Medicine

Volume 51, Issue 7, July 2023, Pages 461-468

Nutrition
Malnutrition and undernutrition: causes, consequences, assessment and management
Benjamin Allen, John Saunders

The term 'malnutrition' encompasses deficiencies, excesses, or imbalances in nutrients, affecting

body composition, function, and clinical outcomes. While commonly associated with the developing
world, it occurs frequently in UK health settings due to psychosocial circumstances, illness, or
injury. Recognizing and treating malnutrition is crucial for improving patient outcomes and
reducing healthcare costs, making it the responsibility of healthcare professionals. Globally,
malnutrition is widespread, with millions affected, and in the UK, it is both a cause and
consequence of disease, impacting nearly 3 million people at any given time.

Malnutrition in developed countries, including the UK, is linked to factors like poverty, social
isolation, and substance misuse, particularly affecting older adults due to mobility and cognitive
issues. Reduced dietary intake, influenced by various factors, is a major cause, often worsened by
disease processes that lead to a physiological reduction in appetite. Hospitalized patients face
additional challenges, such as missed meals during clinical investigations. Surgical procedures,
especially abdominal, and conditions like haemato-oncology can pose further nutritional risks.
Despite historical beliefs about increased energy expenditure, recent data suggest that total energy
expenditure in many diseases is less than in normal health, often due to reduced physical activity.
Disease-related malnutrition involves complex interactions affecting body composition and
function.

The impact of malnutrition on physiological function significantly influences clinical outcomes, with
malnourished surgical patients experiencing higher complication and mortality rates compared to
well-nourished individuals. Malnourished patients also face longer hospital stays, increased post-
discharge support needs, a higher likelihood of requiring care, and up to 50% greater costs. Despite
challenges in distinguishing malnutrition from underlying disease processes, clear evidence shows
that nutritional support significantly improves outcomes, emphasizing the importance of identifying
malnutrition through screening. From a public expenditure perspective, disease-related malnutrition
in the UK incurred costs of £19.6 billion in 2011-2012, surpassing those associated with obesity.
Preventing and treating malnutrition can lead to substantial cost savings, with a 1% saving equating
to £196 million annually. Training medical professionals in nutrition is crucial, as recognized by the
Royal College of Physicians, which emphasizes the fundamental role of proper nutritional care in
good clinical practice. Collaborative efforts with nutrition teams, prescribing supplements, and
facilitating communication between primary and secondary care are highlighted as essential
components of nutritional education for doctors.
The crucial diagnosis of malnutrition should be well-documented, accompanied by a comprehensive
management plan, and coded in discharge letters and clinical correspondence. It is essential for
hospitals to establish multidisciplinary nutrition support teams to handle complex nutritional issues.
Each organization should also maintain a nutrition steering committee to develop and regularly
audit policies for nutritional care within clinical governance frameworks. Tailoring management to
individual patient needs involves setting realistic, specific goals in collaboration with patients and
caregivers. Nutritional support aims to provide sufficient energy, protein, fluids, and micronutrients
to correct deficits and meet ongoing needs. In most cases, a collaborative approach involving
clinicians, nursing staff, ward catering, and dietitians manages patients, while those with complex
conditions benefit from nutrition support teams. Dietary advice suffices for many cases, but oral
nutritional supplements become necessary when intake is insufficient. Care must be taken when
using food fortification or supplementation with calorie-dense items to avoid compromising protein
and micronutrient intake. Balanced oral nutritional supplements are often a logical choice for
individuals with illness- or injury-related appetite suppression. Enteral tube feeding or parenteral
nutrition becomes necessary if the gastrointestinal tract is inaccessible or non-functioning.
Managing severe malnutrition involves initial resuscitation, thiamine provision, and close
monitoring of electrolytes to prevent complications like Wernicke encephalopathy and refeeding
syndrome. Addressing and rectifying acute insults, such as persisting inflammatory states, is crucial
for successful nutritional replenishment, balancing the need for supplementation to avoid excess
energy supply and potential health risks. Pharmacological attempts to increase appetite are
generally ineffective.
 Causes of Malnutrition
Tariku Laelago Ersado

