research paper on malnutrition

REVIEW article

The intertwined relationship between malnutrition and poverty.

• 1 Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
• 2 Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia

Despite social and economic development, the burden of malnutrition across the globe remains unacceptably high. A vital relationship exists between nutritional status, human capital, and economic standing. Malnutrition adversely affects the physiological and mental capacity of individuals; which in turn hampers productivity levels, making them and their respective countries more susceptible to poverty. A two-way link exists between malnutrition and poverty, creating a vicious cycle with each fueling the other. Malnutrition produces conditions of poverty by reducing the economic potential of the population and likewise, poverty reinforces malnutrition by increasing the risk of food insecurity. The aim of the paper is to describe the interconnection between malnutrition and poverty, and to highlight how both serve as the cause and consequence of each other. The paper also discusses ways to move ahead to tackle these issues in a parallel manner rather than in separate silos.

Introduction

Malnutrition relates to a deficiency, excess, or imbalance of energy and other macro and micro-nutrients. It comprises of varying degrees of under- or over- nutrition, which leads to changes in body composition, body function, and clinical outcomes. In other words, malnutrition is an all-inclusive term that represents all manifestations of poor nutrition and ranges from extreme hunger and undernutrition to obesity ( 1 , 2 ). Despite social and economic development, the burden of malnutrition across the globe remains unacceptably high ( 2 ), recent data suggests that ~800 million people are undernourished, out of which 780 million reside in low-to-middle income countries, especially in Sub-Saharan Africa and South Asia ( 2 ). In 2015, inadequate food intake and poor dietary quality were responsible directly or indirectly for causing ill-health with six of the top 11 global risk factors being associated with dietary imbalances ( 2 ) and in 2017, 11 million deaths and 255 million disability-adjusted life years (DALYs) were attributable to dietary risk factors ( 3 ). Children under the age of 5 years are highly vulnerable to malnutrition with estimates suggesting that in 2019, globally 144 million children under the age of five were stunted (short for his/her age), 47 million wasted (thin for his/her height) and 38 million overweight (abnormal or excess bodyweight) ( 4 ). In adults, obesity is becoming more prevalent worldwide with ~38.9% of the adult population being either overweight or obese ( 5 ). Paradoxically, even though women have a higher prevalence (15.1%) of obesity than men (11%) ( 5 ); millions of women around the world are still underweight and one-third of women of reproductive age are estimated to have anemia ( 5 ).

Malnutrition has long been linked to poverty as higher rates of malnutrition are found in areas with chronic poverty ( 6 ). The impact of poverty on individuals can be seen through multiple manifestations and includes poor nutritional status, food insecurity, vulnerability to disease, reduced productivity levels, and compromised physical and intellectual development. Additionally, people living in poverty are unable to access necessities including nutritious food, hygienic environment, appropriate shelter, and adequate health care ( 7 ). Therefore, it would not be incorrect to suggest that even though malnutrition is a global phenomenon, those living in poverty face a higher burden. The question that now arises is whether malnutrition is a cause or consequence of poverty. The relationship between the nutritional status and economic standing has been further explored through the course of this paper.

The World Bank has set the International Poverty Line at $1.90 per person per day using 2011 Purchasing Power Parity (PPP) conversion factors ( 8 ). Therefore, households with a per capita income or expenditure less than the standard poverty line are defined as being poor ( 9 ). This makes income level the prime indicator for poverty, however with the passage of time, the need for re-conceptualizing poverty is becoming more evident as poverty is complex and multifaceted. Therefore, the conceptualization of poverty should not be limited to average income and wealth only but should encompass various other deprivations that are often experienced by people living in poverty. The global Multidimensional Poverty Index (MPI) is an international measure of acute poverty covering over 100 developing countries; created by the Oxford Poverty and Human Development Initiative (OPHI) and the United Nations Development Programme (UNDP) in 2010 ( 10 ). The global MPI steps away from the traditional view of poverty being solely limited to average income and wealth; to a more holistic view that highlights the need for using multiple indicators to account for various issues faced by people as a consequence of poverty ( 10 ). Through this index, poverty is portrayed to be a deprivation of basic amenities that restricts individuals from leading a good and healthy life ( 11 ) and takes into account the systemic disparities within a country and stretches the boundaries of poverty beyond the shortage of material assets to a concept that encompasses multiple deprivations, including but not limited to: assets, living standards, education, sanitation and hygiene, health and nutrition ( 10 ).

Since the 1990s, it is estimated that the proportion of the world's population living in extreme poverty has declined by more than a half ( 8 ). In 2015, 10% of the world's population lived under the poverty line; compared to nearly 36% in 1990 ( 8 ). Unfortunately, despite the overall decline in global poverty, progress has been uneven and disproportionate with the majority of the world's poor residing predominantly in Sub-Saharan Africa and South Asia ( 8 ). In 2015, 736 million people lived in extreme conditions of poverty with half of them i.e., 368 million residing only in five countries of India, Nigeria, Democratic Republic of Congo, Ethiopia, and Bangladesh ( 8 ). This illustrates that certain countries especially those afflicted by conflict, poor governance, and natural disasters continue to experience a skewed burden of poverty.

To analyze the vital linkages between poverty and malnutrition; it is important to highlight the growing evidence that health outcomes including malnutrition are driven by social determinants of health i.e., the conditions and circumstances in which people live, learn, work, and even play have a significant impact on their health ( 12 ). This interconnection between people's conditions and circumstances and their health can be displayed using the concept of poverty and food insecurity. The term “food insecurity” refers to a situation in which people do not have adequate physical, social or economic access to sufficient and nutritious food ( 13 ). Broadly, food insecurity is assessed using four dimensions i.e., food availability, access to food, stability of supply and safe, and healthy food utilization ( 14 ). Food insecurity may occur at various levels including regional, national, household, or individual. Poverty and food insecurity are deeply related, as poverty may adversely affect the social determinants of health and may create unfavorable conditions in which people might experience unreliable food supply ( 13 ). Food is a major household expenditure for the poor households ( 15 ). Data from African countries indicate that close to half of household income is spent on food: Nigeria (56.4%) ( 16 ); Kenya (46.7%), Cameroon (45.6%), Algeria (42.5%) ( 17 ). Similarly, within high-income countries, low-income households spend a significant proportion of their income on food: Ireland (14–33%), USA (28.8–42.6%) ( 17 , 18 ). In comparison, the wealthiest households in the USA spend a much lower 6.5–9.2% of household income on food ( 17 ). Despite spending a large proportion of their household income on food, many poor households continue to remain food insecure because of their insufficient, irregular, and fluctuating incomes ( 2 , 13 ).

Poverty, Food Insecurity and Double Burden of Malnutrition

A vital relationship exists between malnutrition and poverty. Poverty creates unstable and unfavorable conditions that may contribute to fueling the problem of malnutrition ( 7 ). People living in poverty often face financial limitations, which hinders their ability to access safe, sufficient, and nutritious food ( 7 ). Food insecurity compromises people's ability to acquire the amount of food needed to fulfill the bodily requirement of calories and without sufficient calorie intake, an individual may not be able to build up energy or strength to carry out everyday life activities and this also hampers the capacity and productivity to earn ( 19 ). While people living in poverty may require a greater quantity of food than they cursrently have, it is important to take into consideration that appropriate intake of nutrients and quality of food is equally important ( 19 ). Poverty can contribute to worsening malnutrition by compromising the quality of food intake and bolstering hidden hunger which is the deficiency of essential vitamins and minerals. The burden of obesity has extended beyond wealthier, developed nations and has now also become a feature of the developing world ( 16 ). Poverty leads to financial constraints that in turn lead to the consumption of cheap, high-energy staple foods, primarily carbohydrates, and fats rather than nutritionally dense food. Through the consumption of carbohydrates and fats, energy levels spike; but nutritional quality becomes compromised. The consequence of this is reduced nutritional quality and nutrient deficiencies. Poverty plays a significant role in regulating access and preference of foods ( 13 , 16 ), and this is evident in studies that showcase that when people living in poverty get a chance to spend relatively more on food; they often prefer to buy better tasting food, rather than good quality food ( 19 ).

