riboflavin, niacin, vitamin B6, pantothenic acid, biotin, folate, vitamin C, antioxidants, calcium, iron, zinc, selenium, magnesium, and iodine. Most important are protein and the caloric/energy requirement needed to utilize protein. If these elements are inadequate, the result is a protein-energy malnutrition (PEM), or protein-calorie malnutrition (PCM), which affects one in every four children worldwide, with the highest concentration in Asia. Chronic deficiencies of protein and calories result in a condition called marasmus, while a diet high in carbohydrates but low in protein causes a condition called kwashiorkor.

Malnutrition and Growth
Malnutrition from any cause retards normal growth. Growth assessments are therefore the best way to monitor a person's nutritional status. While there are a variety of methods used to measure growth, the most common are known as anthropometric indices, which compare an individual's age, height, and weight, each of which is measured against the others. The values are expressed as percentages, or percentiles, of the normal distribution of these measurements. So, for example, a child with a given height and age might rank in the 90th percentile for height based on all children of that particular age, meaning that 90 percent of children that age are shorter than this particular child. Through anthropometric studies, researchers have found that particular measurements correlate with specific growth trends, based on how the body normally changes over time. Abnormal height-forage (stunting) usually measures long-term growth faltering. Low weight-for-height (wasting) correlates with an acute growth disturbance.

Malnutrition can have severe long-term consequences. Children who suffer from malnutrition are more likely to have slowed growth, delayed development, difficulty in school, and high rates of illness, and they may remain malnourished into adulthood.

Limited growth patterns are distributed unevenly across the globe. Eighty percent of children affected by stunting or wasting live in Asia, with 15 percent in Africa and 5 percent in Latin America. Low weight-for-age (underweight) is usually used as an overall measurement of growth status. More than 35 percent of all preschool-age children in developing countries are underweight. There are differences, however, across regions. "The risk of being underweight is 1.5 times higher in Asia than in Africa, and 2.3 times higher in Africa than Latin America" (Onis, p. 10). In some ways, these indices also enable an indirect understanding of the societal factors in these regions that contribute to malnutrition as mentioned above.

The Universal Declaration of Human Rights, established by the United Nations (UN) in 1948, identifies nutrition as a fundamental human right. Malnutrition remains one of the world's highest priority health issues, not only because its effects are so widespread and long lasting, but also because it can be eradicated. Given the multifactorial causes of malnutrition, interventions must be focused on both acute and broad goals. Current efforts are targeted at high-risk groups, particularly infants and pregnant women, for it is "in these populations and during these ages that nutritional interventions have the greatest potential for benefit" (Schroeder, p. 46). Even the simple supplementation of vitamin A or beta-carotene supplements during pregnancy can decrease maternal mortality by 40 percent. Interventions include direct food supplementation, food access, agricultural enrichment, nutritional education, and improved infrastructure related to hygiene, sanitation, and health care delivery. Each of these programs "must be tailored to the particular problems, cultural conditions, and resource constraints of the local context" (Schroeder, p. 417). Strategies for reducing the prevalence of malnutrition must effectively address its many causes.

See also Kwashiorkor; Marasmus; Nutrients; Nutrition.

Bibliography
Gillespie, Stuart, and Lawrence Haddad (2001). Attacking the Double Burden of Malnutrition in Asia and the Pacific. Washington, DC: International Food Policy Research Institute.
Onis, M.; Monteiro, C.; Akre, J.; and Clugston, G. (1993). "The Worldwide Magnitude of Protein-Energy Malnutrition." In Bulletin of the World Health Organization 71(6).
Schroeder, Dirk G. (2001). "Malnutrition." In Nutrition and Health in Developing Countries, ed. Richard Semba and Martin Bloem. Totowa, NJ: Humana Press.
Shannon, Joyce Brennflck (2001). Worldwide Health Sourcebook. Detroit, MI: Omnigraphics.

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Malnutrition results from the chronic dietary intake of nutrients or energy that provides considerably less or more than is required to be considered adequate or appropriate to support the everyday needs of the human body. Such adverse nutrient intakes are detrimental to human health and may lead to a state of deficiency, dependency, toxicity, or obesity. Malnutrition includes undernutrition, which means the body is not receiving nearly enough nutrients, and overnutrition, which means the intake of nutrients is grossly excessive.

