Malnutrition's Prevalence and Associated Factors

*Arslan Ahmad, Sakhawat Riaz, Nosheen Ijaz, Maleeha Fatima and Muntaha Latif*

## **Abstract**

Malnutrition, which affects roughly 2 billion people worldwide, is among the country's most pressing health issues. In comparison to other developing nations, Pakistan has one of the worst prevalence of childhood malnutrition. We'll explore how people in poor countries manage food scarcity. Owing to low per capita income and a lack of purchasing power for fundamental food staples that meet the human body's nutritional demands. Malnourished children in Pakistan suffer from stunting, wasting, and being underweight. The causes of child malnutrition and stunting in Pakistan are discussed in this chapter, as well as the impact of numerous factors on stunting and the types of intervention methods and practices that should be devised and executed to address the problem.

**Keywords:** malnutrition, stunting, food insecurity, interventions, strategies

### **1. Introduction**

Malnutrition is commonly referred to as under-nutrition [1]. Stunting, wasting, and being underweight in children under the age of five are all signs of malnutrition [2]. Malnutrition refers to any shortage, surplus, or volatility in energy and/or nutritional demands, and includes both under and over-nutrition [3, 4]. 165 million children under the age of five suffer from malnutrition across the world. India (46.6 million), Nigeria (13.9 million), and Pakistan (10.7 million) have the world's least stunted children, according to the 2018 Global Nutrition Report [5]. Malnutrition is responsible for at least half of all child deaths globally [6, 7]. Children's malnutrition is mostly a problem in developing and disadvantaged countries [8]. The leading cause of sickness and death among children is malnutrition [9]. Malnutrition is among the world's most serious health problems, affecting around 2 billion people. Malnutrition in all forms (appetite, undernourishment, vitamin deficiencies, overweight, and obesity) appears to be a severe concern for both emerging and industrialized countries, according to the World Committee on Food Security. Hunger may be characterized in many different ways, including individual experiences and behavioral reactions in the home, food shortages, and national food balance sheets [10]. Approximately 151 million children under the age of five are stunted, over 50 million are wasted, and nearly

17 million are seriously wasted, according to UNICEF/WHO/World Bank Group estimates [11, 12]. Although the total rate of stunting in Asia has decreased from 38 percent to 23 percent between 2000 and 2017, it is still the highest [13].

Pakistan is now experiencing a complicated malnutrition problem that affects people of all ages, especially newborns, children, adolescents, and pregnant and nursing mothers. As per UN Worldometer statistics, Pakistan's population is now predicted to be about 219.1 million, with a potential increase to >260 million by 2030 [14]. Malnutrition is predicted to cost emerging nations between 2 and 3% of their GDP (GDP). Malnutrition is estimated to cost a person one-tenth of their lifetime wages [15]. Pakistan has a high rate of malnutrition. As a result, nearly a quarter of the population of a low-middle-income, fifth nation is unable to meet an adult's dietary needs (2350 calories per day) [16–18]. According to a recent global report on child malnutrition, The majority of households in low and middle-income countries are facing dual-faced malnutrition as a result of a dietary shift, which is defined as a home with an obese mother and an undernourished child. On the other hand, stunting is declining relatively slow, whereas excess weight continues to rise globally [19]. As a result, while establishing policies, programs, and interventions to prevent undernutrition, food insecurity and dietary variety should be considered [20].

### **2. Childhood stunting's causes**

Stunting develops in children as a result of a regular caloric intake and nutrients that are insufficient to meet their needs. A lack of linear development, or a modest stature or height in one's age, is referred to as stunting. This is evaluated by dividing a child's height for his or her age to either a comparison group of well-fed and healthy children (Z score of 2 or less). Stunting refers to excess or inequality in a person's energy or calorie consumption that is linked to stunted physical and psychological development [21]. Stunting is associated with the phrase "small for gestational age" (SGA) globally [22]. If pregnant women's nutritional demands are not addressed sufficiently, they might not be able to provide the fetus with the nourishment it needs during pregnancy. Malnourishment in pregnancy is a big issue in Pakistan since it can inhibit a baby's development and raise the risk of certain diseases later in life [23]. According to the United Nations Children's Fund, almost 10 million Pakistani children are stunted (UNICEF). For the first 6 months of their lives, just 38% of newborns are exclusively breastfed. As a result, more than half of children under the age of five are deficient in vitamin A, 40% are zinc and vitamin D deficient, and 62% are anemic. In Pakistan, 4 out of every 10 children under the age of five are stunted, with 40.2 percent wasting and 17.7% stunting. According to the 2018 national nutritional survey, more than one-third of children (28.9%) are underweight, with a high prevalence of overweight (9.5%) in the same age range shown in **Figure 1**.

The nutritional challenges of their children are linked to the moms' diet and wellness during adolescence, gestation, and breastfeeding periods. As a result, expectant moms must receive appropriate and balanced nourishment. Maternal micronutrient supplementation (MMS) during pregnancy improved gestation, birth weight, and fetal development in Tanzanian infants, as evidenced by their 6-week mortality rate, which was only quantifiable in females but not males newborns [24]. Due to compromised immune systems, malnutrition and infection combined to raise the risk of childhood morbidity and death. More than half of all children under the age of five are expected to die from malnutrition. Immunological changes have been associated with decreased intestinal activities, the

inadequate release of protective material from exocrine glands, and decreased participation of the signaling pathway in serum proteins, albeit the underlying processes are unknown [25]. Children's intrinsic and innate immune responses are also influenced by protein and micronutrient deficits [26]. In children, changes in the gut microbiota can limit growth, disrupt inflammatory immunological processes, reduce functional brain connections, and also delay psychomotor and intellectual abilities [27, 28].

Other geriatric syndromes have been associated with depressive symptoms and malnutrition, both of which are modifiable risk factors for 30-day readmission in hospitalized older people [29]. The prevalence of malnutrition, as measured by the CONUT score, was high in older people undergoing elective surgery for colon cancer patients. Malnutrition has been related to a prolonged stay in the hospital as well as a higher chance of negative outcomes. Both death and readmissions to the intensive care unit are on the rise. CONUT is a quick and easy nutritional screening test that has previously been used to assess nutritional status in people who have had CRC surgery. A longer hospital stay is linked to a lower nutritional state. It's more likely that difficulties may occur. as well as a higher mortality risk [30]. Sarcopenia, cachexia, diminished sensory function, and alterations in the gastrointestinal system are some of the factors linked to old age [31].

## **3. Malnutrition in Pakistan: consequences**

In South Asian nations, the primary factors of malnutrition and stunting are remarkably similar. The key categories include food insecurity and insufficient nutritional intake, social status and inequality, maternity and environmental factors, poverty, and water sanitation hygiene.

## **3.1 Inadequate dietary intake and food insecurity**

Poverty and food insecurity are the two most persistent and major variables that cause stunting. Food insecurity affects children's nutrition, growth, and

cognition and is a serious problem in developing nations. Food insecurity and diet variation should be considered while establishing strategies, plans, and interventions to address the problem of undernutrition [20]. The potential for economic growth of a country can impact food insecurity and, subsequently, the frequency of child stunting [32]. In Pakistani children, food insecurity is a major contributor to their low nutritional condition. In Pakistan, about two-thirds of families with nearly 80% of children lack adequate access to good and nutritional foods [33]. Insufficient diet, anemia, and nutrient deficits in pregnant mothers have been linked with lower childbirth weights in Pakistan. Even though Pakistan is a significant producer of rice and wheat becoming a food supply state, the nation's economic insecurity has exacerbated the nutritional inequality among children and babies. According to the Pakistan Economic Survey 2018–2019, Pakistan's overall food output and accessibility to basic food items are sufficient to meet the population's nutritional needs [34].

