Nutrition and the

Physiology of
Malnutrition
Lia Fernald, Ph.D., M.B.A.
Human Biology Lecture
May 14, 2002

Male, 17, Oakland, weekly diet

Mon

Tues

Wed

Sat

Sausage, egg
cheese burrito
(McD)

Nothing

Frosted Flakes

Hot link with

mustard,
ketchup, Coke

Personal size
pepperoni pizza

Double cheese
burger, fries,
Coke (BK)

Pepperoni pizza
(PH) and french
fries

Nations
cheeseburger,
large fries, Coke

Burrito from
vending
machine, Lays

Banana nut
muffin and
carton of milk

2 ham & cheese

sandwiches and
can of soda

2 hot dogs,
blueberry muffin

Spaghetti, fried
chicken, fruit
punch

Small round
pizza

Baked pork
chops, mac &
cheese, Pepsi

Fries, BBQ
bacon cheese
burger (McD)

B
L

3,045
(38%)

2,400
(41%)

2,739
(33%)

3,163
(36%)

Overweight 9th graders in the Bay Area

Overweight defined as more than 25% body fat for boys

and more than 32% for girls. Less than 1% of students
are out of shape because they are too thin.

Todays Class

Overview of Nutritional Requirements

Definition of Malnutrition
Causes and correlates of Malnutrition
Measurement and Types of Malnutrition
Severe Malnutrition
Mild/Moderate Malnutrition (Underweight
and Stunting)
Specific Nutritional Deficiencies (Iodine and
Iron)

Nutritional requirements

Macro v. micro nutrients

Macro-nutrients
Protein (amino acids)
Energy (carbohydrates)
Fat (fatty acids)

Micro-nutrients
Water soluble vitamins (assist in energy-release of
carbohydrates and red blood cell formation)
Fat soluble vitamins (development & metabolism)
Minerals

Macro-nutrients
Energy
Necessary for all bodily function

Protein
Necessary for structural development (muscle
and bone)

Fat
Necessary for cell membrane and skin cell
development

Dietary Reference Intakes

Macronutrient

F (19-30 y.o.)

M (19-30 y.o.)

Energy (Kcal)

1940 2200

2550 2900

36 46

44 60

15 33%

15 33%

Protein (g)
Fat

Water soluble vitamins

Thiamin B
nervous system function, enzymatic energy release of carbohydrates
(beef, pork, liver, legumes, breads)
Riboflavin B2
Participants in enzymatic energy release of carbs, fat & protein (milk,
dairy, dark green vegetables, yogurt)
Niacin
Participates in enzymatic energy release of energy nutrients (beef,
pork, liver, breads, nuts)
Folate
Red blood cell formation, new cell division (veg, seeds)
Vitamin B12 (Cobalamin)
Red blood cell formation, nervous system maintainance (animal prod)
Pantothenic Acid
Biotin (Vitamin H, CoEnzyme R)
Vitamin B6 (Pyridoxine)
Vitamin C

Fat soluble vitamins

Vitamin A
Essential to vision, fetal development, immune response
Found in dairy products, fish liver oils; as B-carotene found in many
plants (e.g. carrots, mango)

Vitamin D
Bone formation, calcium metabolism and absorption
Found in sunlight, egg yolk, dairy products and fish liver oil

Vitamin E
Cell membrane construction and maintenance
In fats and oils, green leafy vegetables, poultry, fish

Vitamin K
Blood clotting, protein synthesis
In green leafy vegetables, liver, cabbage

Minerals
Major Bone Minerals

Trace Minerals

Calcium (bones) Iodine (thyroid function)

Phosphorus (DNA)
Iron (hemoglobin)
Magnesium (bones) Zinc (enzyme, hormone)
Sodium (nerve impulse)
Copper (abs. of iron)
Chloride (fluid balance)
Flouride (bone & teeth)
Potassium (prot. syn) Chromium (energy rel.)
Sulfur (some a.a.s)
Molybdenum (enzymes)
Manganese (enzymes)
Selenium (antioxidant)
Cobalt (part of B12)

Summary: Nutritional requirements

In order to live and function, humans need
macro- and micro- nutrients;
Macro-nutrients are fat, protein and
carbohydrates;
Micro-nutrients are water-soluble vitamins,
fat-soluble vitamins, and minerals (bone
and trace); the most critical micro-nutrients
are iron, iodine, zinc, vitamin A and vitamin
D.