The deficiency of micronutrients or “hidden hunger” is an important component of malnutrition ( 13 ). Micronutrient deficiencies can exists in all age groups and in any socioeconomic bracket. Iron, folate, vitamin A, iodine, and zinc deficiencies are among the most common and widespread micronutrient deficiencies among women and children in low- and middle- income countries and many of these micronutrient deficiencies co-exist. Assessing the relationship between malnutrition and poverty, requires consideration of micronutrient deficiencies. While macro- and micro- nutrient deficiencies may cause suboptimal mental and physical development, recurrent infections and growth retardation ( 20 , 21 ); micro-nutrient deficiencies may also result in adverse birth outcomes including low birth weight babies ( 22 , 23 ). To date, ~20 million babies are born with low birth weight each year and there is growing evidence of the connections between slow growth in height early in life and impaired health and educational and economic performance later in life ( 5 , 24 ). Low birth weight in babies can contribute to the vicious cycle of malnutrition since maternal nutrition status especially maternal stature has been reported to be inversely associated with offspring mortality, underweight, and stunting in infancy and childhood ( 22 , 23 ). Moreover, the importance of adequate intake of micronutrients can be noted in children born to mothers with sufficient amounts of iodine during pregnancy ( 19 ), as these children tend to complete one-third or one-half a year more schooling than children born to mothers with inadequate amount of iodine during pregnancy ( 19 ). It has been suggested that if every mother took iodine capsules during pregnancy then this could improve educational attainment among children in Central and Southern Africa ( 19 ).

Briefly put, the double burden of malnutrition and the importance of micro-nutrients should be recognized when analyzing the malnutrition-poverty cycle. There is a growing need to reimagine the concept of malnutrition and development experts and policy makers should make strides to account for the inherent complexities of both concepts in order to develop successful and sustainable nutritional strategies ( 19 ).

Malnutrition: Cause or Consequence of Poverty?

The question that now arises is whether malnutrition is a cause or consequence of poverty and vice versa? To elaborate upon this, it is important to highlight the relationship of human capital with nutrition and poverty.

Human capital is an integral asset of any country and the process of developing human capital begins from infancy and continues throughout the course of an individual's life ( 25 ). Nutritional status has a profound impact on human capital. The reasoning is simple, improved nutritional status is vital for escaping poverty, as good health is needed to increase productivity levels, contribute to economic growth, and improve a country's overall welfare ( 6 ). Without adequate nutrition, human capital starts to decline. This is because malnutrition negatively impacts physical and mental development, intellectual capacity, productivity, and the economic potential of an individual ( 25 ). As a consequence, economic stability is threatened, making a country more vulnerable to poverty. Poverty contributes to the problem of food insecurity which is referred to as a “resourced-constrained” or “poverty related” condition. Although the populations affected by poverty and food insecurity overlap; it is important to note that not all people living in poverty are food insecure and that this problem also exists in people living above the poverty line. Moreover, poverty also contributes in creating conditions of micro-nutrient deficiencies and hidden hunger. These factors exacerbate the issue of malnutrition and makes individuals more vulnerable to other health concerns. Irregular and unstable food supply along with low quality of food due to insufficient or inadequate nutrient intake can compromise immunity and make individuals more susceptible to infections. Additionally, if infected, matters tend to become worse because infections may further reduce nutritional and health status, thereby aggravating malnutrition and reinforcing its cycle with poverty ( 25 , 26 ).

A vicious cycle exists through which both poverty and malnutrition fuel and reinforce each other ( 25 ). Globally, the poorest countries are the countries bearing the highest burden of malnutrition. Nutritional imbalances reduce work capacity and human capital; and this makes countries more susceptible to poverty. Furthermore, malnutrition is also a consequence of poverty, as poverty increases food insecurity and hidden hunger; which contributes to the problem of malnutrition. This makes both these elements a cause and a consequence of each other. Establishing a linear relationship between the two would overlook the complexities and nuances that exist within the framework of this topic.

What Will be the Next Steps?

In order to progress socially and economically, there is an urgent need to recognize the burden of poverty and malnutrition and to take immediate steps to break the ongoing cycle. To achieve this target, it is important to understand what factors feed and reinforce it.

The cycle of poverty and malnutrition appears to be intergenerational. Evidence suggests that malnourished women are at a higher risk of having malnourished children and this creates an intergenerational effect ( 6 ). It is imperative to intervene early in life in order to maximize the effectiveness of interventions and break the cycle. The Lancet Nutrition Series ( 27 ) modeled the effect of 10 evidence based nutrition specific interventions on lives saved in the 34 countries that have 90% of the world's children with stunted growth. The series also examined the effect of various delivery platforms and delivery options using community health workers to engage poor populations and promote behavior change, access to and uptake of these interventions. Findings suggest that the current total of deaths in children younger than 5 years can be reduced by 15% if populations can access these 10 evidence-based nutrition interventions at 90% coverage. These nutrition specific interventions included salt iodization, multiple micronutrient supplementation in pregnancy (includes iron-folate), calcium supplementation in pregnancy, energy-protein supplementation in pregnancy, vitamin A supplementation in childhood, zinc supplementation in childhood, breastfeeding promotion, complementary feeding education, complementary food supplementation, and management of severe acute malnutrition in children. The findings also support the use of various community engagement and delivery strategies that can help reach poor segments of the population at greatest risk in order to make a difference ( 27 ). In other words, the interventions need to reach the poorest of the poor to break the cycle of malnutrition and poverty and should also incorporate disease and infection prevention as a part of their strategy ( 25 ).

Considering the inter-linkages described above between malnutrition and poverty, nutrition specific interventions need to be augmented with nutrition sensitive interventions in order to accelerate the progress of reducing malnutrition. Nutrition sensitive interventions are those that address intermediate and underlying causes of malnutrition and help to improve access to nutritious food, clean water and sanitation, education and employment, and health care etc. Large scale nutrition programs focusing on evidence based nutrition interventions should also target key underlying determinants of nutrition including poverty in order to enhance the coverage and effectiveness of nutrition-specific interventions. These include interventions in the sectors of agriculture, social safety nets, early child development, education, and women's empowerment. Women's empowerment is instrumental in not only improving malnutrition but general well-being ( 28 ). Hence, a parallel focus on nutrition sensitive and nutrition specific interventions has the potential to greatly accelerate progress in not only the areas of nutrition but also break the intergenerational cycle of malnutrition and poverty ( 29 ). More recently, bio-fortification and agricultural biodiversity are also considered to have the potential to cater to the issues of poverty and malnutrition in a parallel manner ( 30 ). In developing countries, bio-fortification could focus on improving quality of coarse cereals, as well as fodders along with community participatory approaches to enhance agricultural biodiversity. This approach not only could contribute to a reduction in malnutrition and poverty, but reduce food insecurity and improve sustainability ( 31 , 32 ), though further research is needed in the domain ( 30 , 31 ). Income disparity is also a factor that allows the malnutrition-poverty cycle to persist. In fact, a country may experience economic growth, but still have widespread poverty and high levels of malnutrition. This is because income inequality translates as health inequality; as the income gap grows, so does health disparity ( 7 , 13 , 25 ). Furthermore, gender inequities have also been associated with both poverty and malnutrition as a result of lower opportunities for women in the fields of education and employment. A recent analysis based on data from 49 low- and middle-income countries assessing the relationship between gender equity and malnutrition and health suggests that gender equity in education and employment decreases child malnutrition and is an important determinant in nutrition and access to health care ( 33 ). Therefore, any attempt to improve global nutritional status and to achieve the targets set by the “2030 Agenda for Sustainable Development” requires a focus on alleviating poverty and simultaneously focusing on agriculture, social safety nets, early child development, education, and strengthening women's position in society ( 34 – 37 ).

