What is ?Statistics on Risk Factors for Progression of Symptoms of Clinical Examination of How is Diagnosed?Prognosis of How is Treated? ReferencesWhat is ?
is a condition in which an individual has insufficient energy to maintain their body's essential functions, including growth, maintenance and movement. It is defined by the British National Institute for Clinical Excellence as "a state in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on tissue/body form, composition, function or clinical outcome." As the definition suggests, can be further classified as either protein-energy/protein-calorie (i.e. a deficiency in protein energy), or micronutrient deficiency (i.e. a deficiency in one or more micronutrients), depending on the specific nature of the nutritional intake/expenditure imbalance. These two sub-types of commonly coexist.
Regardless of the type, may be a consequence of primary or secondary , or both.
Primary refers to which is caused by inadequate energy intake. This condition often occurs in relation to food insecurity or when adequate food is not available (in terms of total calories or specific micronutrients). It can also result from poor appetite due to illness or eating disorders such as anorexia nervosa.
Secondary arises when an individual's dietary intake is sufficient, but energy is not adequately absorbed by the body as a result of infectious conditions such as diarrhoea, measles or parasitic infections, or medical or surgical problems affecting the digestive system. can also occur as a result of increased metabolic demands following illness or surgery.
is strongly associated with ill health, as both a cause and consequence. Individuals who are malnourished are more susceptible to disease and infection due to impaired immune function, and tend to consult health practitioners more frequently and take longer to recover from episodes of illness or injuries. Illness, and particularly long episodes of illness, can also frequently result in , as individuals tend to eat and drink less when they are ill.
Statistics onaffected some 148 million children around the world in 2007, although the vast majority of malnourished children resided in developing countries. In Australia, the 2007 Child Nutrition Survey reported some 5% of children were underweight for their height. In addition the survey revealed that, in a substantial proportion of children, daily intake of some micronutrients was insufficient to meet the children's development needs, indicating the potential for micronutrient deficiencies. For example, calcium intake was insufficient in more than half of all 9-16 year old, while some 15% of 14-16, 6% of 9-13 and 7% of 2-8 year old children did not consume the average requirement for iodine estimated by the National Health and Medical Research Council. Substantial proportions of children in the 14-16 year age group also consumed less than the estimated average requirement for vitamin A, folate, phospohorous, magnesium, iron and zinc.
Calcium Intake CalculatorHow much calcium do you consume?
Calcium is found in many foods, in particular dairy products and to a lesser degree bony fish, nuts and legumes, fruit and vegetables. It plays an important role in building and maintaining healthy bones and teeth.
Individuals need to consume sufficient amounts of calcium throughout their lifespan. Calcium requirements increase throughout childhood, peak during puberty, then stabilise until an individual is approximately 50 years old, when bone mass deteriorates and more calcium is required.
Click here to calculate your required calcium intakeIn England, an estimated 5% of the general population is malnourished, although prevalence is much higher in specific sub groups. In Australian adults, has typically been studied in specific subgroups with a high risk of , for example hospital inpatients, the elderly and individuals undergoing chemotherapy. A 1997 study in two Sydney hospitals found that 36% of patients admitted to hospital were malnourished. Studies from Britain also indicate that and some micro-nutrient deficiencies are common amongst the elderly. For example, amongst elderly individuals in aged care homes, an estimated 35% are deficient in folate and 40% deficient in vitamin C.
Indigenous Australians are also at increased risk of due to their typically low socioeconomic status and associated difficulties accessing food. Up to 30% of Indigenous Australians report that being able to access food is a concern to them at least some of the time, indicating that this proportion of the population are at high risk of becoming malnourished. Indigenous women are also more than twice as likely to bear low birth weight infants, demonstrating a higher prevalence of in pregnant indigenous women than in the general population of pregnant women in Australia.
Risk Factors for
occurs throughout the world, however a number of geographic and demographic groups have an increased risk of becoming malnourished. Overall, individuals who reside in developing countries are more likely to suffer from than those who reside in developed countries, due to the higher prevalence of poverty and infectious disease in developing nations. However, there are a number of factors which may predispose an individual to , regardless of their area of residence.
In general, factors which affect adequate nutrition include:
Poverty: Individuals from low socio-economic backgrounds and particularly those living in poverty are more likely to be malnourished than individuals from higher socio-economic classes. This is most often primary a result of food insecurity (being unable to access adequate sources of nutrition to meet the body's daily demands). Secondary (stemming from infectious disease) is also more prevalent in situations of poverty due to overcrowding and poor sanitation (which for example increase the risk of infection) and contributes to the increased incidence of amongst the poor.History of or recent infectious and parasitic disease, in particular diarrhoea, malaria, or intestinal worms predisposes an individual to and these conditions reduce the proportion of nutrients which the body is able to consume;History of recent surgery, particularly surgery involving the gastrointestinal system may increase an individual's risk of .Medications: A number of medications, for example medications used in chemotherapy, can reduce an individual's appetite or lead to eating difficulties (e.g. difficulty swallowing) and therefore predispose an individual to .Chronic diseases for example HIV is often associated with reduced appetite and food consumption (usually resulting from toxic medication regimes) which in turn causes .