Todays Class

Overview of Nutritional Requirements

Definition of Malnutrition
Causes and correlates of Malnutrition
Measurement and Types of Malnutrition
Severe Malnutrition
Mild/Moderate Malnutrition (Underweight
and Stunting)
Specific Nutritional Deficiencies (Iodine and
Iron)

What is malnutrition?
World Health Organization definition:
The term is used to refer to a number of
diseases, each with a specific cause related to
one or more nutrients (for example, protein,
iodine or iron) and each characterized by
cellular imbalance between the supply of
nutrients and energy on the one hand, and the
body's demand for them to ensure growth,
maintenance, and specific functions, on the
other.

Countries at risk of malnutrition

Geneva Declaration
1924: Declaration of the Rights of the Child (also
known as the Declaration of Geneva).
Adopted after World War I by the League of Nations
through the efforts of British child rights pioneer
Marks the beginning of the international child rights
movement and is also the first international affirmation of
the right to nutrition.
Affirms that "the child must be given the means needed
for its normal development, both materially and spiritually"
and states that "the hungry child should be fed."

Death from malnutrition

*
*
*At least 70%

of childhood
diseases are
related with
one of these
conditions

*
*
Source: WHO, based on C.J.L. Murray and A.D. Lopez, The Global Burden of Disease, Harvard University Press,
Cambridge (USA) 1996 and American Journal of Public Health 1993-83.

Summary: Definition of malnutrition

Malnutrition is having the inappropriate
level of a micro- or macro- nutrient;
In some cases (i.e. the US), malnutrition
can be associated with being grossly
overweight;
In most of the world, malnutrition is defined
as a LACK of nutrients;
Malnutrition contributes to over 50% of
deaths in children in the world.

Todays Class

Overview of Nutritional Requirements

Definition of Malnutrition
Causes and correlates of Malnutrition
Measurement and Types of Malnutrition
Severe Malnutrition
Mild/Moderate Malnutrition (Underweight
and Stunting)
Specific Nutritional Deficiencies (Iodine and
Iron)

Causes of malnutrition
Child malnutrition
death and disability

Inadequate
Diet

Disease

Insufficient Poor water/ sanitation Inadequate

access to food inadequate health maternal and
child care
services

Higher
mortality rate
Reduced
capacity
to care
for baby

Elderly
Malnourished

Inadequate
food,
health
& care

Inadequate
fetal
nutrition

Woman
Malnourished
Start here

Pregnancy
Low Weight
Gain

Higher
maternal
mortality

Impaired
mental
development

Baby
Low Birth
Weight
Inadequate
catch up
growth

Increased risk of
adult chronic disease

Child
Stunted

Untimely/inadequate
weaning
Frequent
Infections
Inadequate
food, health
& care
Reduced
mental
capacity

Adolescent
Stunted

Inadequate
food, health
& care

Reduced
mental
capacity

Inadequate
food, health
& care

Correlate: Unsafe Water

11% urban and 38% rural

households do not have
access to safe water

Source for photos: Overseas Aid: www.nat.uca.org.au, Statistics, UNICEF State of the Worlds Children 2000

Correlate: Inadequate Sanitation

21% urban
and 75% rural
households do
not have
access to
adequate
sanitation

Source for photos: Overseas Aid: www.nat.uca.org.au, Statistics, UNICEF State of the Worlds Children 2000

Correlate: Poor Education

25% of girls and 19% of boys do

not enter primary school;
54% of girls and 45% of boys do
not enter secondary school
Source for photos: Overseas Aid: www.nat.uca.org.au, Statistics, UNICEF State of the Worlds Children 2000

Correlate: Poverty
28% of the
population lives at
below $1 per day
Average GNP per
capita is $1299
(compared with
$29,080 in USA)