Undernutrition

Undernutrition continues to be a significant cause of malnutrition in developing countries, although it is relatively rare in developed countries. Poverty in developing countries contributes more to undernutrition than a lack of global food production and is considered the chief cause of malnutrition. Families that are poor do not have the economic, social, or environmental resources to purchase or produce enough food. Poor soil conditions may also contribute to a family's inability to grow enough food to prevent malnutrition and the accompanying complications to health. Additionally, for the urban poor, low wages, underemployment, and food prices beyond the reach of families also contribute to undernutrition.

Prolonged dietary intakes deficient in energy or calories, protein, fat, vitamins, and minerals lead to illness and eventually death if not corrected. Undernutrition may also be the result of psychological disorders, such as anorexia nervosa, which manifests as an unwillingness to eat enough food to sustain life. Elderly adults often have a decrease both in appetite and intestinal function and are at an increased risk for undernutrition. Children, particularly infants and those under five years of age are also at an increased risk for undernutrition due to a greater need for energy and nutrients during periods of rapid growth and development. Infants born to undernourished mothers are more likely to be low birth weight infants. Addiction to alcohol or drugs may also lead to undernutrition when the addicted individuals favor alcohol and/or drug intake over adequate food intake. Severe, prolonged diarrhea, renal failure, infection, or diseases that cause the malabsorption of nutrients in the small intestine also may cause undernutrition even if dietary intake is adequate. It is obvious that the causes of undernutrition are varied and complex, requiring solutions that may also be complex.

Nutrients Required to Prevent Undernutrition

The nutrients required in adequate amounts by the body to prevent undernutrition are carbohydrates, fat or lipids, protein, vitamins, minerals, and water. Carbohydrates provide the body with energy (about 4 kilocalories per gram of carbohydrate consumed). Carbohydrates also protect protein stores in the body. A minimal intake of 50 to 100 grams (1.8 to 3.5 oz.) of carbohydrates is required to prevent the development of ketones that the brain can use somewhat inefficiently for energy. The brain optimally uses carbohydrate for energy, but when carbohydrate intake is inadequate for several weeks, the body does not metabolize fatty acids completely in order to produce ketones for energy. In addition to ketone formation resulting from insufficient carbohydrate consumption, body protein will also be lost, and the body will generally become weakened.

Fats or lipids provide essential fatty acids upon metabolism following consumption. Essential fatty acids are obtained from dietary lipids and are termed essential because the human body cannot synthesize them. Essential fatty acids are important for human health because they participate in immune processes, vision, are an integral part of cell structures, and participate in hormone-like compound production. If an inadequate intake of lipids is routinely consumed, the body becomes deficient in essential fatty acids. This results in skin problems, diarrhea, and an increase in infections with a corresponding decrease in the ability of the body to heal wounds. Lipids also provide energy for the body (about 9 kilocalories per gram (28 kilocalories per ounce of fat consumed), can be stored for future use as energy, insulate the body and protect body organs, and aid in the absorption and transport of fat-soluble vitamins (vitamins A, D, E, and K) throughout the body. The fat-soluble vitamins are important for vision (vitamin A), bone metabolism (vitamin D), providing antioxidant protection from free radicals (vitamin E), and blood coagulation (vitamin K), among other functions.