Children and adolescents
In children and adolescents factors which predispose include:
Low birth weight: Individuals born with a low birth weight are more likely to suffer throughout their life and are unlikely to "catch-up" in terms of growth.Adolescent mothers: Children who were born to adolescent mothers are more likely to be malnourished than those born to older women, as during adolescence, a young woman's body is still developing and the additional stress of pregnancy at this time creates an extremely high risk of the child being born at a low birth weight.Not being breastfed: Breast milk is the ideal food for an infant as it is nutritionally balanced and provides antibodies which strengthen the developing infant's immune system reducing the chance of infectious and other diseases which can lead to . Children who are not breastfed therefore have a higher risk of becoming malnourished.
Adults
In adults factors which can predispose an individual to include:
which is related to poverty often begins early in life, or even in utero (when the foetus is developing in a woman's uterus), and continues throughout the lifecycle. A child who is malnourished early in life is likely to have their growth retarded as a result, and is unlikely to ever "catch-up" in terms of their body size. As adults, they will be shorter and weigh less than their adequately nourished counterparts.
In many cases also has inter-generational effects. For example, a woman who suffered from as a child, is more likely to bear underweight infants (infants weighing less than 2.5kg) and low birth weight infants are more likely to suffer nutritional problems throughout their lifecycle.
also commonly begins or worsens following a period of illness, when an individual is unable to eat or drink sufficient amounts of energy to fulfill their daily needs. This in turn reduces the body's immune function, leading to longer periods of illness and inadequate food consumption. This is particularly true amongst the elderly.
Symptoms of
There are a range of symptoms associated with .
Children
in children may lead to illness (e.g. diarrhoea, acute respiratory infection) as a result of reduced immune function. It is also commonly associated with reduced appetite, developmental regression and low levels of physical activity.
Adults
In adults can also result in illness, eating difficulties or suppressed appetite.
Clinical Examination ofChildren
If a health professional suspects a child is underweight, they are most likely to measure the child's weight and height, to determine whether or not the child is an appropriate weight for their height. They may measure a child's head circumference and/or mid-upper arm circumference. Practitioners may also look out for the following signs as indicators of :
Short stature;Thin arms and legs;Visible rib cage or vertebrae;Wasted buttocks; and/orPoor skin and hair condition.
Adults
When is suspected in adults, a health professional will measure the patient's BMI. A BMI less than18.5kg/m2 indicates current while a BMI less than 20kg/m2 indicates an individual is underweight, at an increased risk of becoming malnourished and is potentially already malnourished. Other physical appearances which may indicate to a health professional that an adult is malnourished include:
Loose fitting clothes;Fragile skin;Poor wound healing; and/orWasted muscles.
Patients who are diagnosed with should receive prompt treatment. Those who are not malnourished but at risk of future should receive nutritional counseling and be scheduled for repeat screening.
This tool needs Javascript enabled to run.
The formula for calculating your body mass index is:
BMI = weight (kilograms) / (height (metres) * height (metres))
For example:
A man who weighs 85 kilograms and is 1.8 metres tall would have a BMI of
BMI = 85 / (1.8 * 1.8)
BMI = 85 / 3.24
BMI = 26.2
A child will be diagnosed as malnourished if their weight is low for their height. An adult will be diagnosed with if they have a BMI less than18.5kg/m2.
Prognosis of
is a condition with far reaching health and social consequences, particularly if it is not promptly treated.
In both children and adults the effects of include an increased risk of:
Illness and infection: Individuals who are malnourished are more likely to become ill or infected due to the reduced capacity of their immune system associated with .Mortality: A study of patients admitted to two Sydney hospitals found that those who were malnourished at the time of admission were more likely to die in the following twelve months than those who were not malnourished at the time of admission. is also a contributing factor in more than half of all childhood deaths globally.
Children
The effects of chronic during childhood include an increased risk of:
Cognitive development disorders: Children who are chronically under nourished may have difficulty learning and concentrating while they are malnourished, and this can impair their mental development both at the time of and in the future.Stunted growth: also affects a child's physical growth, and a child who is malnourished for a significant time at any point, is likely to become stunted (short for their age during childhood and of short stature as an adult).Regressive development: can lead to regressive development. For example, a child who began walking may then stop walking again.Susceptibility to chronic diseases: Evidence suggests that during pregnancy or early childhood leads to an increased risk of chronic disease such as diabetes, coronary heart disease and renal failure later in life.