Malnutrition, characterized by nutritional deficiencies or excesses, encompasses undernutrition and

overnutrition. Undernutrition, leading to stunting, wasting, underweight, and micronutrient
deficiencies, results from deficiencies in energy, vitamins, and minerals. Overnutrition, causing
overweight and obesity, is linked to excessive energy and micronutrient consumption. Immediate-
level causes of malnutrition include inadequate dietary intake and disease, underlying-level causes
involve household food security, social and care environment, health services, and environment,
while basic-level causes consist of climate variability, sociocultural factors, and economic and
political context. Wasting, defined as low weight for height, can lead to severe acute malnutrition
and moderate acute malnutrition. Stunting, characterized by low height for age, results from
chronic undernutrition, often associated with poverty and health issues. Underweight is defined as
low weight for age, and micronutrient deficiencies involve insufficient essential vitamins and
minerals. Various factors, including food availability, eating difficulties, health conditions, mental
health disorders, and medications, contribute to malnutrition. The causes vary across regions and
require updated information for effective prevention strategies. The chapter aims to provide
comprehensive insights into the causes of malnutrition using different conceptual frameworks,
addressing specific causes for common malnutrition types.

Underlying-level causes of malnutrition encompass household food insecurity, poor social and care
environments, inadequate access to health care, and an unhealthy environment. These issues are
often triggered by factors like conflict, inadequate education, poverty, gender inequality, and
insufficient infrastructure. Household food insecurity, specifically problematic for displaced
individuals, arises when people struggle to access a sufficient amount of safe, affordable, and
nutritious foods due to a lack of income. Poor social and care environments involve inadequate
infant feeding behaviors, home care for ill children, and health-seeking behaviors, directly impacting
malnutrition within households and local communities. Access to affordable health services, safe
water, sanitation, and suitable housing conditions are crucial for adequate nutrition, with poverty
identified as a significant factor in malnutrition.

Basic-level causes of malnutrition, as identified in different conceptual frameworks, include

potential resources and control such as human, economic, and organizational resources. A new
conceptual framework addressing acute malnutrition in Africa's dry lands emphasizes factors like
environment and seasonability, system, formal and informal institutions, and livelihood systems.
Human, economic, and organizational resources are essential components of these basic causes.
Formal national institutions, both civic and economic, and informal institutions like markets and
traditional customs, play a vital role in determining power relations, resource distribution, and,
consequently, the risk of malnutrition. Basic causes of malnutrition include poverty, lack of
information, political and economic insecurity, war, insufficient resources at all levels, unequal
status of women, and natural disasters.

In children, malnutrition arises when there is a deficiency in the demand for nutrients and calories.
Preterm babies, infants during weaning, and those with congenital heart disease, childhood cancers,
cystic fibrosis, and other long-term diseases are at higher risk. Neglected children, orphans, and
those in care homes are also prone to malnutrition. Some children may experience malnutrition due
to an eating disorder, behavioral, or psychological condition leading to food avoidance or refusal.
Causes of overnutrition, although often overshadowed by the focus on undernutrition, are gaining
international attention due to the double burden of malnutrition. Overnutrition, commonly
observed in developed countries, results from consuming excessive energy daily. It can lead to
weight gain unless physical activity is increased. Overnutrition is associated with excessive food
consumption, resulting in an excessive intake of various nutrients, rather than a single one. In
developed countries, energy overnutrition sometimes coexists with micronutrient undernutrition
when foods are high in calories but low in essential micronutrients.
 Racial and ethnic demographics in malnutrition related deaths
Bradley Kawano a, Braylee Grisel a, Paul Wischmeyer b, Maximilian Holsman a, Suresh Agarwal a, Joseph
Fernandez-Moure a, Krista L. Haines a, *
a Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center,
Durham, NC, USA b Division of Critical Care Surgery, Department of Anesthesia, Duke University Medical
Center, Durham, NC, USA