Protein is a very important nutrient because so many substances in the body are made from it. Proteins are made when amino acids are combined in specific sequences to form specific proteins. The sequence of the amino acids determines the shape of the protein, and the shape of the protein, in turn, determines the function of the protein. Amino acids can be obtained from plant or animal sources. There are nine essential amino acids: histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine. The human body is not able to synthesize these amino acids, so they must be derived from the foods we eat. There are eleven nonessential amino acids that the human body is able to make: alanine, arginine, asparagine, aspartic acid, cysteine, glutamic acid, glutamine, glycine, proline, serine, and tyrosine. As stated previously, amino acids are necessary for protein synthesis, but they are also important because they provide the body with a special form of nitrogen that the body cannot get from carbohydrates or lipids. Protein, like carbohydrate, provides approximately 4 kilocalories per gram of protein consumed, but requires much more metabolizing and processing by the liver and kidneys to put the energy from protein to use. Protein is a part of every cell in the human body. Blood proteins enable the body to maintain the right balance of fluid inside and outside of cells. When adequate protein is not consumed, there is a lower concentration of blood proteins in the bloodstream, which causes the balance of fluids inside and outside of cells in tissues to be thrown off, resulting in swelling of tissues or edema, which can lead to serious medical problems. Proteins also help regulate the pH, or acid-base balance, in the blood, are necessary for the synthesis of many hormones and enzymes, and participate in important cell formation for cells vital for the immune system. Amino acids from protein can also be used to produce glucose, which is a positive thing for providing glucose after an overnight fast. But in the case of starvation, excessive muscle tissue is wasted and results in diminished health. Protein-energy malnutrition results from near starvation and may be seen in the body tissues in either a wet, dry, or combined form. The dry form, marasmus, is caused by deficiency of protein and nonprotein nutrients, with the individual being very thin from the loss of muscle and body fat. The wet form, kwashiorkor, is caused primarily by protein deficiency, with energy deficiency being secondary, and is accompanied by edema. The combined form, marasmic kwashiorkor, results from protein and energy deficiency with edema and more body fat than is seen in marasmus.

There are also water-soluble vitamins in addition to the fat-soluble vitamins. Because water-soluble vitamins are not stored in any appreciable amounts in the body, but are excreted readily in urine, it is relatively easy to become depleted of them. Fat-soluble, in contrast, are stored in adipose tissue and the liver, and consequently it is more difficult to become deficient of them. The water-soluble vitamins are the B vitamins and vitamin C. The B vitamins are thiamin, riboflavin, niacin, pantothenic acid, biotin, pyridoxine, folate, and vitamin B₁₂. All of the water-soluble vitamins except vitamin C have coenzyme functions and are involved in a variety of reactions including energy metabolism, DNA synthesis, nerve function, protein and carbohydrate metabolism, and fat synthesis. Vitamin C is involved in protecting the body from oxidative damage caused by substances called free radicals. It also functions in connective tissue synthesis, hormone synthesis, and neurotransmitter synthesis. Physiological consequences of deficiency include inflammation of the mouth and tongue (riboflavin deficiency); diarrhea, dermatitis (niacin deficiency); edema, weakness (thiamin deficiency); tongue soreness, anemia (biotin deficiency); fatigue, tingling in hands (pantothenic acid deficiency); poor growth, inflammation of the tongue (folate deficiency); poor nerve function, macrocytic anemia (vitamin B₁₂ deficiency); and poor wound healing, bleeding gums (vitamin C deficiency).

Minerals are important nutrients that must be obtained from foods consumed, as the human body is unable to synthesize them. Some factors that influence mineral bioavailability (the extent to which minerals in food consumed is available for the body to put to use) are the amount of mineral content in the soil in which the food providing the mineral was grown; dietary fiber consumed in the same meal as a food containing the minerals; mineral-mineral interactions; and vitamin-mineral interactions. Sodium, potassium, chloride, calcium, phosphorus, magnesium, and sulfur are the major minerals. Deficiencies of these minerals lead to such symptoms as muscle cramps (sodium), irregular heartbeat (potassium), convulsions in infants (chloride), an increased risk for osteoporosis (calcium), diminished bone support (phosphorus), and poor heart function (magnesium). There are also so-called trace minerals that are only required in very small amounts to contribute to optimal health. These trace minerals are iron, zinc, selenium, iodide, copper, fluoride, chromium, manganese, and molybdenum. When inadequate amounts of foods containing the trace minerals are consumed, symptoms begin to appear. These symptoms include low blood iron (iron), skin rash/poor growth and development (zinc), muscle weakness (selenium), goiter (iodide), anemia/poor growth (copper), increased risk for dental cavities (fluoride), and high blood glucose after eating (chromium).