According to the Journal of the American Dietetic Association 3, in 2025, the supply of calories from key food groups per person would climb to 2530 calories. As per the Pakistan Cost of Diet Analysis, 67% of Pakistani families cannot afford a scientifically appropriate meal, while around 5% cannot afford a diet that fulfills even the necessities of energy needs [35]. Despite rising per capita wealth, increased food production and accessibility, and better intakes of gross energy (calories from food), Pakistan's current child stunting incidence is 40.2%. Nevertheless, over 60% of the people themselves are affected by food insecurity, with the lowest and perhaps most susceptible individuals in particular unable to buy sufficient healthy food [36]. Despite this, little is known about the non-nutritional repercussions of food insecurity, such as its implications on brain development and cognitive impairments, especially in developing countries [37]. The likelihood of baby undernourishment has also been connected to poor maternal mental health. Women with prenatal indicators of distress who lived in rural parts of Pakistan, and they had smaller amounts, larger family debts, and were food insecure, exhibited severe depression than women in high-income nations [38]. Young children are going through a phase of rapid growth and development, which necessitates more energy consumption. Humans and caretakers, on the other hand, meet their nutritional and dietary requirements. As a result, they are more likely to become malnourished [39]. Longterm exposure to natural disasters like landslides causes a decrease in the food supply, a lack of access to safe and nutritious food, a decrease in the quantity and quality of food consumed, and a lack of access to health, safe water, and sanitation facilities, all of which contribute to child malnutrition [40]. Long-term exposure to natural disasters, such as landslides, causes a decrease in the food supply, a lack of access to safe and nutritious food, a decrease in the quantity and quality of food consumed, and a lack of access to health, safe water, and sanitation facilities, all of which contribute to child malnutrition [41].

#### **3.2 Socioeconomic status and disparities**

There is a strong relationship between several indicators of socioeconomic status (SES) and child stunting in low- and middle-income countries (LMIC). Children's stunting is said to be impacted by socioeconomic inequity. Children in rural regions of the Democratic Republic of the Congo (DRC) were found to have a greater frequency of stunting than those in city environments. Boy stunting was much higher than girl stunting, especially among boys from low-income families. Breastfeeding,

#### *Malnutrition's Prevalence and Associated Factors DOI: http://dx.doi.org/10.5772/intechopen.104455*

along with other nutrition treatments, must be given prompt attention to prevent stunting, they said [42]. Parents' educational levels, particularly mothers', mothers' health and nutritional status during pregnancy and lactation, children's vaccinations, family income level, and the current system were all socioeconomic factors affecting the nutritional health of children under the age of five in Nigeria [43, 44].

Stunting and thinness in Pakistani primary school kids (5–12 years) in Lahore, Pakistan, were studied for frequency and socioeconomic determinants. Researchers discovered that 8% of children were stunted and 10% were underweight, with no gender differences. Both boys and girls showed signs of stunting as they grew older, but only males were skinny. Stunting and thinness were found to be influenced by age, socioeconomic status, parental education, the number of siblings, overcrowding, and living in a smoky environment. Children from poorer, less qualified families who lived in low-income neighborhoods and in cramped residences with a smoking culture were considerably more likely to be stunted and skinny. Programs aiming at the disadvantaged and socially marginalized should be prioritized [45]. Stunting, underweight, and waste were identified in 44.4%, 29.4%, and 10.7% of Pakistani children (0–59 months), respectively. Mothers of children were under the age of 18 at the time of marriage, resided in rural regions, and attended a maternity clinic at least 3 times during pregnancy had a low risk of being stunted. Underweight in children was strongly linked to the mother's level of education, height, BMI, and birth weight. Investigators concluded that the majority of the variables that cause malnutrition in Pakistani children may be avoided [46]. A higher amount of income or wealth, on the other hand, has been linked to a lower incidence of malnutrition in children. As a consequence, Pakistani women's empowerment can help improve people's health, which is key for the country's future progress [47]. Parents with a lower degree of education have a lower household income and are more likely to live in poverty. They spend less money on appropriate nutrition because of a shortage of food, basic health care services, and exposure to terrible living conditions and diseases, and their children are more prone to growth failure [48].

#### **3.3 Poverty**

Many of us associate poverty with pictures of starvation or children dying from avoidable diseases on television from the poor world [49, 50]. Poverty is a multifaceted issue in Pakistan. It is firmly embedded in the social, economic, and political systems of the country. The lack of good economic and political governance is the greatest obstacle to poverty reduction. Poverty was once associated with the severe types of malnutrition, particularly in children, that were common during times of famine and starvation. As indicated in **Figure 2**, the World Bank utilized the lower-middle-income poverty rate (\$3.2 per day) to predict that Pakistan's poverty rate stood at 39.3% in 2020–2021, is expected to continue at 39.2% in 2021–2022, and may drop to 37.9% by 2022–2023. Impoverished individuals are more susceptible to natural dangers (lack of sanitation, inadequate food, crime, and natural disasters), are far less aware of the benefits of good health, and get less access to quality health care. As a result, individuals seem to be more prone to disease and disability [51]. When girls reach reproductive age, they are more likely to give birth to low-birth-weight babies, who have a worse chance of survival than typical babies. Undernutrition is one of the most frequent diseases, the major cause of inadequate healthy development, and by far the most important component inhibiting a country's progress [52].

#### **Figure 2.**

*Poverty rate from 2020 to 2023.*

#### **3.4 Maternal and environmental factors**

Malnutrition and stunting in children are generally induced by several factors, namely maternal health, ecological and home circumstances, poverty, socioeconomic disparities, low birth weight, dirty water, sanitation, proper hygiene, infections, and diarrhea [53, 54]. Gastrointestinal tract damage, immune suppression, including liver illness across both mothers and infants, as well as stunting in children, are all linked to aflatoxin and mycotoxin exposure from contaminated food [55]. Children who grow up in agricultural areas tend to have development problems throughout pregnancy, childhood, and adolescence [56]. The use of polluted water and the early introduction of supplemental feeding raises the risk of infections and water-borne illnesses including diarrhea and cholera, which impairs children's food intake and nutrient utilization, causing stunting and wasting [57].

#### **3.5 WASH (water, sanitation, and hygiene)**

Poverty, poor sanitary conditions, and dirty water are the causative factors of child retardation in Pakistan, by a World Bank study. In Pakistan, open latrines are widely used, and the country is ranked third in the world for open defecation. Many nutritional and health issues are linked to open latrines, including intestinal infection and disease transmission. In Sindh, water and soil polluted with *Escherichia coli* are detected in greater quantities than in Punjab [58]. This is due to an insufficient sewage disposal system and inappropriate human waste treatment. The feces-infected water enters the irrigation system, causing tainted crops to grow that are unsafe to eat. Because of too much access to intestinal parasites, poor drainage, sanitation, and sanitary circumstances influence children's growth and development. On-diarrheal sickness and death in children can be reduced by using nutritional, therapeutic, and behavioral strategies [59]. **Figure 3** depicts the effect of household income on energy intake, which results in anthropometric measurements of stunting and wasting. If one's calorie intake is less than one's energy expenditure, it leads to physical inactivity and makes it difficult to work as an adult. All of these factors have an impact on health, resulting in illnesses. This clarifies the relationship between economy,

*Malnutrition's Prevalence and Associated Factors DOI: http://dx.doi.org/10.5772/intechopen.104455*

**Figure 3.** *Consequences of undernutrition.*

nutrition, and health. In children, *E. coli* causes environmental enteric dysfunction (EED), which causes profuse diarrhea. In underdeveloped nations, EED suppresses the immune system, impairs children's cognitive and mental development, causes growth retardation, and causes malnutrition [60, 61].