Nutritional interventions should be designed in an all-rounded, holistic manner. It would be fruitful to involve multiple stakeholders including health, education, agriculture, water, sanitation and hygiene, gender and economics. To ensure sustainability, nutritional interventions should be context-specific and should also be cost-effective since these issues concern low and middle income countries.

Ending poverty in all its forms is the first of the 17 Sustainable Development Goals and ending hunger, reducing food insecurity and improved nutrition and agriculture is the second goal. Furthermore, at least 12 of the 17 goals contain indicators that are highly relevant to nutrition. Poverty and malnutrition are deeply interrelated, with each fuelling the other and hence it is imperative to tackle both issues simultaneously rather than in parallel silos. A two-way link exists, with both elements being the cause and consequence of each other. This vicious cycle remains a prime public health concern and immediate strides need to be made against it. For a sustainable improvement in nutritional outcomes, the battle against poverty and malnutrition has to be fought on all fronts, to achieve a healthier and more equitable society.

Author Contributions

All authors contributed to the study and the write-up.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1. Soeters P, Bozzetti F, Cynober L, Forbes A, Shenkin A, Sobotka L. Defining malnutrition: a plea to rethink. Clin Nutr. (2017) 36:896–901. doi: 10.1016/j.clnu.2016.09.032

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Webb P, Stordalen GA, Singh S, Wijesinha-Bettoni R, Shetty P, Lartey A. Hunger and malnutrition in the 21st century. BMJ . (2018) 361:k2238. doi: 10.1136/bmj.k2238

3. Afshin A, Sur PJ, Fay KA, Cornaby L, Ferrara G, Salama JS, et al. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet . (2019) 393:1958–72. doi: 10.1016/S0140-6736(19)30041-8

4. UNICEF WHO WBG. Levels and Trends in Child Malnutrition UNICEF-WHO-World Bank Group Joint Child Malnutrition Estimates: Key Findings of the 2020 Edition . Geneva (2020).

Google Scholar

5. Development Initiatives. Global Nutrition Report: Shining a Light to Spur Action on Nutrition . Bristol: Development Initiatives (2018).

6. Setboonsarng S. Child Malnutrition as a Poverty Indicator: An Evaluation in the Context of Different Development Interventions in Indonesia . Tokyo: ADB Institute Discussion Papers (2005).

7. Peña M, Bacallao J. Malnutrition and poverty. Annu Rev Nutr. (2002) 22:241–53. doi: 10.1146/annurev.nutr.22.120701.141104

8. The World Bank. Poverty . (2019). Available online at: https://www.worldbank.org/en/topic/poverty/overview (accessed January 3, 2019).

9. Heltberg R. Malnutrition, poverty, and economic growth. Health Econ. (2009) 18(S1):S77–88. doi: 10.1002/hec.1462

CrossRef Full Text | Google Scholar

10. Oxford Poverty and Human Development Initiative and UNDP. Global Multidimensional Poverty Index 2019: Illuminating Inequalities . Oxford (2019).

11. Knech A. Understanding and fighting poverty–Amartya Sen's capability approach and related theories. Soc Change Rev. (2012) 10:153–76. doi: 10.2478/scr-2013-0016

12. WHO. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Commission on Social Determinants of Health final report . Geneva: World Health Organization (2008).

13. Tanumihardjo SA, Anderson C, Kaufer-Horwitz M, Bode L, Emenaker NJ, Haqq AM, et al. Poverty, obesity, and malnutrition: an international perspective recognizing the paradox. J Am Diet Assoc. (2007) 107:1966–72. doi: 10.1016/j.jada.2007.08.007

14. Mundial B. Biofuels: Prospects, Risks and Opportunities . Washington, DC: The State of Food and Agriculture (2008).

15. Schanzenback D, Nunn R, Bauer L, Mumford M. Where Does All the Money Go: Shifts in Household Spending Over the Past 30 Years . Washington, DC: The Brookings Institute (2016).

16. Delisle H, Batal M. The double burden of malnutrition associated with poverty. Lancet. (2016) 387:2504–5. doi: 10.1016/S0140-6736(16)30795-4

17. World Economic Forum. Which Countries Spend the Most on Food? This Map Will Show You . Dublin (2016). Available online at: https://www.weforum.org/agenda/2016/12/this-map-shows-how-much-each-country-spends-on-food/ (accessed April 24, 2020).

18. Safefood. What Is the Cost of a Healthy Food Basket in the Republic of Ireland in 2018? Dublin (2019).

19. Banerjee A, Duflo E. More than 1 billion people are hungry in the world. Foreign Policy . (2011). p. 66–72.

20. WHO. Nutritional Landscape Information System: Country Profile Indicators - Interpretation Guide . Geneva: World Health Organization (2010).

21. World Health Organization. UNICEF-WHO-The World Bank: Joint Child Malnutrition Estimates: Levels and Trends . Geneva (2019).

PubMed Abstract | Google Scholar

22. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. (2013) 382:427–51. doi: 10.1016/S0140-6736(13)60937-X

23. Özaltin E, Hill K, Subramanian S. Association of maternal stature with offspring mortality, underweight, and stunting in low-to middle-income countries. JAMA . (2010) 303:1507–16. doi: 10.1001/jama.2010.450

24. Dewey KG, Begum K. Long-term consequences of stunting in early life. Maternal Child Nutr . (2011) 7:5–18. doi: 10.1111/j.1740-8709.2011.00349.x

25. Vorster HH. The link between poverty and malnutrition: a South African perspective. Health SA Gesondheid. (2010) 15:1–6. doi: 10.4102/hsag.v15i1.435

26. Thompson B, Cohen MJ, Meerman J. World food insecurity and malnutrition: scope, trends, causes and consequences. In: Thompson B, Cohen MJ, editors. The Impact of Climate Change and Bioenergy on Nutrition . Springer (2012). p. 21–41.

27. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet . (2013) 382:452–77. doi: 10.1016/S0140-6736(13)60996-4

28. Van den Bold M, Quisumbing AR, Gillespie S. Women's Empowerment and Nutrition: An Evidence Review . Washington, DC: International Food Policy Research Institute (2013).

29. Ruel MT, Alderman H, Maternal Group CNS. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet . (2013) 382:536–51. doi: 10.1016/S0140-6736(13)60843-0

30. Johns T, Eyzaguirre PB. Biofortification, biodiversity and diet: a search for complementary applications against poverty and malnutrition. Food Policy. (2007) 32:1–24. doi: 10.1016/j.foodpol.2006.03.014

31. Hunter D, Özkan I, Moura de Oliveira Beltrame D, Samarasinghe WLG, Wasike VW, Charrondière UR, et al. Enabled or disabled: is the environment right for using biodiversity to improve nutrition? Front Nutr. (2016) 3:14. doi: 10.3389/fnut.2016.00014

32. Kennedy G, Stoian D, Hunter D, Kikulwe E. Agricultural Biodiversity for Healthy, Diverse Diets . Rome: Bioversity International (2016).

33. Ekbrand H, Halleröd B. The more gender equity, the less child poverty? A multilevel analysis of malnutrition and health deprivation in 49 low-and middle-income countries. World Dev. (2018) 108:221–30. doi: 10.1016/j.worlddev.2018.01.028

34. Doss CR. Women and agricultural productivity: reframing the issues. Dev Policy Rev. (2018) 36:35–50. doi: 10.1111/dpr.12243

35. Fernandez RM. SDG3 good health and well-being: integration and connection with other SDGs. In: Leal Filho W, Wall T, Azul AM, Brandli L, Özuyar PG, editors. Good Health and Well-Being . Springer Nature (2020). p. 629–36.