Source for photos: Overseas Aid: www.nat.uca.org.au, Statistics, UNICEF State of the Worlds Children 2000

Correlate: Poor Stimulation

39% of females
and 21% of males
over the age of 15
cannot read or
write
199 radios per
1000 population;
154 TVs per 1000
population
Source for photos: Overseas Aid: www.nat.uca.org.au, Statistics, UNICEF State of the Worlds Children 2000

Correlate: Poor Public Health

About 30% of 1year olds are not
fully immunized
for TB, DPT
(Diptheria,
Pertussis, and
Tetanus), polio
and measles

Source for photos: Overseas Aid: www.nat.uca.org.au, Statistics, UNICEF State of the Worlds Children 2000

Correlate: No Breastfeeding
Babies are twins (boy and
girl)
Mother was told that she
wouldnt have enough
breast milk for both,
so should bottle feed girl . . .
girl died the day after
this photo was taken
56% babies in developing
countries are not breastfed
from 0-3 months
Source: Childrens Hospital Islamabad

Summary: Causes/correlates
Malnutrition rarely exists in isolation, and many
other factors contribute to its detrimental impact;

Poor physical resources, and overcrowded homes

Poor sanitation and water supply
Low income
Parents with little education
Minimal interaction/stimulation in the home

Malnutrition has repercussions throughout the life

cycle and is thus multi-generational (diagram with
lots of arrows)

Todays Class

Overview of Nutritional Requirements

Definition of Malnutrition
Correlates of Malnutrition
Measurement and Types of Malnutrition
Severe Malnutrition
Mild/Moderate Malnutrition (Underweight
and Stunting)
Specific Nutritional Deficiencies (Iodine and
Iron)

Types of malnutrition
Severe Protein-Energy Malnutrition (>3 S.D.)
Kwashiorkor (low protein)
Marasmus (low calories)

Mild/moderate undernutrition (>2 S.D.)

Stunting
Underweight
Wasting

Micro-nutrient deficiency

Iodine
Iron
Vitamin A
Vitamin D

Measurement of Malnutrition
STUNTING: Height for age height
compared to a reference population of the
same age.
= represents long term growth retardation

UNDERWEIGHT: Weight for age weight

compared to age in a reference population
WASTING: Weight for height weight
compared to a reference population of the
same height.

Growth Curves (0-3 years)

Length/
Height
Weight

Age

Summary: Measurement
There are several types of malnutrition,
micro- and macro-malnutrition;
Measurement of severe malnutrition (>3
S.D.) and micro-nutrient deficiency usually
occurs due to presence of critical signs (to
be discussed);
Measurement of mild/moderate
malnutrition (>2 S.D.) occurs with growth
charts.

Todays Class

Overview of Nutritional Requirements

Definition of Malnutrition
Correlates of Malnutrition
Measurement and Types of Malnutrition
Severe Malnutrition
Mild/Moderate Malnutrition (Underweight
and Stunting)
Specific Nutritional Deficiencies (Iodine and
Iron)

Severe malnutrition % <5 y.o.

Developing Countries
Least Developed Countries

12%
13%

(India 21%, Bangladesh 21%, Cambodia 18%)

Data for 1992-98, UNICEF State of the Worlds Children 2000

Severe PEM: Real Numbers

Example: India
21% of all children under 5
# children under 5 is 115,615,000
24M children severely malnourished (Bigger than
population of Texas 20M)
Example: All developing countries
Total # <5 in developing countries: 536,105,000
and 12% of that is:
64M children under 5y.o. severely malnourished
(California & New York & Florida)
Example: World (total number is 603,449,000)
11% = 66M (France or England)

Kwashiorkor
Infection

Sparse
hair

Swollen
belly
Decreased
muscle
mass
Pellagra

Apathy

Kwashiorkor (low protein)

Decreased muscle mass (failure to gain weight and of
linear growth)
Swollen belly (edema and lipid build-up around the liver)
Changes in skin pigment (pellagra); may lose pigment
where the skin has peeled away (desquamated) and the
skin may darken where it has been irritated or traumatized
Hair lightens and thins, or becomes reddish and brittle.
Increased infections and increased severity of normally
mild infection, diarrhea
Apathy, lethargy, irritability
Death does not occur from actual starvation but from
secondary infection