Inadequate toilet facilities, inadequately treated water supplies, underprivileged healthcare access in remote regions, diarrhea and diseases, and food insecurity are among the most powerful factors of malnutrition and stunting in children in the developing world, according to the above-mentioned data.

## **3.6 Strategies to cover malnutrition**

The eradication of child malnutrition is crucial for people's and society's development. To achieve zero stunting, thorough nutritional therapy regimens must be implemented, particularly during the first 2 years of life. Multi-targeted intervention strategies with a focus on growth and anthropometric parameters are advised. Reduced child stunting is a crucial aim in reaching zero hunger, according to the Global Nutrition Targets for 2025 [62]. Scaling Up (SUN) The need to include stunting prevention in all future sustainable development efforts undertaken by member nations is highlighted by nutrition. Poor nursing habits and dietary deficiencies are thought to be the primary health issues of child stunting and bad health. Pakistan should promote supplementary feeding services for kids above the age of 6 months in addition to exclusive breastfeeding. To boost the nutritional impact of supplementary feeding habits and enhance children's nutritional status, recommendations on their entry timing and frequency must be created and executed. It is necessary to develop and deliver suitable, low-cost fortified supplemental nutritious meals that are compatible with unique cultural foods, especially to homes at risk of potential poverty. According to the Global Alliance for Improved Nutrition, the leading causes of stunting in children are premature marriages and breastfeeding females more than boys. Boys are often given more food than girls, resulting in stunting and malnutrition in

the female population. Not only are they unable to compete in many sectors with males, but malnourished moms are also unable to give birth to healthy kids [63].

Cooperative efforts to improve maternal nutrition and to eliminate child stunting, focusing on a variety of actions in areas such as agriculture, the environment, water, sanitation and hygiene, schooling, poverty alleviation, and social welfare, including the implementation of specific laws and policies. In Pakistan, malnutrition must be seen through an ideological lens, with implications for overall growth [64]. Cross strategies including all dietary and micronutrient techniques, to eliminate hunger and childhood stunting in Pakistan, strong political will must be formed and enforced. Deprivation, food shortages, bad sanitation, and hygienic practices, disease infection and vulnerability, maternity care, inequalities gender issues, poor diet patterns, and poor diets, as well as a high population growth rate, increasing urbanization, sensitivity to protection and wellbeing situations, or an absence of adequate ideological would all add to the quality of Pakistan's dietary difficulties. According to the findings of a recent study, the majority of these variables are avoidable. On the other hand, integrated solutions for addressing these concerns should be developed in the framework of society's academic and nutritional efforts [46]. Nutritional therapies can reduce stunting in general. Stunting is a significant danger for children living in urban slums. When creating dietary approaches to reduce low birth weight and child retardation in these kinds of circumstances, the diversity of such conditions in terms of physiological, social, and economic elements should be acknowledged [65]. It's vital to create well-designed coordinated multistakeholder intervention strategies which use rational ways to fulfill the requirements of the most desperate individuals that are more prone to stunting as poverty [66]. As a result, appropriate recommendations initiatives should not only aim to reduce poverty, undernourishment, and climate difficulties but also improve and maintain a lengthy economic growth goal within the native culture. Because nutritional deficiencies, like iron and iodine, can harm children's brain growth early in life, nutritional supplementation throughout pregnancy and childbirth is crucial for preventing cognitive deficits in infants and children [67]. Stunting and malnutrition can be reduced by food adjustments such as food supplements and micronutrient replacement, in combination with diet therapies [68, 69]. Niazi concluded that governmental and non-governmental institutions' nutritious prevention efforts in Pakistan failed to deliver their aimed nutrition outcomes because they did not take an incorporated way of tackling the important principles of malnutrition such as lack of education, economic hardship, and sociocultural deprivation [70]. Every year, stunting among children causes Pakistan to lose 3% of its GDP. It is projected that every rupee spent to combat malnutrition will provide a return of 16 rupees. Well-fed children have a 33 percent higher chance of escaping poverty as adults [71, 72]. If adequate intervention programs and policies are adopted, Pakistan may likewise address the problem of malnutrition and stunting.

#### **3.7 Malnutrition alleviation and economic growth**

The link between economic advancement and improved nutrition can be either positive or negative. As per Wang and Taniguchi, good nutrition is beneficial to protracted income progress, although the benefits could be hidden by a current rapid population surge [73]. Headey investigated the effects of economic growth on dietary stunting in middle- and low-income nations across three continents. Increased food availability, poverty alleviation, and enhanced maternal and child health care, he claims, are all positives [74]. Nonetheless, even within areas, the nutritional impacts

*Malnutrition's Prevalence and Associated Factors DOI: http://dx.doi.org/10.5772/intechopen.104455*

of economic expansion vary greatly. Thus according to conventional anthropometric measures, the incidence of malnutrition declined little in Sub-Saharan Africa despite decades of Economic growth faster than the overall. She also noted substantial differences in the distribution of child nutrition increases among demographic categories (such as urban vs. rural) [75].

## **4. Early (indirect) intervention: nutrition-sensitive programs**

Despite having multiple primary goals, nutrition-sensitive programs could have a similar impact on the underlying cause of child malnutrition as 'micronutrient' initiatives, not only as they are more diverse and larger in scale. Nursing and parental leave laws, free iron and folic acid for pregnant women, and vitamin A for early children are all examples of national programs [76]. Farming, healthcare, social welfare, early education, schooling, irrigation, and cleanliness are among the numerous sectors participating in nutrition-sensitive initiatives [77]. Conditional cash transfers are currently one of the most researched & examined types of planned action [76]. A sort of dietary approach provides financial assistance to individuals and households in need, often in exchange for a reciprocal activity like school attendance or completing a vaccination regimen. Although its main objective is to eliminate misery, such as in an emergency, there is increasing support that they have huge development influence [78].

**Figure 4** depicts interventions that would reduce child malnutrition. Various organizations are collaborating with the UN to combat hunger, malnutrition, food insecurity, and other problems. WHO (World Food Organization), FAO (Food and Agriculture Organization), SUN (Scaling up Nutrition), UNHCR (United Nations High Commission for Refugees), and others are among these bodies. Each group devised its strategy to address the issue of malnutrition, which we will examine

**Figure 4.** *Strategies for child malnutrition.*

below. More Money for Nutrition and more nutrition for money (according to SUN Movement Strategy 2021–2025).


## **5. Conclusion**

Malnutrition is one of the world's most serious health problems, affecting about 2 billion people. UNICEF/WHO/World Bank Group estimates that 151 million children under the age of five are stunted, 50 million are wasted, and 17 million are severely wasted, according to UNICEF/WHO/World Bank Group estimates. Malnutrition is prevalent in Pakistan. Food insecurity, poverty, sanitation, hygiene, maternal and environmental variables, education, stunting, and other factors all contribute to malnutrition. This might be due to inadequate or ineffective intervention policies and programs, which have tended to focus on a single issue at a time rather than employing multi-sectoral methods to address the various factors that contribute to stunting. Cost-effective multitier interventions must be administered during the preconception, prenatal, and especially early postoperative periods to prevent malnutrition, stunting, and wasting in children. It is suggested that a comprehensive plan be devised and implemented to address the problem of malnutrition and stunting, which includes nutrition and WASH treatments, as well as activities to improve socioeconomic status. To guarantee that particular projects are created, performed, and sustained promptly, legislators, government and non-government agencies, other parties, and, most importantly, individual contributions and support are required.