Developed countries typically have water supplies that are monitored for safety by government agencies and are provided in large enough quantities that a lack of drinking water is not the norm. Developing countries, however, may not have water that is free from contamination, or because of drought or other natural disasters do not have a large enough water supply for human consumption or to provide water for livestock or crops. Water is vital for life and, without it, an adult can survive only a few days because the human body does not have the ability to store water. Water is found inside of cells as intracellular fluid and outside of cells as extracellular fluid. A proper balance between intracellular and extracellular water is necessary to prevent complications such as edema. Water also is responsible for regulating body temperature, most notably through the cooling-off process accomplished by perspiration. Water is necessary to provide lubrication for joints such as the knees. Without adequate water in the form of amniotic fluid in the womb of a pregnant woman, the growing fetus does not have sufficient support to prevent injury should the mother fall or be otherwise jarred abruptly. Water is also the primary avenue utilized by the body to rid itself of waste products. While water does not supply energy as carbohydrates, protein, and fats are able to do, it is still a very important nutrient necessary to prevent malnutrition.

Overnutrition

Overnutrition results when energy expenditure is grossly exceeded by energy intake and leads to overweight and obesity. Developed countries, with their abundant food supplies and processed foods, are most afflicted with overnutrition and the medical complications associated with it. Due to the excessive intake of food products, the amount of fat-soluble vitamins and minerals in the body can rise to toxic levels because they are stored in the body. Developed countries have greater incidences of cardiovascular disease, blood lipids, diabetes mellitus, hypertension, respiratory problems, gallbladder disease, arthritis, and cancer, all of which are connected to complications stemming directly from overnutrition.

Methods of Evaluating Malnutrition

Malnutrition is diagnosed based on the findings of a medical and diet history, physical examination, and laboratory tests. The results are then compared with norms of weight for height, body mass index (body weight in kilograms divided by height in meters squared), dietary intake, physical findings, and plasma levels of nutrients and nutrient-dependent substances such as hemoglobin. The physical examination would necessarily include anthropometric measurements, as well as close examination of the skin, hair, and mouth for symptoms of malnutrition. For example, depigmentation of the hair is indicative of undernutrition, and a body weight that is 20 percent above the average desirable body weight as determined by insurance company standardized charts would indicate overnutrition. A triceps skinfold test may be utilized to determine the body's energy stores. Laboratory tests are used to reveal the extent to which amino acid nutrition is meeting the body's needs to determine undernutrition, or plasma lipids in the diagnosis of overnutrition. In the field when assessing nutritional status, the medical and diet history and physical examination may be the only tools accessible to the physician or nurse, particularly in developing countries.

Who Is At Increased Risk for Malnutrition?

The risk for malnutrition is increased for a variety of reasons. Increased nutritional needs during growth, pregnancy, lactation, old age, infection, certain cancer therapies, or immune deficiency disorders increase the risk of malnutrition. Diets that focus on a narrow range of foods may not provide the variety of nutrients required and lead to deficiencies. Those experiencing famine, with the accompanying reduction in available food, are at great risk for malnutrition in the form of undernutrition. Lack of money to purchase an adequate diet or cultural practices that dictate which members in the family get a large or small amount of food may also lead to malnutrition. Any medical condition that effects the absorption of nutrients from foods, or requires medication that has adverse consequences on appetite, may cause malnutrition if the condition is long term. Taking megadoses of vitamin/mineral supplements may result in toxic levels of the substances taken in the body with the outcome being a state of overnutrition.

Correcting Malnutrition in the United States

Since the Great Depression of the 1930s, the federal government of the United States has undertaken the task of alleviating and/or preventing malnutrition. In the 1960s, President John F. Kennedy reestablished the federal government's efforts to end debilitating hunger. Individuals and families who have low incomes may take advantage of several federally sponsored programs to ensure a better quality of nutrient intake. Food stamps are available to those who are usually employed but having difficulty purchasing an adequate food supply by using coupons to purchase food from grocery stores. The Commodity Supplemental Food Program distributes U. S. Department of Agriculture surplus foods through county agencies to such low-income populations as pregnant women and families with young children. The School Lunch and Breakfast Programs offer free or reduced-priced meals based on the Food Guide Pyramid to children of low-income families, with the cost of the reduced-priced meals being based on family income. The Summer Food Service Program offers free, nutritious meals and snacks to low-income children and distributes the meals from a central location during lower and secondary school vacations. There are also programs targeted specifically at different age groups. Preschool children enrolled in organized child-care programs receive meals at no cost, and the child-care program receives reimbursement for the meals through participation in the Child-Care Food Program. For individuals 60 years or older, a free noon meal is provided at centralized sites as part of the Congregate Meals for the Elderly Program. Homebound individuals over 60 years of age can take advantage of home-delivered meals at no cost or for a fee, depending on income, at least five days per week.