Kwashiorkor mechanisms
Occurs in reaction to emergency situations
(famine)
Kwashiorkor more likely in areas where
cassava, yam, plantain, rice and maize are
staples, not wheat
Increased carbohydrate intake with
decreased protein intake eventually leads
to edema (water) and fatty liver

Marasmus (low calories)

Ravenously
hungry
Gross
weight
loss &
no fat

Marasmus
Deficit in calories marasmus comes
from Greek origin of word to waste
Gross weight loss
Hyper-alert and ravenously hungry
Children have no subcutaneous fat or
muscle
eventually starve to death (immediate
cause often is pneumonia)

Marasmus mechanism
Energy intake is insufficient for bodys
requirements body must draw on own stores
Liver glycogen exhausted in a few hours
skeletal muscle protein used via gluconeogenesis
to maintain adequate plasma glucose
When near starvation is prolonged, fatty acids are
incompletely oxidized to ketone bodies, which can
be used by brain and other organs for energy
High cortisol and growth hormone levels

Mechanism is same as anorexia

Severe Malnutrition: Consequences

Mental development

Lower IQ levels
Poorer school performance

Behaviors of recovered severely malnourished

children

shy, isolated, withdrawn

decreased attention span
immature, emotionally unstable
fewer peer relationships/reduced social skills
played less/stayed nearer to mothers

Summary: Severe malnutrition

Severe malnutrition is defined as > 3 s.d.
away from median reference standards;
66M children under the age of 5 are
severely malnourished (64M of these in
developing countries);
Key types of severe malnutrition are
kwashiorkor (low protein) and marasmus
(low calories);
Severe malnutrition results in severe
deficits for children

Todays Class

Overview of Nutritional Requirements

Definition of Malnutrition
Correlates of Malnutrition
Measurement and Types of Malnutrition
Severe Malnutrition
Mild/Moderate Malnutrition (Underweight
and Stunting)
Specific Nutritional Deficiencies (Iodine and
Iron)

Stunting Height for Age

Height for age reflects pre- and post- natal
linear growth
Stunting refers to shortness that is not
genetic, but due to poor health or nutrition
Most standard definition < 2 S.D.
Stunting is good cumulative measure of
well-being for populations of children
(because not affected by weight recovery)

Stunting
These girls are:
From same school
and the same
neighborhood
Both have the
same birthday

Stunting % <5 y.o.

Developing Countries
39%
Least Developed Countries
47%
(India 52%, Bangladesh 55%, Cambodia 56%)
Data for 1992-98, UNICEF State of the Worlds Children 2000

Stunting: Real Numbers

India where 52% of all children under 5 (total <5 is
115,615,000) are stunted
60M children in India are stunted (as many people
live in the MidWest)
Example all developing countries, where 39% of all
children under 5 (536,105,000)
209M children in dev world
In world, the total # of children <5 is 603,449,000 and
37% of that is
223M children in world (US popn 272M US minus
California and Texas)

Stunting: Causes
Poor nutrition plays major role
Role of environment: improvements in
average height shown by populations over
last century (impact of genetic influence
subsumed by level of socio-economic
development)
In 1833, British children were as tall as
children today from India and Guatemala
All immigrant populations have same height
after 3 generations in US

Stunting: Timing
Age of onset varies, but usually in first 2-3
years of life
First few months, infants in developing
countries grow just as quickly as children in
reference populations
Growth retardation starts from 2-6 month of life
(often associated with weaning)
Infants at risk during this time because of high
nutritional requirements and high rates of
infections (breast fed infants often protected)

Stunting: Consequences
Cross-sectional associations Low height
for age associated with:
Reduced cognitive development
Poor motor skills
Poor neuro-sensory integration
Quiet, reserved, withdrawn, timid, passive
Difficulty making decisions
Decreased involvement with environment,
toys, tasks
Less able to deal with stressor such as hunger
or parasites

Hypothesized Mechanisms
alterations in
development
of CNS

poor
nutrition

emotional
reactivity,
impaired
stress response
functional
isolation

poor mental
development &
behavior

Summary: Mild/moderate maln.