## **Acknowledgements**

We are grateful to the GCUF Digital Library for making the publication available to us.

*Malnutrition's Prevalence and Associated Factors DOI: http://dx.doi.org/10.5772/intechopen.104455*

## **Conflict of interest**

There is no conflict of interest.

## **Author details**

Arslan Ahmad1 \*, Sakhawat Riaz1 , Nosheen Ijaz1 , Maleeha Fatima1 and Muntaha Latif<sup>2</sup>

1 Department of Home Economics, Government College University, Faisalabad, Pakistan

2 University of Agriculture Faisalabad, Pakistan

\*Address all correspondence to: ahmadarslan784@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Shetty P. Malnutrition and undernutrition. Medicine. 2006; **34**:524-529

[2] De Onis M, Onyango AW, Borghi E, Garza C, Yang H, WHO Multicentre Growth Reference Study Group. Comparison of the World Health Organization (WHO) child growth standards and the National Center for Health Statistics/WHO international growth reference: Implications for child health programs. Public Health Nutrition. 2006;**9**:942-947

[3] Ntenda P. Association of low birth weight with undernutrition in preschoolaged children in Malawi. Nutrition Journal. 2019;**18**(1):51. DOI: 10.1186/ s12937-019-0477-8

[4] WHO. Malnutrition-key facts. In: Malnutrition-Key Facts. Geneva: World Health Organization; 2018

[5] 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**:427-451

[6] Meshram II, Arlappa N, Balakrishna N, Rao KM, Laxmaiah A, Brahmam GNV. Trends in the prevalence of undernutrition, nutrient, and food intake and predictors of undernutrition among under five-year tribal children in India. Asia Pacific Journal of Clinical Nutrition. 2012;**21**:568-576

[7] Demissie S, Worku A. Magnitude, and factors associated with malnutrition in children 6-59 months of age in pastoral community of Dollo Ado District, Somali region, Ethiopia. Science Journal of Public Health. 2013;**1**:175-183

[8] Müller O, Krawinkel M. Malnutrition, and health in developing countries. Canadian Medical Association Journal. 2005;**173**:279-286

[9] Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health Epidemiology Reference Group. WHO estimates the causes of death in children. Lancet. 2005;**365**:1147-1152

[10] Webb P, Stordalen GA, Singh S, Wijesinha-Bettoni R, Shetty P, Lartey A. Hunger and malnutrition in the 21st century. BMJ. 2018;**361**:k2238

[11] United Nations Children's Fund (UNICEF), WHO, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: Key findings of the 2019 edition of the joint child malnutrition estimates. In: Levels and Trends in Child Malnutrition: Key Findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 License: CC BY-NC-SA 3.0 IGO; 2019

[12] Development Initiatives. 2018 global nutrition report: Shining light to spur action on nutrition. In: 2018 Global Nutrition Report: Shining Light to Spur Action on Nutrition; Bristol, UK. Development Initiatives, Poverty Research Ltd; 2018.

[13] UNICEF. Press release on global nutrition report 2018. In: Press Release on Global Nutrition Report 2018

[14] United Nations (UN). Worldometer, Pakistan Population (Live). 2020

[15] The World Bank. Repositioning Nutrition as Central to Development. Washington, D.C; 2006

*Malnutrition's Prevalence and Associated Factors DOI: http://dx.doi.org/10.5772/intechopen.104455*

[16] The World Bank. Available from: http://data.worldbank.org/country/ pakistan [Accessed February 1, 2015]

[17] World Health Organization. Country Cooperation Strategy at a Glance-Pakistan (2011) http://www.who.int/ countryfocus/cooperation\_strategy/ ccsbrief\_pak\_en.pdf [Accessed November 12, 2014]

[18] United Nations Children's Fund. Situation Analysis of Children and Women in Pakistan. Islamabad: UNICEF; 2012

[19] Chika H, Julia K, Richard K, Vrinda M, Mercedes d O, Elaine B, et al. Joint Malnutrition Estimates 2017 Edition—Worldwide. UNICEF-WHO-WB; 2017 Available from: http:// public.tableau.com/views/JointMalnutrit ionEstimates2017Edition-Wide/WB

[20] Chandrasekhar S, Aguayo VM, Krishna V, Nair R. Household food insecurity and children's dietary diversity and nutrition in India. Evidence from the comprehensive nutrition survey in Maharashtra. Maternal & Child Nutrition. 2017;**13**(Suppl 2):e12447. DOI: 10.1111/mcn.12447

[21] World Health Organization and UNICEF. Who child growth standards and the identification of severe acute malnutrition in infants and children. In: Who Child Growth Standards and the Identification of Severe Acute Malnutrition in Infants and Children; Department of Nutrition Health and Development. Switzerland: World Health Organization and UNICEF; 2009

[22] Woldeamanuel BT, Tesfaye TT. Risk factors associated with under-five stunting, wasting, and underweight based on Ethiopian demographic health survey datasets in Tigray region, Ethiopia. Journal of Nutrition

and Metabolism. 2019;**2019**:1-11. DOI: 10.1155/2019/6967170

[23] National Institute of Population Studies—NIPS/Pakistan, ICF. Pakistan demographic and health survey 2017- 18. In: Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan: NIPS/Pakistan and ICF; 2019. Available from: http://dhsprogram. com/publications/Citing-DHS-Publications.cfm The 2017-2018 Pakistan Demographic and Health Survey (2017- 2018 PDHS) was implemented by the National Institute of Population Studies (NIPS) under the aegis of the Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan. ICF provided technical assistance through The DHS Program, a project funded by the United States Agency for International Development (USAID) that provides support and technical assistance in the implementation of population and health surveys in countries worldwide. Support for the survey was also provided by the Department for International Development (DFID) and the United Nations Population Fund (UNFPA)

[24] Quinn MK, Smith ER, Williams PL, Urassa W, Shi J, Msamanga G, et al. The effect of maternal multiple micronutrient supplementation on female early infant mortality is fully mediated by increased gestation duration and intrauterine growth. The Journal of Nutrition. 2019;**150**(2):356-363. DOI: 10.1093/Jn/ nxz246

[25] Rytter MJH, Kolte L, Briend A, Friis H, Christensen VB. The immune system in children with malnutrition—A systematic review. PLoS One. 2014;**9**(8):e105017. DOI: 10.1371/journal. pone.0105017

[26] Ibrahim MK, Zambruni M, Melby CL, Melby PC. Impact of childhood malnutrition on host defense and infection. Clinical Microbiology Reviews. 2017;**30**(4):919-971. DOI: 10.1128/CMR.00119-16

[27] Xie W, Jensen SKG, Wade M, Kumar S, Westerlund A, Kakon SH, et al. Growth faltering is associated with altered brain functional connectivity and cognitive outcomes in urban Bangladeshi children exposed to early adversity. BMC Medicine. 2019;**17**(1):199. DOI: 10.1186/ s12916-019-1431-5

[28] Vonaesch P, Randremanana R, Gody J-C, Collard J-M, GilesVernick T, Doria M, et al. Identifying the etiology and pathophysiology underlying stunting and environmental enteropathy: Study protocol of the AFRIBIOTA project. BMC Pediatrics. 2018;**18**(1):236. DOI: 10.1186/ s12887-018-1189-5