36. Ishikawa M, Yokoyama T, Sagehashi M, Kunugita N, Miura H. Diagnosing the double burden of malnutrition using estimated deviation values in low-and lower-middle-income countries. PLoS ONE. (2018) 13:e0208525. doi: 10.1371/journal.pone.0208525

37. Leal Filho W, Tripathi SK, Andrade Guerra J, Giné-Garriga R, Orlovic Lovren V, Willats J. Using the sustainable development goals towards a better understanding of sustainability challenges. Int J Sustain Dev World Ecol. (2019) 26:179–90. doi: 10.1080/13504509.2018.1505674

Keywords: malnutrition, poverty, undernutrition, obesity, food insecurity

Citation: Siddiqui F, Salam RA, Lassi ZS and Das JK (2020) The Intertwined Relationship Between Malnutrition and Poverty. Front. Public Health 8:453. doi: 10.3389/fpubh.2020.00453

Received: 07 January 2020; Accepted: 21 July 2020; Published: 28 August 2020.

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Copyright © 2020 Siddiqui, Salam, Lassi and Das. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jai K. Das, jai.das@aku.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Tackling malnutrition: a systematic review of 15-year research evidence from INDEPTH health and demographic surveillance systems

Samuelina s. arthur.

1 INDEPTH Network, Accra, Ghana

2 Department of Demography and Population Studies, University of the Witwatersrand, Johannesburg, South Africa

Bongiwe Nyide

3 Library Department, Systems and Technical Services, Mangosuthu University of Technology, Umlazi, Durban, South Africa

4 Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa

Abdramane Bassiahi Soura

5 Ouagadougou HDSS, ISSP, University of Ouagadougou, Ouagadougou, Burkina Faso

Kathleen Kahn

6 MRC Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

7 Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden

Mark Weston

8 Independent Consultant, Mwanza, Tanzania

Osman Sankoh

9 School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

10 Faculty of Public Health, Hanoi Medical University, Hanoi, Vietnam

Nutrition is the intake of food in relation to the body's dietary needs. Malnutrition results from the intake of inadequate or excess food. This can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

To perform a systematic review to assess research conducted by the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) of health and demographic surveillance systems (HDSSs) over a 15-year period on malnutrition, its determinants, the effects of under and over nutrition, and intervention research on malnutrition in low- and middle-income countries (LMICs).

Relevant publication titles were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords ‘nutrition’, ‘malnutrition’, ‘over and under nutrition’, we selected publications that were based only on data generated through the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion in this study, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight papers were identified and reviewed, and 67 were selected for this study.

The INDEPTH research identified rising levels of overweight and obesity, sometimes in the same settings as under-nutrition. Urbanisation appears to be protective against under-nutrition, but it heightens the risk of obesity. Appropriately timed breastfeeding interventions were protective against malnutrition.

Conclusions

Although INDEPTH has expanded the global knowledge base on nutrition, many questions remain unresolved. There is a need for more investment in nutrition research in LMICs in order to generate evidence to inform policies in these settings.

Nutrition has been defined as the ‘science of food, the nutrients and other substances therein, their action, interaction and balance in relation to health and disease, and the processes by which the organism ingests, absorbs, transports, utilises and excretes food substances’ ( 1 ).

In low- and middle-income countries (LMICs) studies of nutrition generally focus on malnutrition, defined by the World Health Organization (WHO) as ‘inadequate or excess intake of protein, energy and micronutrients such as vitamins, and the frequent infections and disorders that result’ ( 2 ). It is estimated that globally 2 billion people suffer from malnutrition ( 3 ), and this has been recognised as a leading cause of death, disability, and ill-health ( 4 ). Malnutrition is consequently the most important risk factor for the burden of disease in developing countries ( 5 ).

The long-term impact of malnutrition cannot be overemphasised ( 6 – 9 ). Such effects have severe consequences for individuals and families, dampening economic growth and poverty reduction. Currently, the commitment by developing countries and international bodies to address the problem of malnutrition – especially child under-nutrition – has never been higher ( 10 , 11 ). Nutrition has consequently been elevated up the global development agenda, as the era of the post-Millennium Development Goals approaches. Synthesised research on key findings is needed to inform researchers and policy-makers of new evidence and knowledge as well as about neglected areas and gaps in nutrition research. This will help inform policy formulation aimed at addressing malnutrition. This paper highlights the contribution made by a longitudinal platform, the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH), to nutrition research in LMICs.

The member centres of INDEPTH have played an important role in their efforts to measure the prevalence of nutritional disorders, understand their determinants and effects, and assess the effectiveness of interventions to tackle the problem ( 12 ). INDEPTH is a network of 49 health and demographic surveillance systems (HDSSs) based in Africa, Asia, and the Pacific region. Its member centres use longitudinal data, collected through regular visits to all households in a geographically defined area, to address the gaps in information on population health in LMICs. The HDSSs monitor new health threats; track population changes via fertility rates, death rates and migration; and measure the impact of policy interventions on communities. They aim to provide information that helps policy-makers to make informed decisions that adapt to changing conditions. While each centre contributes locally or nationally, as a network, INDEPTH has the potential to make global contributions.

In Africa and Asia, the HDSS centres have examined the problem of malnutrition using various methods, including cohort studies, nested surveys, case–control studies, qualitative focus group discussions, key informant interviews, literature reviews, clinical trials, and the testing of diagnostic tools. The centres have also developed and tested measurement and screening tools to facilitate a more accurate diagnosis of nutritional problems and to draw a more robust picture of food intake patterns in low- and middle-income settings.

In this paper, we review studies of malnutrition conducted by HDSSs published in peer-reviewed English language journals, and we outline the key findings reported by INDEPTH member centres and discuss their implications for future nutrition policy. This study includes 67 published papers on malnutrition between 1998 and 2013, covering nine countries in Africa and four in Asia.

Standard systematic review methods by Higgins and Green ( 13 ) and the Centre for Reviews and Dissemination, York, United Kingdom, were used ( 14 ). Relevant publications titles (related to malnutrition studies) from the member research centres of INDEPTH were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords ‘nutrition, malnutrition, and over and under nutrition’, publications were selected that were based only on data generated through research which used the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight papers were identified and independently reviewed by the authors and 67 were selected for this study.

This paper deals with five tropical issues: The problem of malnutrition as manifested in member centres' demographic surveillance areas, including the prevalence of malnutrition and population groups most affected; the biological and social determinants of malnutrition; the effects of malnutrition; the interventions that have attempted to tackle malnutrition; and concludes with discussion and policy and research recommendations ( Fig. 1 ).

Diagram showing how the papers were selected for the study.

The problem of malnutrition

Under-nutrition.

Insufficient or inadequate food intake – be it from lack of quantity or lack of essential nutrients including protein and specific micronutrients – remains a blight across the developing world. Under-nutrition can have effects throughout the life cycle. Physical stunting (defined by the WHO as low height-for-age) can affect cognitive development, increase susceptibility to infection, and impair school attainment and future productivity of survivors as well as of later generations. Deficiencies in iron, iodine, zinc, and vitamins can cause problems ranging from brain damage to blindness, anaemia, and stunted growth. Being underweight makes it harder to fight off infection and recover from illness, and harder to study and work.

Inadequate food intake in the early years of life is particularly damaging. In a cohort survey of children at Nouna HDSS in Burkina Faso, the authors found a reduction in underweight prevalence from 40% in June 1999 to 35% in June 2009 and from 43% in December 1999 to 34% in December 2009. The prevalence for wasting and severe wasting prevalence remained high in under-five children ( 15 ). In a 2010 study by Agincourt HDSS in rural South Africa, stunting was found in approximately 20% of children aged 1–4 years, and in almost one-third of those aged 1 year ( 16 ). In the same area in 2003/04, a case–control study, which aimed to determine risk factors for severe child malnutrition in Agincourt, found that 45% of controls under 5 years were stunted ( 17 ). Despite high levels of HIV in hospitalised cases, the persistence of more traditional risk factors indicated the need for interventions that concurrently target household socio-economic status, food security, education, feeding practices, and access to health and social services.