Stunting refers to growth retardation (>2
S.D.) secondary to malnutrition;
Almost 40% (223M) of children <5 in the
developing world are stunted;
Children are most at risk for stunting in the
first 2-3 years of life;
Stunting is associated with poor mental
development and altered behavior.

Todays Class

Overview of Nutritional Requirements

Definition of Malnutrition
Correlates of Malnutrition
Measurement and Types of Malnutrition
Severe Malnutrition
Mild/Moderate Malnutrition (Underweight
and Stunting)
Specific Nutritional Deficiencies (Iodine,
Iron, Vitamin A, Vitamin D)

Specific Nutritional Deficiencies

Iodine Deficiency
Iron Deficiency
Vitamin A
Vitamin D

Iodine deficiency - thyroid

Simple goiter is the easiest of all known diseases to prevent . . .

It may be excluded from the list of human diseases as soon as
society determines to make the effort David Marine 1923

Iodine Deficiency Disorders

Source: State of the Worlds Children, 1998

Causes of Iodine Deficiency

Mountainous areas at risk (soils leached by
high rainfall, melting snow, flooding)
Culturally induced behavioral change
Tasmanian Aboriginals migrated every season
until European invasion, became sedentary
and had incidence of thyroid problems

Iodine Deficiency: Severe

Goiter: most commonly recognized
consequence (enlarged thyroid)
Occurs when thyroid gland is unable to meet
the metabolic demands of the body through
sufficient hormone production thyroid
compensates by enlarging (works in short
term)

Cretenism: proximal pyramidal signs,

intellectual impairment, primitive reflexes
Only occurs with severe fetal iodine deficiency

Iodine Deficiency: Moderate

Studies comparing 2 Villages
Consistent results: meta-analysis showed 13.5
IQ point difference between groups

Intervention Studies
Prenatal supplementation (esp. 1st trimester):
clear impact prevents cretenism, and affects
mental development in children
Childhood supplementation: many mediocre
studies, but positive impact

Iron deficiency - anemia

Source:UN ACC-SCN-IF

Source: UN-ACC-SCN-IFPRI-4 Report on World Nutrition Situation

Iron Deficiency
Iron is critical for body:
Carries oxygen to tissues from lungs
Transports electrons within cells
Integral part of important enzyme reactions

Anemia is caused most commonly by iron

deficiency (anemia is found in 40-60% of
women and children in developing
countries)

Iron Deficiency Consequences

Iron deficiency results in:
Decreased work capacity and work productivity
Permanently impaired development
Psychomotor development of anemic children will
be reduced by 5-10 IQ points

Increased morbidity and mortality from

infections
Decreased growth

Vitamin A Deficiency
Vitamin A is important
because it is essential to
vision, fetal development,
immune response
250 million children of preschool age lack sufficient
Vitamin A in their diet.
350,000 become blind each
year, and half of them die
within a year of becoming
blind.

Vitamin A Deficiency
Associated

with blindness and increased

severity of infections such as measles and
diarrhoeal disease
WHO estimates that 2.8 million children
under 5 years old have signs of clinical
xerophthalmia (childhood blindness)
WHO estimates that 14 million pre-school
children already have some eye damage
from Vitamin A deficiency

Vitamin D Deficiency: Rickets

http://www.spoilheap.co.uk/rickets.htm

Summary: Micronutrient deficiency

Iodine is critical for thyroid function
deficiency results in cretinism & goiter
Iron is critical for blood and muscles
deficiency results in anemia
Vitamin A is critical for visual development
deficiency results in blindness
Vitamin D is critical for bone development
deficiency results in rickets

Where do we go from here?

Increased
productivity

Poverty
reduction

Economic growth

Improved child
nutrition

Social sector
investments

Enhanced human
capital
From UNICEF, State of the Worlds Children: Adapted from Stuart Gillespie, John
Mason and Reynaldo Martorell, How nutrition improves, ACC/SCN, Geneva 1996.