Presently, 40 million Americans face food insecurity, compelling them to skip meals and opt for
non-nutritious food, resulting in health disparities among those with low socioeconomic status. This
study aims to explore the connections between malnutrition-related deaths and sociodemographic
groups. Methodology: Conducted from 2009 to 2018, this cross-sectional study utilized aggregate
data from the CDC Wide-ranging Online Data for Epidemiologic Research (CDC Wonder).
Inclusion criteria involved patients under 18 with known race, gender, and Hispanic origin who died
from malnutrition (E40-E46). Place of death was categorized into home, inpatient medical facility,
hospice facility, nursing facility/long-term care, other (including outpatient, ED, and DOA), and
unknown. Malnutrition death rates per 100,000 persons for race, gender, and Hispanic origin were
calculated using US census estimates. Gross proportions of total deaths were determined for each
place of death. Findings: Between 2009 and 2018, there were 46,517 malnutrition-related deaths in
the US. Death rates for Black (1.8) and White Americans (2) were twice as high as those for Native
Americans (1.1) and Asians or Pacific Islanders (0.7). Females experienced higher death rates (2.3)
compared to males (1.5). Non-Hispanics had death rates twice as high as Hispanics (0.7). The
majority of individuals who succumbed to malnutrition died in hospitals (37%). Conclusion:
Malnutrition-related deaths are more prevalent among White, Black, non-Hispanic Americans, and
females. Despite documented disparities in food access, the study raises concerns about potential
under-diagnosis of malnutrition among Black patients. Further investigation is warranted in light of
this finding and the existing body of nutrition literature.
Between 2009 and 2018, the US witnessed a total of 46,517 malnutrition-related deaths, detailed by
demographics and place of death in Table 1. The crude rates of malnutrition deaths per 100,000
individuals are presented in Table 2, revealing that death rates for Black (1.8) and White Americans
(2) were double those of Native Americans (1.1) and Asians or Pacific Islanders (0.7). Furthermore,
malnutrition death rates among non-Hispanics (2.1) were twice as high as those among Hispanics
(0.7), and rates were higher among females (2.3) than males (1.5).

The distribution of malnutrition deaths across various places of death is illustrated in Table 3. A
majority of malnutrition deaths occurred in hospitals (37%), with similar proportions observed at
decedents' homes (25.8%) and in nursing facilities or long-term care (24.8%). Conversely, hospice
facilities (6.3%) and other locations reported the fewest malnutrition-related deaths.

Malnutrition contributes significantly to elevated morbidity and mortality rates across the United
States. The data reveals that a larger percentage of malnutrition-related deaths are observed in
White, Black, non-Hispanic, and female patients, with the majority of these deaths occurring in
healthcare facilities. Given that Black populations face a higher rate of food insecurity and are at an
increased risk of malnutrition in outpatient settings, there is a concern that this population may be
underdiagnosed. Further research is necessary to investigate effective ways for hospitals and
healthcare providers to identify and address malnutrition, particularly in hospital and nursing home
settings.
 Global Food Security
Volume 26, September 2020, 100396

Reframing malnutrition in all its forms: A critique of the tripartite classification of malnutrition
Gyorgy Scrinis

Conventional scientific and policy analyses commonly categorize malnutrition into three forms:
under-nutrition, micronutrient deficiencies, and over-weight/obesity. This paper critically
examines the tripartite classification and paradigm of malnutrition, emphasizing their features,
limitations, and consequences. Within this framework, the three forms of malnutrition are defined
as nutritionally and biologically specific, essentially separate, internally uniform, singular, and
decontextualized conditions. The argument presented suggests that this classification promotes
narrowly-focused policies, technological solutions, and serves specific political and commercial
interests. The paper concludes by proposing an alternative framing of malnutrition.
Introduction Paraphrased:
Traditionally synonymous with hunger and undernutrition, the term 'malnutrition' now
encompasses various forms, including the health implications of both undernutrition and over-
nutrition/obesity. While malnutrition is often classified into undernutrition and over-
nutrition/obesity, a more detailed classification includes undernutrition, micronutrient deficiencies
(termed 'hidden hunger'), and over-nutrition/obesity/over-weight. The emergence of this tripartite
classification in the 1990s aimed to better represent changing dietary and health patterns,
acknowledging the coexistence of these malnutrition forms within individuals and communities.
Differing among institutions and experts, the tripartite classification, summarized in a recent
World Health Organization factsheet, addresses malnutrition as deficiencies, excesses, or
imbalances in energy and/or nutrient intake, categorizing it into undernutrition, micronutrient-
related malnutrition, and overweight, obesity, and diet-related noncommunicable diseases.