[29] Tay L, Chua M, Ding YY. Depressive Symptoms and Malnutrition Are Associated with Other Geriatric Syndromes and Increase Risk for 30-Day Readmission in Hospitalized Older Adults: A Prospective Cohort Study. 2022

[30] Martínez-Escribano C, Arteaga Moreno F, Pérez-López M, Cunha-Pérez C, Belenguer-Varea Á, Cuesta Peredo D, et al. Malnutrition and increased risk of adverse outcomes in elderly patients undergoing elective colorectal Cancer surgery: A case-control study nested in a cohort. Nutrients. 2022;**14**(1):207

[31] Cederholm T, Barazzoni R, Austin P, et al. Clinical Nutrition. 2017;**36**:49-64

[32] Moradi S, Mirzababaei A, Mohammadi H, Moosavian SP, Arab A, Jannat B, et al. Food insecurity and the risk of undernutrition complications among children and adolescents: A systematic review and meta-analysis. Nutrition. 2019;**62**:52-60. DOI: 10.1016/j. nut.2018.11.029

[33] FAO, IFAD, UNICEF, and WHO. The state of food security and nutrition in the world 2018. Building climate resilience for food security and nutrition. In: The State of Food Security and Nutrition in the World 2018. Building Climate Resilience for Food Security and Nutrition. Rome: FAO; 2018

[34] Ministry of Finance, Government of Pakistan. Pakistan Economic Survey 2018-2019. Islamabad, Pakistan: Ministry of Finance, Government of Pakistan; 2019

[35] Government of Pakistan, UNICEF, and UK Aid. Cost of the diet analysis report in Pakistan. In: Cost of the Diet Analysis Report in Pakistan. Islamabad, Pakistan: Government of Pakistan, UNICEF, and UK Aid; 2018

[36] USAID. Food assistance fact sheet Pakistan. In: Food Assistance Fact Sheet Pakistan. 2019

[37] Weaver LJ, Hadley C. Moving beyond hunger and nutrition: A systematic review of the evidence linking food insecurity and mental health in developing countries. Ecology of Food and Nutrition. 2009;**48**(4):263-284. DOI: 10.1080/03670240903001167

[38] Maselko J, Bates L, Bhalotra S, Gallis JA, O'Donnell K, Sikander S, et al. Socioeconomic status indicators and common mental disorders: Evidence from a study of prenatal depression in Pakistan. SSM— - Population Health. 2018;**4**:1-9. DOI: 10.1016/j. ssmph.2017.10.004

[39] WHO, UNICEF. Indicators for Assessing Infant and Young Child Feeding Practices: Definitions and Measurement Methods. Geneva: World Health Organization and the United Nations Children's Fund (UNICEF); 2021

*Malnutrition's Prevalence and Associated Factors DOI: http://dx.doi.org/10.5772/intechopen.104455*

[40] Food and Agriculture Organization. The Impact of Disasters and Crises on Agriculture and Food Security. Rome: Food and Agriculture Organization of the United Nations; 2018

[41] Thurstans S, Opondo C, Seal A, Wells J, Khara T, Dolan C, et al. Boys are more likely to be undernourished than girls: A systematic review and meta-analysis of sex differences in undernutrition. BMJ Global Health. 2020;**5**:e004030

[42] Kismul H, Acharya P, Mapatano MA, Hatløy A. Determinants of childhood stunting in the Democratic Republic of Congo: Further analysis of demographic and health survey 2013-14. BMC Public Health. 2018;**18**(1):74

[43] Akombi BJ, Agho KE, Hall JJ, Merom D, Astell-Burt T, Renzaho A. Stunting and severe stunting among children under-5 years in Nigeria: A multilevel analysis. BMC Pediatrics. 2017;**17**(1):15. DOI: 10.1186/ s12887-016-0770-z

[44] Akombi BJ, Agho KE, Renzaho AM, Hall JJ, Merom DR. Trends in socioeconomic inequalities in child undernutrition: Evidence from Nigeria demographic and health survey (2003- 2013). PLoS One. 2019;**14**(2):e0211883. DOI: 10.1371/journal.pone.0211883

[45] Mushtaq MU, Gull S, Khurshid U, Shahid U, Shad MA, Siddiqui AM. Prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children. BMC Public Health. 2011;**11**(1):790. DOI: 10.1186/1471-2458-11-790

[46] Khan S, Zaheer S, Safdar NF. Determinants of stunting, underweight and wasting among children < 5 years of age: Evidence from 2012-2013 Pakistan

demographic and health survey. BMC Public Health. 2019;**19**(1):358

[47] Shafiq A, Hussain A, Asif M, Hwang J, Jameel A, Kanwal S. The effect of "women's empowerment" on child nutritional status in Pakistan. International Journal of Environmental Research and Public Health. 2019;**16**(22):4499. DOI: 10.3390/ ijerph16224499

[48] Alderman H, Headey DD. How important is parental education for child nutrition. World Development. 2017;**94**:448-464

[49] Arif GM, Bilquees F. (forthcoming) Pakistan Socio-Economic Survey (PSES). Islamabad: Pakistan Institute of Development Economics; 2001

[50] Arif GM, Ahmad M. Poverty across the agro-climatic zones in Pakistan. In: Paper Presented at the National Workshop on pro-Poor Intervention Strategies in Irrigated Agriculture in Asia: Pakistan; Organized by IWMI. 2001

[51] WHO. Obesity: Preventing and Managing the Global Epidemic. Rep. Of WHO Consultation on Obesity. Tech. Rep. Ser. #894. Geneva: WHO; 2000

[52] Comm. Nutr. Challenges of 21st Century. Global nutrition challenges: A life-cycle approach. Food and Nutrition Bulletin. 2000;**21**(Suppl):18-34

[53] Tette EMA, Sifah EK, Nartey ET. Factors affecting malnutrition in children and the uptake of interventions to prevent the condition. BMC Pediatrics. 2015;**15**(1):189. DOI: 10.1186/ s12887-015-0496-3

[54] Islam MR, Rahman MS, Rahman MM, Nomura S, de Silva A, Lanerolle P, et al. Reducing childhood malnutrition in Bangladesh: The

importance of addressing socioeconomic inequalities. Public Health Nutrition. 2020;**23**(1):72-82. DOI: 10.1017/S136898001900140X

[55] Watson S, Gong YY, Routledge M. Interventions targeting child undernutrition in developing countries may be undermined by dietary exposure to aflatoxin. Critical Reviews in Food Science and Nutrition. 2015;**57**(9):1963-1975. DOI: 10.1080/10408398.2015.1040869

[56] Kartin A, Subagio HW, Hadisaputro S, Kartasurya MI, Suhartono S, Budiyono B. Pesticide exposure and stunting among children in agricultural areas. International Journal of Occupational and Environmental Medicine. 2019;**10**(1):17-29. DOI: 10.15171/ijoem.2019.1428

[57] Young SL, Frongillo EA, Jamaluddine Z, Melgar-Quiñonez H, Pérez-Escamilla R, Ringler C, et al. Perspective: The importance of water security for ensuring food security, good nutrition, and well-being. Advances in Nutrition. 2021;**12**:1058-1073

[58] PCRWR, Resources PCoRiW (PCRWR). Water Quality Status of Major Cities of Pakistan 2015-16. In: Technology MoSa Editor. Water Quality Status of Major Cities of Pakistan 2015-16. Islamabad, Pakistan: PCRWR, Ministry of Science and Technology; 2016

[59] Gera T, Shah D, Sachdev HS. Impact of water, sanitation and hygiene interventions on growth, non-diarrheal morbidity and mortality in children residing in low- and middle-income countries: A systematic review. Indian Pediatrics. 2018;**55**(5):381-393. DOI: 10.1007/s13312-018-1279-3