Being undernourished poses great risk for infants. A cohort study by researchers at the Nouna HDSS in Burkina Faso found that children aged between 6 and 30 months who were malnourished were more than twice as likely to die during the seven-month research period than other children ( 18 ).

Adult under-nutrition receives less attention than under-nutrition affecting children, but a population-based study at the Purworejo HDSS in Java, Indonesia, found that 15% of adult women were classified as suffering from chronic energy deficiency resulting from insufficient food intake ( 19 ). A later study by the same centre found that many women began pregnancy with suboptimal nutritional status and that most did not gain enough weight during pregnancy to avert the risk of adverse health outcomes ( 20 ). Malnutrition in pregnant women can pose problems not only for the women themselves but also for their newborns. A study in West Kiang HDSS, Gambia, showed that nutritional rickets, a disease caused largely by vitamin D deficiency, the effects of which can include cardiac failure and hypoglycaemic seizures, was more prevalent in infants whose mothers had poor vitamin D status during pregnancy ( 21 ).

A study of 457 people aged 60 years and above in rural Bangladesh found that 50% of older adults had chronic energy deficiency, and 62% were at risk of malnutrition ( 22 ). The authors argued that if global targets to reduce world hunger are to be achieved, ‘it is important to recognise that a substantial proportion of the elderly population, particularly in low-income countries, is undernourished’ ( 22 ).

Overweight and obesity

Under-nutrition is not the only form of malnutrition. Overweight and obesity, caused by an over-consumption of calories relative to energy expended, has long been considered a problem only in high-income countries, but in recent years it has begun to emerge as a threat in poorer countries.

As countries grow wealthier, the intake of refined and fatty foods and foods of animal origin increases. In 2002, the WHO ranked being overweight as the fifth most serious risk factor underlying the disease burden in low-mortality developing countries. INDEPTH member centres have begun to track the rise of obesity in developing countries over the past decade and a half. In the study of adult women by the Purworejo HDSS in Indonesia, researchers found an obesity rate in 1997 of 14% and showed that the rate had increased by almost three percentage points over the previous 12 months ( 19 ). Gendered patterns exist in rural South Africa. One study showed that females aged 50 years and older in Agincourt were significantly more obese than males, yet there was no difference in the prevalence of hypertension between men and women ( 23 ).

A 2005 study of 3-year-old children in the Limpopo province of South Africa found that 22% were overweight and 24% were obese. Nineteen percent of children were found to have both stunted growth and obesity ( 24 ). In Agincourt, rural South Africa, Kimani-Murage et al. ( 25 ) investigated adolescent weight status and central obesity (measured by abdominal circumference) and found much higher rates of combined overweight and obesity and of central obesity among girls (15% for each) than among boys (4% of whom had combined overweight and obesity, and 2% central obesity). In that study, risk factors for overweight and obesity included high socio-economic status and a household head who had completed secondary education. For central obesity, the risk factors included age, having a mother aged 50 years or above, and having high socio-economic status. A study at Kanchanaburi HDSS in Thailand found that urban residence, affluence, and possession of a television were associated with higher rates of obesity ( 26 ). Under-nutrition, on the other hand, was associated with poverty. The studies on over-nutrition point to the impact of modernisation in transforming lifestyles and suggest that as countries develop economically, the risk of obesity may increase.

Like under-nutrition, over-nutrition can also have harmful impacts on health. A cohort study of 1,888 rural women in Bangladesh found that those with the highest body mass index (BMI) had a higher mortality risk than those with intermediate BMI ( 27 ). Table 1 displays key findings on under-nutrition and obesity.

Prevalence of under-nutrition and obesity: findings from INDEPTH studies

The determinants of malnutrition

Biological causes.

Under-nutrition does not only come about because of lack of food. Exposure to disease can increase the risks posed to health by under-nutrition.

In a study at the Agincourt HDSS in South Africa, Kimani-Murage et al. ( 28 ) found that children infected with HIV had significantly worse nutritional outcomes than their uninfected peers. In Gambia, HIV-positive children had significantly worse scores in terms of weight-for-age, height-for-age, and BMI than HIV-negative children ( 29 ). In mothers, too, HIV poses problems. Research at the Africa Centre in Kwazulu-Natal found that breastfeeding mothers in South Africa who were HIV-positive had poorer protein and micronutrient status than HIV-negative women ( 30 ). Mean serum concentrations of albumin, pre-albumin, folate, retinol, and haemoglobin were all lower in the group of 92 HIV-positive breastfeeding women than in a control group of 52 HIV-negative women. Filteau et al. ( 31 ) found that providing pregnant women who are HIV-positive with vitamin A supplementation may improve the gut function of their HIV-infected infants. They also found that vitamin A supplementation for HIV-infected infants may decrease gastrointestinal morbidity.

Nyakeriga et al. ( 32 ) found a significant relationship between malaria and subsequent underweight and stunting in children below the age of 2 years at the Kilifi HDSS in Kenya. However, the authors found no association between malaria and subsequent protein-energy malnutrition. A Kisumu HDSS study in Kenya showed that infants who had had malaria were more likely to have stunting, anaemia, and iron deficiency ( 33 ). On the other hand, researchers at Farafenni HDSS in Gambia found no association between malaria and subsequent malnutrition in children below the age of 5 years during the malaria season ( 34 ). In Nouna, Burkina Faso, anaemia was significantly associated with malnutrition but not with the frequency of malaria episodes or its prevalence ( 35 ). A Kilifi HDSS study identified hospital-acquired bacteraemia (nosocomial bacteraemia) as a significant risk factor for severe malnutrition. Nosocomial infections, the study authors wrote, ‘are largely unrecognised or undocumented as a health risk in low-income countries, but they are likely to become public health priorities as awareness of their occurrence increases and as other prominent childhood diseases are progressively controlled’ ( 36 ). Table 2 displays key findings on biological causes of malnutrition.

Biological causes of malnutrition: findings from INDEPTH studies

Social causes

INDEPTH member centres have extensively investigated the social factors that increase the risk of malnutrition in LMICs. Three major contributors have been identified.

The first is wealth. Families themselves recognise this as important. Focus group discussions among mothers in Gambia revealed that poverty is one of the key constraints preventing mothers from putting into practise their knowledge of child health and nutrition ( 37 ). In similar discussions in Kenya, mothers reported that financial constraints were the main cause of severe malnutrition in children, with mothers’ heavy workload and inability to generate income were also reported as key factors. Witchcraft and the violation of sexual taboos were among the other reported causes ( 38 ). Household wealth and community socio-economic status were significantly associated with childhood stunting in Nairobi, Kenya ( 39 ). The authors of this study posited that the community effect occurs because of the availability of social services, physical environment, and the wealth of individuals. In an earlier paper, the same authors showed that neighbourhood characteristics exert an influence on malnutrition independently of household wealth – ‘when basic socio-economic and health services are lacking in the poorest communities’, they observed, ‘families therein can hardly take advantage of their increased means, ability and knowledge in caring for their children’ ( 40 ). In Agincourt, rural South Africa, cases with severe malnutrition were from households with fewer assets and lower incomes, who were less likely to receive a social support grant or to have anyone employed, compared with control groups in the village ( 17 ). In the same area, Kimani-Murage et al. ( 25 ) observed four-fold higher odds of overweight for adolescent girls and two-fold higher odds for participants from households with the highest socio-economic status. The causes of childhood malnutrition have been studied more extensively than those of adult malnutrition, but there is evidence that wealth continues to play a part in nutritional status later in life. As a 1998 study at Matlab HDSS in Bangladesh showed, women aged 35 years and older from wealthier households were less likely to have chronic energy deficiency than poorer women ( 41 ).