Adults
In adults the effects of include an increased risk of:
Low birth weight offspring: The offspring of women who are malnourished are more likely to suffer from growth retardation as a foetus and be born at a low birth weight. This in turn increases the likelihood of early childhood illness and death, as well as the likelihood that the offspring will suffer from .Lengthy hospital admission: An Australian study reported that patients who were malnourished at the time of hospital admission were admitted for an average of six days more than adequately nourished admissions.Reduced muscle capacity is associated with and can reduce an individual's capacity to perform tasks, particularly strenuous tasks, as well as increase their susceptibility to falls and other injuries.Menstrual irregularities: Women who are malnourished are more likely to experience irregular or absent menstrual cycles, which can in turn lead to fertility problems.Impaired psychosocial function: There are a range of psychosocial consequences of including an increased risk of depression, lack of self-esteem and poor body image, lack of appetite, disinterest in social activities and loss of libido.How is Treated?
Treating often involves interventions from a range of health professionals which, depending on the specific nature of the individual's , may include:
Children
Malnourished children need immediate attention. Children who display signs of mild or moderate may remain in the care of their parents/guardians, but will probably need to return to a health facility for future weight checks. In cases where is severe, children will most likely be admitted to hospital for treatment.
Health professionals will discuss the child's condition and habits with their parents/guardians. Discussion will include the child's eating habits and any potential barriers to nutritious food intake (e.g. financial circumstances, cultural beliefs which prevent the consumption of certain foods) which may affect the parent's ability to adequately nourish their child.
A health professional will probably also provide counseling regarding appropriate infant and child feeding patterns, for example the importance of breastfeeding, preparation of infant foods, the importance of micronutrients and appropriate meal sizes for children. They are also likely to advise that malnourished children benefit from physical contact, structured playtime, physical activity and maternal involvement throughout their treatment.
Treatment of severe is best carried out in hospital. In the first week it typically focuses on stabilising the child through the provision of intravenous feeding and treating any coexisting complications. For example, wide spectrum antibiotics are often prescribed to prevent infection, rehydration is usually, glucose is commonly given to prevent hypoglyaecemia (low blood sugar) and electrolytes and micronutrients given to balance or increase required concentrations in the child's body.
The focus then shifts to rehabilitating the child and feeding is cautiously reintroduced, usually in the form of specially prepared, protein-energy and nutrient rich formulas, when the child's appetite returns. Feeding is usually performed regularly (i.e. every four hours) until the child gains sufficient weight to be discharged.
Prior to a child being discharged, a health professional will usually provide the parents with advice about appropriate feeding and preventative intervention, including giving high energy foods and supplements, ensuring children are immunised and given six monthly vitamin-A supplements. Parents are also likely to be advised of the need for daily structured play, and follow up visits to a clinic to check weight and development.
Adults
In the majority of adult cases, will be treated by ensuring the availability of nutritious food, advising the patient regarding nutritional eating habits and developing an eating plan which meets the patient's nutritional requirements. In determining an eating plan for the patient, their daily energy requirement in terms of total protein energy and micronutrients should be determined. A health professional will also consider any additional metabolic demands the individual may have, due to illness or injury, which may require oral nutritional supplements (e.g. vitamin supplements). Counseling usually encourages malnourished patients to:
Health professionals should also be able to provide referrals if help obtaining or preparing food is needed. They will attempt to refer to an agency which can provide a needing individual with nutritionally appropriate food is prepared in such a way that they can consume it (e.g. precooked for those unable to prepare their own food, of the right consistency for those who have difficulty chewing or swallowing).
In more severe cases of , food supplements may be required to ensure an individual consumes their daily nutritional requirements in terms of total energy and micronutrients. A practitioner may consider prescribing food supplements in cases where the patient has:
A BMI less than 18.5kg/m2;Lost more than 10% of total body weight in the past 3-6 months;A BMI less than 20kg/m2 and has lost more than 5% of total body weight in the last 3-6 months;Eaten little or nothing for the past five days or are unlikely to eat for the next five days;Increased nutritional needs due to reduced absorption, nutrient losses or increased metabolic needs.There are a range of methods by which supplements can be administered, and wherever possible, they are administered via the gastrointestinal tract either in the form of:
Food fortification, for example provision of micronutrient fortified bread, which may be administered in inpatient or community settings (in conjunction with adequate monitoring and support) for individuals with specific micronutrient deficiencies;Proprietary oral nutritional support, for example provision of micronutrient tablets, may be administered in inpatient or community settings (in conjunction with adequate monitoring and support) for individuals with specific micronutrient deficiencies;Enteral tube feeding (providing nutritionally complete food directly to the gut via a tube) may be administered in inpatient or community settings (in conjunction with adequate monitoring and support) and used either alone or in conjunction with oral nutrition for patients who are unable to consume their daily nutritional requirements orally.In cases where gastrointestinal feeding is not possible (e.g. intestinal failure), nutritional support may be given via parenteral nutrition (intravenous infusion of nutrients).