World Hunger: Addressing a Global Problem

In 1798 the English clergyman and political economist Thomas Malthus suggested that the world's population was growing at a rate faster than the food supply. The year 2002 finds world population growth exceeding economic growth, and poverty on the rise. Globally less than one-half of 1 percent of the world's yearly production of goods and services goes exclusively to economic development assistance, yet 6 percent goes to support the world's military operations. Civil wars in some countries have substantially retarded progress of the poor and continue to contribute to massive undernutrition. Environmental factors such as soil erosion or lack of fresh water for irrigation of crops exacerbate the problem of providing sufficient quantities of foods for many countries. What is being done to overcome all of these detriments to feeding the world's hungry? Since the 1960s, an American program, the Peace Corps, has been instrumental in providing education, distributing food and medical supplies, and building structures for locals to use in developing nations. National surveys such as the National Family Health Survey conducted in India are valuable tools in the determination of whether any progress is being made to improve the nutritional status of the nation. Advances in biotechnology to genetically alter plants and animals to improve the nutritive quality of the foods produced from them may help to meet increasing food needs both now and in the future. The United Nations and the World Health Organization cry out for governments in developed countries to facilitate greater strides in improvements in malnutrition in undeveloped countries by financial, educational, and scientific interventions. What will be required to eradicate malnutrition in this world is a coming together of the leaders of rich and poor nations to the same degree. Globally, there is an adequate food supply and the technical expertise necessary to address the problems and complications of malnutrition. All that is lacking is the political cooperation to address this devastating situation.

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—Rebecca J. (Bryant) McMillian

Inadequate nutrition caused by the lack of a balanced diet or by disorders of the digestive system in which the nutrients from food cannot be absorbed properly.

any imbalance, usually a deficiency, between the nutrients taken in by an organism and the amounts necessary to maintain that organism's normal development and health.

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The term used to describe the condition caused by a diet that contains all of the essential nutrients but in suboptimal amounts—an intermediate stage to starvation. It is compatible with life and the same metabolic changes occur as in starvation but to a lesser degree. Ketosis, loss of body weight and muscular power accompany a lower metabolic rate. There is also a fall in body temperature, reduced heart and respiratory rates and sexual activity. Could also be used to describe gross over-nutrition. See also cachexia, starvation.

• milk replacer m. — see milk replacer.

n

Any disorder concerning nutrition. It may result from a poor diet or from impaired utilization of foods ingested.

For a list of words related to malnutrition, see:

• Afflictions and Conditions - malnutrition: insufficient food consumption to satisfy bodily needs over prolonged period
• Nutrition For Fitness - malnutrition: chronic lack of essential and beneficial nutritional foodstuffs
• Populations and Resources - malnutrition: chronic, pervasive lack of proper food

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Dansk (Danish)
n. - fejlernæring, underernæring

Nederlands (Dutch)
ondervoeding

Français (French)
n. - malnutrition

Deutsch (German)
n. - Unterernährung

Ελληνική (Greek)
n. - υποσιτισμός

Italiano (Italian)
denutrizione

Português (Portuguese)
n. - desnutrição (f)

Русский (Russian)
недоедание

Español (Spanish)
n. - desnutrición

Svenska (Swedish)
n. - undernäring

中文（简体）(Chinese (Simplified))
营养失调, 营养不良

中文（繁體）(Chinese (Traditional))
n. - 營養失調, 營養不良

한국어 (Korean)
n. - 영양불량

日本語 (Japanese)
n. - 栄養不足, 栄養不良

العربيه (Arabic)
‏(الاسم) سوء تغذيه‏

עברית (Hebrew)
n. - ‮תת-תזונה, תזונה לקויה‬

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