Education is a second key factor. Children born to Nairobi mothers who had been educated to primary level had a 94% lower chance of stunting than those born to mothers with no education ( 42 ). In one study in Vietnam, birth weight and growth were statistically significantly and positively associated with economic conditions and the education of the mother ( 43 ). In another study however, mothers’ education level was associated with their children's stunting in early childhood ( 44 ). As with wealth, education continues to have repercussions for nutritional status later in life – in the above-mentioned study in Bangladesh, women over the age of 35 were half as likely to suffer chronic energy deficiency if they had had one or more years of education, than if they had had no schooling ( 41 ).

Linked to both wealth and education is the associated process of urbanisation. Five of the nutrition studies carried out by INDEPTH member centres between 1998 and 2013 demonstrate a link between urban residence and reduced malnutrition. In a study in FilaBavi, Vietnam, Nguyen et al. ( 45 ) found an association between household socio-economic status, education of the mother and birth weight. The Nairobi study ( 39 ) discussed above confirmed this finding, with urban children significantly less likely to be malnourished than rural children, while two studies in Senegal showed that rural adolescent girls who migrated seasonally to urban areas for work had improved nutritional status, as reflected in BMI, compared with girls who remained in villages ( 46 , 47 ). Although urbanisation appears to reduce the risk of under-nutrition, it may increase that of obesity. A study at Kanchanaburi HDSS in Thailand found that urban residence was associated with lower rates of under-nutrition in children, but also with higher rates of obesity ( 26 ). Household wealth was also associated with obesity.

One additional, yet less extensively studied social factor, which also appears to have an impact on nutrition, is paternal involvement in caring for children. Children in a study in South Africa whose fathers did not provide financial support were found to be at higher risk of malnutrition ( 48 ), while in Hanoi, Vietnam, children whose fathers took them to a medical facility to be immunised against childhood diseases were 1.7 times less likely to be underweight and stunted than other children ( 49 ). These points to the need for a multi-pronged response to the problem of malnutrition which has many causes ( Table 3 ).

Social causes of malnutrition: findings from INDEPTH studies

The effects of malnutrition

Obesity is a relatively new threat in LMICs and is, as yet, not generally widespread in these countries. Therefore in researching the effects of malnutrition, HDSS centres have largely focused their attentions on the problem of under-nutrition.

A study by the Kilifi HDSS in Kenya found that among children admitted to a rural district hospital, under-nutrition was a factor in half the in-hospital deaths and half the morbidity from severe diseases such as malaria, gastroenteritis, lower respiratory tract infection, HIV, and invasive bacterial disease ( 50 ). At West Kiang in Gambia, young adults born in the ‘hungry season’ – that is, the non-harvest season between July and December when less food is available – had 10 times higher mortality than those born in the harvest season ( 51 ). Conversely, two studies at Institut de Recherche pour le Developpement IRD HDSS in Senegal found that although child mortality in the rural Casamance region declined sharply between 1969 and 1992, infants’ nutritional status did not improve over the period, suggesting other factors such as vaccination were more important ( 52 , 53 ).

As well as increasing mortality, under-nutrition also impairs the development of those who survive it. In a study in Bangladesh, stunting in early childhood, which is in part the result of a combination of disease and under-nutrition, was found to be a significant predictor of stunting in adolescence ( 54 ). A four-country study covering Ethiopia, India, Peru, and Vietnam found that stunting in early childhood was associated with lower cognitive achievement in 5-year-old children ( 44 ). In infants and young children in Kenya, stunting is also associated with developing severe respiratory syncytial virus-associated pneumonia, and with lower respiratory tract infections from all causes ( 55 ).

The effect of under-nutrition on malaria outcomes is disputed in the literature. In a Kilifi HDSS study, Berkley et al. ( 56 ) found that malnutrition was associated with severe disease due to falciparum malaria. A cohort study at Farafenni HDSS in Gambia calculated that 51% of children with stunting subsequently experienced malaria during the malaria season, compared with 38% of children who were not stunted. The study authors concluded: ‘Our findings suggest that chronically malnourished children may be at higher risk for developing malaria episodes’ ( 34 ). On the other hand, Muller et al. ( 18 ), working at Nouna HDSS in Burkina Faso, found no association between protein-energy malnutrition and malaria morbidity, while a Kilifi HDSS study concluded that children with iron deficiency were less likely than other children to develop mild clinical malaria ( 32 ). Table 4 displays key findings on effects of malnutrition.

Effects of malnutrition: findings from INDEPTH studies

Tackling malnutrition

The role of breastfeeding.

Nutrition in infancy, as we have seen, is important to an individual's prospects of a good life. Breastfeeding has therefore been the subject of much analysis by nutrition researchers, who have assessed its benefits and analysed breastfeeding practices in LMICs.

Working at the Kintampo HDSS in Ghana, Edmond et al. ( 57 ) demonstrated for the first time that there is a causal link between early breastfeeding and declines in infection-specific neonatal mortality in infants aged between 2 and 28 days. Delayed initiation of breastfeeding until after the first day of life led to a 2.6 times higher risk of neonatal mortality as a result of infectious disease, while partial breastfeeding led to a 5.7 times higher risk. Researchers at Bandim HDSS in Guinea-Bissau found that children weaned early for reasons other than ‘being healthy’, including a new pregnancy, had higher mortality ( 58 ). Bahl et al. ( 59 ), meanwhile, found that non-breastfed infants had a 10-fold higher risk of dying than predominantly breastfed and exclusively breastfed infants, although there was no significant difference in risk between the latter two groups. This finding suggests that in areas where most women already predominantly breastfeed, breastfeeding promotion efforts should be directed at those who chose not to breastfeed or who partially breastfed. A case–control study by Saloojee et al. in rural South Africa ( 17 ) also found that risk factors for severe malnutrition included poor weaning practices.

The positive effects of breastfeeding have also been demonstrated in older children. Vohr et al. ( 60 ) found that extremely low birth weight babies who ingested breast milk while in the neonatal intensive care unit (NICU) had significantly higher scores in cognitive and behaviour tests at 18 months of age than similar non-breastfed NICU infants.

However, breastfeeding is not universally practised. Researchers at Nanoro HDSS in Burkina Faso who conducted a multi-centre study of women infected with HIV, highlighted the size of the task facing those engaged in breastfeeding promotion efforts. In sub-Saharan Africa, fluids other than maternal milk are often introduced within the first six months of life, notwithstanding WHO guidelines that recommend exclusive breastfeeding for the first six months (including where the mother is HIV-positive). Although 53% of women in the Nanoro study saw exclusive breastfeeding as the preferred feeding method, only 11% reported exclusively breastfeeding after previous pregnancies ( 61 ). Conversely, some mothers choose to prolong breastfeeding beyond the recommended duration, which has been found to be associated with reduced nutritional status and impaired growth. However, as Simondon and Simondon ( 62 ) and Simondon et al. ( 63 ) found in two studies conducted in Senegal, these consequences are a result not of prolonged breastfeeding itself, but of the fact that women prolong breastfeeding beyond 12 months for children who are undernourished and tend to wean well-nourished children. The authors surmised that this is a result of mothers’ awareness of the mortality risks to children following weaning.

Prevention efforts

A number of interventions to prevent or cure malnutrition have been tested by HDSS sites. The vast majority of the trials have focused on infants, children and women of childbearing age.

Efforts to tackle malnutrition in infants and children have met with mixed success. Studies by the Bandim HDSS in Guinea-Bissau of malnutrition campaigns during that country's 1998 civil war found that vitamin A supplementation for children ( 64 ) and a supplementary feeding programme for children ( 65 ) helped to reduce mortality during the conflict. Compared with the 3-year period before the war, the authors reported that children offered vitamin A at home during the war had a 12% reduction in mortality, whereas the overall impact of the war was an 89% increase in mortality.