This tripartite classification and framing of malnutrition play a crucial role not only in shaping
scientific research and comprehension of the issue but also in influencing policy and practical
responses to malnutrition (Aronowitz, 2008; Macauslan, 2009). I will argue that this precise and
segmented framing inevitably endorses nutritionally and biologically specific technological
solutions, supporting the political and commercial interests aligned with such solutions.

Over the past two decades, nutrition experts have questioned several aspects of the tripartite
paradigm, and emerging evidence challenges its validity. Criticisms include nutrient and
biomarker-specific approaches, such as the energy-focused definition of undernutrition, strategies
like supplementation and fortification for addressing micronutrient deficiencies, and the emphasis
on body size and BMI. The recognition of the double or triple burden of malnutrition has
underscored the coexistence of these forms, interconnected biological pathways connecting
undernutrition and obesity, and shared dietary, socio-economic drivers, and health outcomes
(WHO, 2017; Swinburn et al., 2019; Wells et al., 2019b). Many experts acknowledge that poor-
quality diets can lead to both nutritional deficiencies and obesity, emphasizing the importance of
providing nutritious and high-quality foods and diets (Pradeilles et al., 2018; Farrell et al., 2017;
Mozaffarian et al., 2018; Hawkes et al., 2019).
 Clinical Nutrition
Volume 43, Issue 2, February 2024, Pages 446-452
Original article
The Malnutrition Awareness Scale for community-dwelling older adults: Development and psychometric
properties
M. Visser, M.J. Sealy, E. Leistra, E. Naumann, M.A.E. De van der Schueren, H. Jager-Wittenaar

The creation of the Malnutrition Awareness Scale (MAS) aimed to quantitatively evaluate
awareness of malnutrition in older adults residing in the community. Covering areas such as
knowledge, perceived cues, risk perceptions, and cognizance, the MAS underwent pilot testing and
a feasibility study, revealing favorable outcomes. Psychometric analyses demonstrated reliability,
with an overall Cronbach's alpha of 0.67. Recognized as a feasible and dependable tool with
sound content validity, the MAS provides a foundation for interventions designed to improve
knowledge and awareness of malnutrition in older adults.

A feasibility study involving 42 community-dwelling adults aged 60 years and older in the
Netherlands was conducted. Two trained students from Hanze University of Applied Sciences,
Groningen, recruited participants using convenience sampling to complete the Dutch
Malnutrition Awareness Scale (MAS) on paper. The aim was to achieve a balanced representation
across gender, age groups, and educational levels. The questionnaire included additional
demographic questions, and participants rated their self-perceived health, answered questions
about weight, and provided feedback on the MAS items. Ethical approval was obtained from the
Ethical Advisory Committee of Hanze University.

For the psychometric properties study, 216 community-dwelling adults aged 60 years and older
were interviewed by trained Health Sciences students from Vrije Universiteit Amsterdam. The
sample size adhered to recommended guidelines. The MAS was adjusted for both self-
administration and interviewer-administration. Interviews covered demographics, self-rated
health, height, weight, and involuntary weight loss in the past 6 months. Ethical approval was
granted by the Research Ethics Review Committee of the Faculty of Science, Vrije Universiteit
Amsterdam.

Research indicates that older adults often lack awareness about malnutrition. This study aimed to
address this issue by creating a questionnaire to objectively measure malnutrition awareness in
community-dwelling individuals aged 60 years and above. The Malnutrition Awareness Scale
(MAS) was developed based on the Integrated-Change model, comprising four domains:
knowledge, perceived cues, risk perceptions, and cognizance. Twenty-six scale items were crafted
using insights from qualitative research and expert input. Pilot testing with 10 Dutch older adults
aided in refining the questionnaire. A feasibility study involving 42 participants assessed
completion time, annoyance, difficulty, and comprehensibility of the MAS. Subsequent
psychometric analyses with a larger sample of 216 individuals confirmed its reliability. The final
MAS, comprising 23 items, exhibited a scoring range of 0 to 22 and an overall Cronbach's alpha
of 0.67. It demonstrated good content validity and is deemed a viable tool for assessing
malnutrition awareness in older adults. This scale can now be utilized to identify individuals with
low malnutrition awareness and facilitate interventions to enhance knowledge and awareness in
this population.