[60] Iqbal NT, Syed S, Sadiq K, Khan MN, Iqbal J, Ma JZ, et al. Study of environmental enteropathy and malnutrition (seem) in Pakistan: Protocols for biopsy-based biomarker discovery and validation. BMC Pediatrics. 2019;**19**(1):247. DOI: 10.1186/ s12887-019-1564-x

[61] Harper KM, Mutasa M, Prendergast AJ, Humphrey J, Manges AR. Environmental enteric dysfunction pathways and child stunting: A systematic review. PLoS Neglected Tropical Diseases. 2018;**12**(1):e0006205. DOI: 10.1371/journal.pntd.0006205

[62] World Health Organization (WHO). Global nutrition targets 2025: Stunting policy brief. In: Global Nutrition Targets 2025: Stunting Policy Brief. WHO reference number: WHO/NMH/ NHD/143; Department of Nutrition for Health and Development. Geneva, Switzerland: World Health Organization; 2014

[63] Beal T, Tumilowicz A, Sutrisna A, Izwardy D, Neufeld LM. A review of child stunting determinants in Indonesia. Maternal & Child Nutrition. 2018;**14**(4):e12617. DOI: 10.1111/ mcn.12617

[64] Bhutta ZA, Gazdar H, Haddad L. Seeing the unseen: Breaking the logjam of undernutrition in Pakistan. IDS Bulletin. 2013;**44**(3):1-9. DOI: 10.1111/1759-5436.12025

[65] Goudet SM, Bogin BA, Madise NJ, Griffiths PL. Nutritional interventions for preventing stunting in children (birth to 59 months) living in urban slums in low- and middle-income countries (LMIC). Cochrane Database of Systematic Reviews. 2019;**6**:CD011695

[66] Angdembe MR, Dulal BP, Bhattarai K, Karn S. Trends and predictors of inequality in childhood stunting in Nepal from 1996 to 2016.

*Malnutrition's Prevalence and Associated Factors DOI: http://dx.doi.org/10.5772/intechopen.104455*

International Journal for Equity in Health. 2019;**18**(1):42. DOI: 10.1186/ s12939-019-0944-z

[67] Prado EL, Dewey KG. Nutrition and brain development in early life. Nutrition Reviews. 2014;**72**(4):267-284. DOI: 10.1111/nure.12102

[68] Bhutta ZA, Salam RA, Das JK. Meeting the challenges of micronutrient malnutrition in the developing world. British Medical Bulletin. 2013;**106**(1):7- 17. DOI: 10.1093/bmb/ldt015

[69] 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**(9890):452-477. DOI: 10.1016/S0140-6736(13)60996-4

[70] Niazi A, Niazi S, Baber A. Nutritional programs in Pakistan: A review. Journal of Medical Nutrition and Nutraceuticals. 2012;**1**(2):98-100. DOI: 10.4103/2278-019X.101297

[71] McGovern ME, Krishna A, Aguayo VM, Subramanian SV. A review of the evidence linking child stunting to economic outcomes. International Journal of Epidemiology. 2017;**46**(4):1171-1191. DOI: 10.1093/ije/ dyx017

[72] Fenn B, Sangrasi GM, Puett C, Trenouth L, Pietzsch S. The REFANI Pakistan study—A cluster randomized controlled trial of the effectiveness and cost-effectiveness of cash-based transfer programs on child nutrition status: Study protocol. BMC Public Health. 2015;**15**(1):1044. DOI: 10.1186/ s12889-015-2380-3

[73] Wang X, Taniguchi K. Does better nutrition enhance economic growth? The economic cost of hunger. In: Taniguchi K, editor. Nutrition Intake and Economic Growth. Rome: FAO; 2003 Available from: www.fao.org/docrep/006/y4850e/ y4850e04.htm

[74] Headey D. Turning economic growth into nutrition-sensitive growth. In: 2020 Conference, Leveraging Agriculture for Improving Nutrition and Health; New Delhi, India. 2011. p. 6 Available from: http://www.ifpri.org/sites/default/files/ publications/oc69ch05.pdf

[75] Garcia V. Children Malnutrition and Horizontal Inequalities in Sub-Saharan Africa: A Focus on Contrasting Domestic Trajectories. Addis Ababa: UNDP Regional Bureau; 2012 working paper 2012-2019. Available from: http:// www.undp.org/…/rba/…/Child%20 Malnutrition%20and%20Inequality.p…

[76] Arnold C, Conway T, Greenslade M. Cash Transfers: Evidence Paper. London: Department for International Development; 2011 Available from: http://www.gsdrc.org/go/display&type5 Document&id54104

[77] Ruel MT, Alderman H. Maternal and child nutrition study group. Nutritionsensitive interventions and programs: How can they help accelerate progress in improving maternal and child nutrition? Lancet. 2013;**382**:336-351

[78] Manley J, Gitter S, Slavchevska V. How Effective Are Cash Transfer Programmes at Improving Nutritional Status? University of London, EPPI Social Sciences Research Unit, Institute of Education; 2012 Available from: http://www.r4d.dfid.gov.uk/PDF/ Outputs/…/Q33-Cash-transfers-2012Manley-rae.pd

### **Chapter 8**

## Perspective Chapter: Early Diagnosis of Malnutrition

*Tomiyo Nakamura and Hiroshi Imamura*

### **Abstract**

Low body mass index (BMI) and unintentional weight loss are the criteria used in many nutritional screening tools (NSTs) to identify the nutritional status of patients and the elderly. However, in hospitals, nursing homes, and communities, weight is often unmeasured. Therefore, we researched the current situation of inadequate nutritional screening due to a lack of weight measurements and what should be done to improve this situation. We conducted a narrative review of peer-reviewed research on nutritional screening, NSTs, missing NST parameters, regular weight measurements, awareness of malnutrition among physicians and others, and nutrition support based on PubMed and J-stage. The NSTs included mostly weight or weight-based parameters (BMI and weight loss). Our findings suggest that, since patients and the elderly do not weigh themselves regularly, they are unaware of their weight loss and do not receive proper nutritional care. The results also show that physicians do not often recognize nutritional problems that require nutritional intervention and do not order nutritional intervention by dietitians. Moreover, patients and community residents at risk of malnutrition do not recognize anorexia and weight loss as nutritional problems. Multidisciplinary and collaborative nutritional interventions are needed to reduce the risk of malnutrition in patients and the elderly.

**Keywords:** malnutrition, weight loss, nutrition screening, nutritional intervention, weight measurement

### **1. Introduction**

Malnutrition in patients and the elderly decreases the activities of daily living and the quality of life, and it contributes to infections and delayed healing due to reduced immunity, which affects patient prognosis and survival [1]. Therefore, it is important to identify malnutrition at an early stage and provide appropriate nutritional care.

A variety of nutritional screening tools (NSTs) have been developed to identify malnutrition in patients and the elderly, and many tools and their diagnostic accuracies have been reported [2–6]. The parameters of NSTs are generally categorized into anthropometric, biochemical, clinical, dietary assessment, psychological, social, and physical parameters [7]. Most NSTs include anthropometric measurements, especially weight and weight-based parameters (body mass index [BMI] and weight loss).