Nutritional supplements, whether delivered orally, enterally or intravenously should be planned by a professional with training in nutrition support. Daily supplements will be planned to reflect the patient's daily nutritional demands, taking into consideration additional requirements which may arise with, for example, severe , reduced absorption or additional demands related to surgery.
More information
For more information on nutrition, including information on types and composition of food, nutrition and people, conditions related to nutrition, and diets and recipes, as well as some useful videos and tools, see Nutrition.
References
National Collaborating Centre for Acute Care. Nutrition Support for Adults, Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. National Collaborating Centre for Acute Care. 2006, London. [cited 2009, January 15] Available from http://www.rcseng.ac.uk/ Golden, B.E. Primary Protein Energy . In: Garrow, G.S. James, W.P.T., editors. Human Nutrition and Dietetics. 9th ed. Churchill Livingstone Press. 1993.pp 440-55.UNICEF, The State of the World's Children 2009. UNICEF. 2008. [cited 2009 January 15] Available from: http://www.unicef.org/Commonwealth Scientific and Industrial Research Organisation. 2007 Australian National Children's Nutrition and Physical Activity Survey: Main Findings. Commonwealth of Australia. 2008. [cited 2008 December 15] Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/66596E8FC68FD1A3CA2574D50027DB86/$File/childrens-nut-phys-survey.pdfBAPEN, The MUST explanatory booklet: a guide to the Universal Screening Tool (MUST) for adults. Advisory Group for BAPEN. 2003. [cited 2009, January 15] Available from: http://www.bapen.org.uk/Middleton, M.H. Nazarenko, G. Nivison-Smith, I. Smerdely, P. Prevalence of and 12-month incidence of mortality in two Sydney teaching hospitals. Internal Med J. 2001;31(8):A11-31.National Public Health Partnership. National Aboriginal and Torres Straight Islander Nutrition Strategy and Action Plan 2000-2010. Strategic Intergovernmental Nutrition Alliance. 2001. [cited 2009, January 15] Available from: http://www.nphp.gov.au/signal Black R.E. Morris S.S. Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361: 2226-34.Seres, N. throughout the lifecycle. In: Fourth Report of the World Nutrition Situation. Geneva: ACC/SCN in collaboration with IFPRI.. 2000. p. 1-22.World Health Organisation. WHO Global Database on Child Growth and . 2008. [cited 2009, January 15], available from: http://www.who.int/nutgrowthdb/en/Van de Broek, N. Anaemia and micronutrient deficiency disorders. Br Med Bul. 2003;67:149-60.Hetzel, B.S. Iodine Deficiency Disorders. In: Garrow, G.S. James, editors. Human Nutrition and Dietetics. 9th ed, W.P.T., Churchill Libingstone Press, 1993, p 534-55.Brewster, D.R. Critical appraisal of the management of severe : 3. Complications. J Paediat Child Health. 2006;42(10):583-93.Weisstaub, G. Soria, R. Araya, M. Improving quality of care for severe . [Correspondence] Lancet. 2004;363(9426):2090.World Health Organisation, Management of Severe : a manual for physicians and other senior health workers. World Health Organisation. 1999. [cited 2009, Jan 15] Available from: http://whqlibdoc.who.int/hq/1999/a57361.pdf Liu, J. Raine, A. Venables, P.H. et al. at age 3 and lower cognitive ability at age 11 years. Arch Pediatr Adolesc Med. 2003;157:593-600.Royal College of Nursing. : what nurses working with children and young people need to know. Position Statement of the Royal College of Nursing. 2006, [cited 2009, January 15] Available from: http://www.rcn.org.uk/__data/assets/pdf_file/0006/65499/.pdf Lean, M. Wiseman, M. in hospitals. [Editorial] BMJ. 2008;336(7639):290.London School of Hygiene and Tropical Medicine. Guidelines for the inpatient treatment of severely malnourished children. London School of Hygiene and Tropical Medicine. 2005. [cited 2009, January 15] available from: http://www.lshtm.ac.uk/nphiru/research/.pdf
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Anorexia nervosa is a psychological disease.
Anorexia nervosa runs a fluctuating course, with exacerbations and partial remissions. Long-term follow up suggests that about two-thirds of patients maintain normal weight and that the remaining one-third are split between those who are moderately underweight and those who are seriously underweight.
Anorexia nervosa treatment can be conducted on an outpatient basis unless the weight loss is severe and accompanied by marked physical symptoms such as dizziness, weakness and/or electrolyte and vitamin disturbances. Hospital admission may then be unavoidable and may need to be on a medical ward initially. Rarely the patient's weight loss may be so severe as to be life-threatening. If the patient cannot be persuaded to enter hospital, compulsary admission may have to be used.