In a randomised controlled trial in Vietnam, fortification with multiple micronutrients of biscuits provided in schools was found to reduce the risk of anaemia and of iron and zinc deficiencies by 40% ( 66 ). At Nouna HDSS in Burkina Faso, on the other hand, a randomised controlled trial to assess the effects of zinc supplementation on the growth of young children in an area with high rates of malnutrition found no significant impact on height-for-age, weight-for-age, and weight-for-height scores. The study authors concluded that zinc supplementation does not have an effect or public health importance on growth in West African populations of young children with a high prevalence of malnutrition, and that multi-nutrient interventions are likely to be more effective ( 67 ).

The effectiveness of vitamin A supplementation has also been questioned. Although it appeared to be beneficial in the above-mentioned trial in Guinea-Bissau, researchers at Kintampo HDSS in Ghana found no positive effect of vitamin A supplements in combination with vaccines during the first few months of life ( 68 ). This finding echoes the findings of similar trials in Peru and India. Fish oil supplementation, too, appears to have limited effects for infants. A study in Gambia found that fish oil had no effect on growth, intestinal integrity, morbidity, or cognitive development ( 69 ).

Only two studies investigated methods to treat children suffering from severe malnutrition. Current guidelines for treating children who develop shock as a result of severe malnutrition recommend using low-dose hypotonic fluid resuscitation. Working at the Kilifi HDSS in Kenya, Akech et al. ( 70 ) tested the safety and efficacy of this recommendation and found ‘universally poor’ outcomes in terms of persistent shock, oliguria, and high case fatality. The authors concluded that the low recommended dose was insufficient to correct shock and suggested that for future guidelines to be more effective, clinical investigation is needed to determine the appropriate volume and rate of dosage of isotonic fluids. Researchers at Agincourt HDSS, meanwhile, found that the introduction of WHO guidelines in two hospitals strengthened the management of malnutrition. The authors concluded that implementation of WHO guidelines on severe malnutrition was feasible, affordable, and sustainable ( 71 ).

Studies of malnutrition prevention campaigns for women of childbearing age also had mixed results. In Ghana, vitamin A supplementation was found to increase liver reserves of mothers during the postpartum period, with the effects persisting for at least five months ( 72 ). A study at Niakhar HDSS in Senegal found that providing high energy, nutrient-dense food supplements to infants aged between four and seven months contributed to decreased postpartum weight loss in their mothers ( 73 ). The supplements reduced the intake of breast milk and therefore the energy costs of lactation on mothers. It also increased the interval between births, thereby potentially having effects on fertility. As with supplements for children, a number of studies – all conducted at the West Kiang HDSS in Gambia – found that supplements of individual nutrients for women were ineffective. Hawkesworth et al. ( 74 ) found that nutrient supplementation during pregnancy had little effect on infants’ risk of cardiovascular disease. Another study found that protein-energy supplementation during pregnancy had no effect on the blood pressure of their children in adolescence ( 75 ), while a third study found that calcium supplementation for pregnant mothers had no effect on foetal and infant growth ( 21 ). A fourth West Kiang study found that calcium supplements could be harmful – women given calcium supplements while pregnant were found to have lower bone mineral content, bone area, and bone mineral density at the hip during the 12-month lactation period than other women. The authors surmised that such supplements may disrupt metabolic adaptation ( 76 ).

Two studies conducted by INDEPTH members in South Africa and Bangladesh addressed the problem of implementing nutrition programmes. In the first, at Dikgale HDSS, the majority of people with type 2 diabetes had poor glycaemic control and were obese or had high blood pressure. Quantitative and qualitative research showed that these patients were often given incorrect and inappropriate dietary advice by health educators ( 77 ). In the second study, researchers showed that agencies working to tackle a flood disaster in Bangladesh in 1998 had mixed results in terms of meeting international disaster response standards. Compliance with standards was variable. Preliminary nutritional analysis was one of the areas in which agencies performed poorly in this regard ( 78 ).

The state of research

Over the past 15 years, INDEPTH member centres have expanded the global knowledge base on nutrition. They have shown how under-nutrition continues to plague children and adults of all ages in LMICs and they have highlighted the emergence of obesity as a growing threat. In some areas, combined under-nutrition early in life with overweight and obesity in adolescence and adulthood, warns of rapidly escalating risk for cardiometabolic disease. The HDSS centres have demonstrated how malnutrition early in life continues to have effects on physical and mental development throughout the life-cycle. They have examined links between disease and malnutrition, and shown how wealth, education, and urbanisation all reduce the risks of under-nutrition but at the same time can increase the risks of obesity. The double burden of malnutrition in LMICs is of major concern to the World Bank, the WHO, and other international bodies.

In terms of tackling malnutrition, INDEPTH members have demonstrated the importance of breastfeeding for infant nutrition and health, and for the health of the infants as they grow older, and they have assessed the reasons why some women choose not to breastfeed or to wean infants too early or too late. Interventions such as micronutrient supplementation for children and their mothers can have beneficial impacts on child health and survival, with some studies suggesting that multiple micronutrient supplementation may be more effective than supplementation with single micronutrients ( Table 5 ).

Tackling malnutrition – prevention efforts: findings from INDEPTH studies

Nutrition is something of an under-researched field; however, over the period 1999–2013, INDEPTH member centres produced almost four times as many published papers on HIV/AIDS as they did on nutrition. Many issues remain unresolved – for example, the impact of malaria on malnutrition and of malnutrition on susceptibility to malaria. There was little attention paid to nutrient supplements or to education and information campaigns to help families improve their diet, while activism campaigns to encourage companies to label foods accurately or to reduce sugar or fat content received no attention from HDSS centres. Likewise, the economic benefits of nutrition interventions also received little attention from HDSSs. One study by the Africa Centre calculated the costs of adding nutritional supplementation to the management of HIV-infected children ( 79 ), but studies on the cost-effectiveness of nutrition programmes were lacking.

Policy implications

In this review, we noted the importance of adopting a multi-pronged approach to tackling malnutrition. Countries including Vietnam and South Africa have had some success in reducing malnutrition in recent years. Researchers at Kaya HDSS in Burkina Faso carried out a nine-site study to assess the impact of United Nations Millennium Project guidelines to reduce child stunting. This holistic approach incorporated nutrition-specific, health-based interventions with food system and livelihood-based approaches, and its adoption reduced stunting in children by up to 43% over 3 years ( 80 ). Programmes in Vietnam to increase nutrition, particularly via animal-source foods, have also been successful in reducing under-nutrition in children and chronic energy deficiency in women ( 81 ), but otherwise investigations of nationwide or multi-pronged nutrition programmes have not been extensively studied by HDSS centres. Lessons from other countries on how to reduce malnutrition may be a useful guide for policy-makers who are attempting to tackle the problem in their own countries.

Although a small number of studies have examined the success of efforts to implement nutrition programmes, there is a need for further investigation in this area. How to effectively change dietary habits, how to educate individuals in LMICs about the availability of healthy natural foods, how to improve compliance with food supplementation programmes, and how to train health workers to provide useful nutrition advice and effective treatment for nutrition problems, are just a few of the many implementation challenges that remain.

The INDEPTH HDSSs have unearthed important findings over the past decade and a half – for example, the vital role of breastfeeding in promoting infant and child health, the benefits of multiple micronutrient supplementation, the under-appreciated prevalence of malnutrition in adults and the elderly, and the rise of obesity in lower-income settings. Although much knowledge generation has already been achieved, there is broad scope for future research to inform policy-makers and researchers on ways to tackle the double burden of malnutrition in order to have a major impact on policy and on the lives of people living in LMICs.

Acknowledgements

We thank all INDEPTH member centres for submitting to the Secretariat all their published papers that are based on the HDSS platform for the period 1998–2013.