The Global Leadership Initiative on Malnutrition (GLIM), developed in June 2018 with the participation of four societies in Europe, the United States, Asia, and

South America, suggests the evaluation of the possibility of malnutrition by assessing phenotypic and etiologic criteria if a validated screening tool determines a patient is at risk [8]. The phenotypic criteria are (1) unintentional weight loss, (2) low BMI, and (3) reduced muscle mass, and the etiologic criteria are (1) reduced food intake or assimilation and (2) inflammation or disease burden. If any of these phenotypic or etiologic criteria are met, a diagnosis of malnutrition is established, and the severity is proposed according to phenotypic metrics. Thus, low BMI and weight loss are not only NSTs, they are also essential components of the GLIM criteria and are equal or more important nutritional parameters compared with other measures of nutrition. Therefore, if the weight of patients and elderly people are not measured and low BMI and unintentional weight loss are not assessed, there is a possibility that truly undernourished patients will not be identified.

Low BMI and unintentional weight loss are the criteria used in many NSTs to identify the nutritional status of patients and the elderly. Unintentional weight loss, a characteristic of malnutrition, is associated with a loss of skeletal muscle mass and increases the risk of sarcopenia, which is characterized by a loss of both muscle mass and muscle strength and function [9]. For this reason, it is important to identify unintentional weight loss.

However, in hospitals, nursing homes, and communities, bodyweight, which is required for evaluating nutritional parameters such as low BMI and unintentional weight loss, is often not measured [10–12]. This has led to the inadequate nutritional screening of patients and the elderly and has caused cases of malnutrition to be overlooked. Therefore, we researched the current situation of inadequate nutritional screening due to the lack of weight measurements to identify strategies to improve this situation.

We conducted a narrative review of peer-reviewed research on nutritional screening, missing NST parameters, regular weight measurements, awareness of malnutrition among physicians and others, and nutrition support from 2010 to 2021 using PubMed and J-stage [13]. Regarding NSTs, the major ones are listed, without any limitations on date.

## **2. Major validated nutritional screening tools**

This section reviews the parameters for assessing the nutritional status of major validated NSTs. Nutritional screening is the first step in nutrition management. A validated NST should be used to identify patients and older adults at nutritional risk, perform a nutritional assessment, and initiate an appropriate intervention for nutrition support.

A systematic review of NSTs for the hospital setting identified 32 different NSTs, most of which were reported to include low BMI and weight loss [14]. Another systematic review reported that 16 NST parameters were categorized as anthropometric, biochemical, clinical, dietary assessment, psychological, social, and physical parameters [7]. In the NSTs, 93% included physical measurements, especially weight or weight-based parameters (BMI and weight loss), and only 12% included biochemical parameters [7]. The commonly NSTs used are described below [2–6].

1.Malnutrition Screening Tool (MST)

The MST is a simple tool designed by Ferguson et al. which inquires only about weight loss and appetite loss [2].

## 2.Malnutrition Universal Screening Tool (MUST)

MUST is an NST developed by the British Society of Venous and Enteral Nutrition [3]. The total score of four items (BMI, weight loss, acute illness, and inadequate nutritional intake) is used to determine low, medium, or high risk.

## 3.Nutritional Risk Screening 2002 (NRS2002)

NRS2002 is an NST developed by the European Society for Clinical Nutrition and Metabolism in 2002, and it is mainly used in acute care [4]. It consists of an initial screening consisting of four items: BMI, weight loss, decreased dietary intake, and the presence of severe disease, and a final screening consisting of nutritional impairment, disease severity, and age-related scores.

## 4.Mini Nutritional Assessment Short-Form (MNA-SF)

The Mini Nutritional Assessment (MNA) was developed to evaluate certain subgroups, especially the elderly, before overt changes in weight or albumin occur [5]. The MNA-SF was later designed to provide a simpler and more practical screening tool [6]. It consists of six items. Each indicator is scored from 0 to 2 or 3, and the total score is used to determine whether the patient has a normal nutritional status, is at risk of malnutrition, or is malnourished.


*BMI, body mass index; MUST, Malnutrition Universal Screening Tool; NRS2002, Nutritional Risk Screening 2002; MNA-SF, Mini Nutritional Assessment Short-Form.*

#### **Table 1.**

*Screening scores for each indicator in the major nutritional screening tools.*

**Table 1** shows the screening scores for each indicator in the three NSTs. All three NSTs assess weight loss, BMI, and food intake. In these three NSTs, only MNA-SF can be assessed even if weight loss is unknown. The duration and amount of weight loss for the three NSTs are not standardized, but a weight loss of 5% within 3 months may be the standard.

Thus, the parameters of NST include mostly weight or weight-based parameters (BMI and weight loss). This suggests the importance of regular nutritional screening and regular weight measurements for identifying malnutrition.

However, some patients and the elderly are unable to measure their own weight. Therefore, the advantage of the MNA-SF is that it can measure the calf circumference (CC) instead of BMI for elderly people who have difficulty measuring their height and weight [6]. However, Kostka et al. evaluated the usefulness of the MNS-SF in different elderly populations in Poland and concluded that BMI is more useful than CC [15]. For this reason, CC should be used only when BMI cannot be measured, and weight should be measured when possible.


*BMI, Body Mass Index; MUST, Malnutrition Universal Screening Tool; ESPEN, European Society for Clinical Nutrition and Metabolism; MNA-SF, Mini Nutritional Assessment Short-Form; NRS2002, Nutritional Risk Screening 2002; NST, Japan Nutritional Screening Tool; nDay Survey, nutritionDay Survey.*

#### **Table 2.**

*Screening scores for each indicator in the major nutrition screening tools.*

## **3. Deficiencies in nutrition screening parameters**

This section reviews the proportion of patients and residents assessed by NSTbased nutritional screening in hospitals, nursing homes, and the community. **Table 2** shows the screening scores for each indicator of the major NSTs.

Neelemaat et al. compared five MSTs for patients in one hospital and found that 47% of the data were missing for MUST and 41% were missing for MNA-SF [10]. They also reported that MUST had low applicability due to the high rate of missing data, while the MNA-SF showed excellent sensitivity but low specificity.

Henriksen et al. attempted to quantify the frequency of malnutrition and the proportion of malnourished patients in two university hospitals in Norway using data from the nDay survey [16]. However, they reported that BMI could be calculated for only two-thirds of the patients because weight and height data were often missing from the patient records.

Ostrowska et al. compared results from all European countries participating in the nDay survey with those from Poland [17]. The results showed that 64% of the data on weight loss within 3 months were missing in both Europe and Poland, and several elements of the nutritional management process in Polish hospitals were inadequate. These results indicate that not all hospital inpatient weight data are available.

Graeb et al. analyzed data from a total of 2058 residents of 19 nursing homes who were hospitalized for more than 3 days in order to determine the causes of their malnutrition risk [11]. The results suggested that the actual prevalence of malnutrition and the risk of malnutrition may still be underestimated, as the last weight measured was a long time ago and some residents did not have access to their weight history prior to hospitalization.

Torbahn et al. investigated predictors of malnutrition in nursing home residents aged 65 years and older who participated in the nDay survey from 2007 to 2018 [19]. They excluded 20,443 (51.3%) of the 39,840 residents with no data on bodyweight at follow-up. This study shows that most nursing homes do not regularly measure the weight of their residents.

Lahmann et al. conducted a multicenter prevalence study of 878 randomly selected clients from 100 randomly selected home care services in Germany in 2012 [12]. They reported that there were many missing values in both NSTs (MNA-SF 48.8%, MUST 39.1%) because many clients did not provide information on weight loss over the past 3–6 months. This finding also emphasizes the need for home care clients to be weighed on a regular basis, so that potential weight loss can be identified early.