Conflict of interest and funding

Samuelina S. Arthur is a research fellow at INDEPTH Network; Bongiwe Nyide was a librarian at INDEPTH Network during the time this paper was written; Abdramane Bassiahi Soura is a member of the INDEPTH Network Board of Trustees and the leader of Ouagadougou HDSS in Burkina Faso, a member of INDEPTH Network; Kathleen Kahn is a scientist at Agincourt HDSS in South Africa, a member of INDEPTH Network; and Osman Sankoh is the executive director of the INDEPTH Network. Osman Sankoh is funded by core support grants from Sida/Research Cooperation Unit, The Wellcome Trust, and The William and Flora Hewlett Foundation. Samuelina S. Arthur is funded by INDEPTH Sexual and Reproductive Health project supported by The William and Flora Hewlett Foundation.

Authors' contributions

All the authors contributed to drafting, analysing, reviewing, and finalising this manuscript.

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Malnutrition in Older Adults-Recent Advances and Remaining Challenges

Affiliations.

• 1 Department of Geriatrics and Medical Gerontology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13347 Berlin, Germany.
• 2 Department of Nutrition and Gerontology, German Institute of Human Nutrition Potsdam-Rehbrücke, 14458 Nuthetal, Germany.
• 3 Institute of Nutritional Science, University of Potsdam, 14458 Nuthetal, Germany.
• 4 German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10115 Berlin, Germany.
• 5 Imperial Oak Outpatient Clinic, Endocrinology, Gastroenterology & Clinical Nutrition, 12159 Berlin, Germany.
• PMID: 34444924
• PMCID: PMC8399049
• DOI: 10.3390/nu13082764

Malnutrition in older adults has been recognised as a challenging health concern associated with not only increased mortality and morbidity, but also with physical decline, which has wide ranging acute implications for activities of daily living and quality of life in general. Malnutrition is common and may also contribute to the development of the geriatric syndromes in older adults. Malnutrition in the old is reflected by either involuntary weight loss or low body mass index, but hidden deficiencies such as micronutrient deficiencies are more difficult to assess and therefore frequently overlooked in the community-dwelling old. In developed countries, the most cited cause of malnutrition is disease, as both acute and chronic disorders have the potential to result in or aggravate malnutrition. Therefore, as higher age is one risk factor for developing disease, older adults have the highest risk of being at nutritional risk or becoming malnourished. However, the aetiology of malnutrition is complex and multifactorial, and the development of malnutrition in the old is most likely also facilitated by ageing processes. This comprehensive narrative review summarizes current evidence on the prevalence and determinants of malnutrition in old adults spanning from age-related changes to disease-associated risk factors, and outlines remaining challenges in the understanding, identification as well as treatment of malnutrition, which in some cases may include targeted supplementation of macro- and/or micronutrients, when diet alone is not sufficient to meet age-specific requirements.

Keywords: DoMAP; GLIM criteria; ageing; anorexia of aging; inflammaging; malnutrition; micronutrients; sarcopenia.

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Conflict of interest statement

The authors declare no conflict of interest.

Model of downward spiral in…

Model of downward spiral in the development of malnutrition in higher age.

Remaining challenges in the effective…

Remaining challenges in the effective prevention and sustainable treatment of malnutrition in old…

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• High Prevalence of Physical Frailty Among Community-Dwelling Malnourished Older Adults-A Systematic Review and Meta-Analysis. Verlaan S, Ligthart-Melis GC, Wijers SLJ, Cederholm T, Maier AB, de van der Schueren MAE. Verlaan S, et al. J Am Med Dir Assoc. 2017 May 1;18(5):374-382. doi: 10.1016/j.jamda.2016.12.074. Epub 2017 Feb 24. J Am Med Dir Assoc. 2017. PMID: 28238676 Review.
• The role of nutrition in geriatric rehabilitation. Diekmann R, Wojzischke J. Diekmann R, et al. Curr Opin Clin Nutr Metab Care. 2018 Jan;21(1):14-18. doi: 10.1097/MCO.0000000000000433. Curr Opin Clin Nutr Metab Care. 2018. PMID: 29059073 Review.
• Effect of peanut butter supplementation on physical and cognitive functions in community-dwelling older adults: study protocol for a 6-month randomised controlled trial. Hettiarachchi J, Feyesa I, Daly RM, George ES, Georgousopoulou EN, Scott D, Baguley BJ, Tan SY. Hettiarachchi J, et al. BMJ Open. 2024 Sep 5;14(9):e086232. doi: 10.1136/bmjopen-2024-086232. BMJ Open. 2024. PMID: 39242158 Free PMC article. Clinical Trial.
• Comparative analysis of nutritional status among institutionalised and community-dwelling elderly women and its association with mental health status and cognitive function. Shakil S, Ghosh J, Singh K, Chaudhury SR. Shakil S, et al. J Family Med Prim Care. 2024 Aug;13(8):3078-3083. doi: 10.4103/jfmpc.jfmpc_1932_23. Epub 2024 Jul 26. J Family Med Prim Care. 2024. PMID: 39228576 Free PMC article.
• The attitudes and knowledge of family physicians regarding malnutrition in the elderly: a call for action. Sheffer-Hilel G, Kachal J, Biderman A, Shahar DR, Amar S. Sheffer-Hilel G, et al. Isr J Health Policy Res. 2024 Sep 2;13(1):42. doi: 10.1186/s13584-024-00631-x. Isr J Health Policy Res. 2024. PMID: 39223630 Free PMC article.
• Lost in Transition: Insights from a Retrospective Chart Audit on Nutrition Care Practices for Older Australians with Malnutrition Transitioning from Hospital to Home. Gomes K, Bell J, Desbrow B, Roberts S. Gomes K, et al. Nutrients. 2024 Aug 22;16(16):2796. doi: 10.3390/nu16162796. Nutrients. 2024. PMID: 39203932 Free PMC article.
• Effects of a Specialized Oral Nutritional Supplement with Dietary Counseling on Nutritional Outcomes in Community-Dwelling Older Adults at Risk of Malnutrition: A Randomized Controlled Trial. Muangpaisan W, Wichansawakun S, Huynh DTT, Intalapaporn S, Chalermsri C, Thititagul O, Chupisanyarote K, Chuansangeam M, Laiteerapong A, Yalawar M, Huang C, Tey SL, Liu Z. Muangpaisan W, et al. Geriatrics (Basel). 2024 Aug 17;9(4):104. doi: 10.3390/geriatrics9040104. Geriatrics (Basel). 2024. PMID: 39195134 Free PMC article.
• Rudnicka E., Napierała P., Podfigurna A., Męczekalski B., Smolarczyk R., Grymowicz M. The World Health Organization (WHO) approach to healthy ageing. Maturitas. 2020;139:6–11. doi: 10.1016/j.maturitas.2020.05.018. - DOI - PMC - PubMed
• United Nations . World Population Prospects 2019: Highlights. Department of Economic and Social Affairs, Population Division; New York, NY, USA: 2019.
• Niccoli T., Partridge L. Ageing as a risk factor for disease. Curr. Biol. 2012;22:R741–R752. doi: 10.1016/j.cub.2012.07.024. - DOI - PubMed
• Biagi E., Nylund L., Candela M., Ostan R., Bucci L., Pini E., Nikkila J., Monti D., Satokari R., Franceschi C., et al. Through ageing, and beyond: Gut microbiota and inflammatory status in seniors and centenarians. PLoS ONE. 2010;5:e10667. doi: 10.1371/annotation/df45912f-d15c-44ab-8312-e7ec0607604d. - DOI - PMC - PubMed
• Hickson M. Malnutrition and ageing. Postgrad. Med. J. 2006;82:2–8. doi: 10.1136/pgmj.2005.037564. - DOI - PMC - PubMed

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