Nakamura et al. conducted nutritional screening of the community's elderly at a daycare facility, but 79% of the participants had no past weight history and their weight loss could not be calculated [20].

Mikkelsen et al. analyzed individual semi-structured interviews of general practitioners and focus group interviews of clinic nurses [21]. They reported that general practices did not routinely identify disease-related malnutrition and rarely saw patients with unintended weight loss.

The results of these studies suggest that many elderly and chronically ill patients in the community do not weigh themselves regularly, are unaware of their weight loss, and do not receive appropriate nutritional care.

**Table 3** shows the routine weight measurements in hospitals and nursing homes.


#### **Table 3.**

*Routine weight measurements in hospitals and home care services.*

Cereda et al. reviewed the data on nutritional care routines collected in the Project: Iatrogenic MAlnutrition in Italy (PIMAI) study [22]. The results showed that only 38.2% of the patients had their BMI calculated based on their care in the wards. Nutritional support was prescribed only in 26/191 (13.6%) patients who presented with obvious malnutrition. In addition, only 21.6% of patients had their weight monitored according to a schedule. They concluded that the routine of nutritional care in Italy is still poor and needs to be improved.

Ostrowska et al. compared results from all European countries participating in the nDay survey with those from Poland and found that the patients' weight was recorded on admission (100% vs. 72.9%; p < 0.0001), weekly (20% vs. 41.4%; p < 0.05), and occasionally (0% vs. 9.2%) [18].

Lahmann et al. reported that the rate of routine weight measurement in 100 homecare services in Germany ranged from 33.6% to 57.3% [12]. These findings suggest that not many of the elderly people living in the community are weighed on a regular basis.

Reports indicate that 89% of dietitians use weight to solve nutrition problems in malnourished community members, and 87% use BMI as an outcome measure for successful nutritional intervention [23]. Furthermore, regular weight measurements are essential for successful nutritional screening and interventions by dietitians in order to solve the nutritional problems of community residents.

## **4. Awareness of malnutrition, nutritional screening, or nutrition support**

This section reviews the perceptions of healthcare providers, staff, patients, residents, and families toward malnutrition, nutritional screening, and nutrition support. We performed a PubMed search using the keywords malnutrition, nutrition screening, nutrition support, and awareness. The results are shown in **Table 4**.


#### **Table 4.**

*Awareness of malnutrition, nutritional screening, and nutrition support.*

Caccialanza et al. noted that there may be a lack of awareness and consideration of nutritional issues among oncologists in Italy, as only 5.7% of the 2375 members participated in the survey [24].

Deftereos et al. conducted a national survey of clinicians with the goal of identifying interdisciplinary clinician practices, perceptions, and perspectives on screening for malnutrition and providing nutritional support for patients undergoing surgery for upper gastrointestinal cancer [25]. The results showed that most participants reported that overall dietary support was available at their healthcare service (98%), but only 41% reported it was available through outpatient services.

Morimoto et al. conducted a web-based questionnaire survey of 500 oncologists [26]. Among the responses, the most common causes of anorexia and weight loss were symptoms due to systemic inflammation caused by cancer (58.8%), and the second most common cause was side effects of anticancer drugs (49.0%). The most common intervention was the prescription of antiemetics (69.7%), and the second most common intervention was teaching patients how to eat recommended foods (49.8%).

Avgerinou et al. conducted a qualitative study using semi-structured interviews to investigate the views of community-dwelling older adults and their caregivers regarding the management of malnutrition [27]. The results showed that older adults at risk of malnutrition rarely recognized lack of appetite or weight loss as a problem.

A web questionnaire survey of cancer patients by Morimoto et al. reported that 38.3% of patients and 46.4% of family members stated they became concerned about weight loss only after a cancer diagnosis [26]. **Figure 1** shows the causes of weight loss during cancer treatment based on patients' perceptions. The patients considered the effects of surgery and the side effects of anticancer drugs as the two most common causes of weight loss.

#### **Figure 1.**

*Responses to a question to patients: "What do you think are the major causes of weight loss during cancer treatment?" (Multiple answers) (n = 538). (Adapted from [26]).*

#### **Figure 2.**

*Responses to a question to patients: "Do you have any trouble with weight loss? (Multiple answers) (n = 361). (Adapted from [26]).*

**Figure 2** presents patients' concerns about weight loss, and 60% of the patients responded that they were unconcerned. Morimoto et al. reported that 42.1% of the patients reported or consulted their doctors or nurses about their weight loss, while 66.5% of those who did not seek consultation reported that they did not think it was something to be concerned about.

These results indicate that physicians do not recognize nutritional problems that require nutritional intervention and do not order for nutritional intervention by dietitians and that patients and community residents at risk of malnutrition do not recognize anorexia and weight loss as nutritional problems.

## **5. Nutrition supports for preventing malnutrition**

Despite the development of various NSTs and the provision of clinical guidelines recommending regular nutritional screening, malnutrition in patients and the elderly remain unrecognized because regular weight measurements, an integral part of nutritional screening, are not performed. To improve this, various nutrition interventions for staff and community residents have been considered. In this section, these nutrition interventions are presented.

Everink et al. compared the prevalence of malnutrition among nursing home residents in the Netherlands in 2009, 2013, and 2018 [28]. They reported that the prevalence of malnutrition was relatively stable at approximately 16% and that it was unclear whether nursing staff were adequately aware of malnourished (at-risk) residents and the interventions that could be implemented to reduce this occurrence.

Charlton et al. evaluated the adoption of a nutrition care model for older adults designed to improve the detection and management of malnutrition [29]. A systematic review aimed at assessing the effectiveness of nutritional interventions on frailty and frailty-related factors (e.g., malnutrition, sarcopenia, functional capacity) in community-dwelling older adults concluded that multifactorial interventions are more effective than nutritional interventions alone in improving frailty and physical performance [30].

A narrative review that aimed to identify practical conclusions to support the interdisciplinary management of malnutrition in cancer patients suggested that knowledge sharing between oncologists and dietitians can help to successfully address and treat malnutrition in this population [31].

Imamura et al. suggest that postoperative weight loss may affect chemotherapy compliance and may be a risk factor for survival [32]. They reported that patients receiving adjuvant chemotherapy with oral elemental nutritional supplements had increased treatment completion.

Considering these various nutritional interventions, it is necessary to improve the assessment and treatment of malnutrition in patients and the elderly.

## **6. Limitation**

This chapter was a narrative review of peer-reviewed research on nutritional screening, NST, missing NST parameters, regular weight measurements, awareness of malnutrition, and nutrition support. However, only a few studies addressed the missing parameters, missing data, or lack of awareness itself. For this reason, relevant reports were examined one by one in detail, which could have led to a selection bias in the literature retrieved.

### **7. Conclusion**

The findings of this research suggest that patients and the elderly do not weigh themselves regularly, are unaware of their weight loss, and do not receive proper nutritional care. The early diagnosis of malnutrition through routine weighing and nutritional screening and interdisciplinary and collaborative nutritional interventions are necessary to reduce the risk of malnutrition in patients and the elderly.

## **Conflicts of interest**

The authors declare no conflicts of interest.

## **Author details**

Tomiyo Nakamura1 \* and Hiroshi Imamura<sup>2</sup>

1 Department of Food Science and Human Nutrition, Ryukoku University, Otsu, Japan

2 Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan

\*Address all correspondence to: tomiyo@agr.ryukoku.ac.jp

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Early Diagnosis of Malnutrition DOI: http://dx.doi.org/10.5772/intechopen.104655*

## **References**

[1] Hirose T, Hasegawa J, Izawa S, Enoki H, Suzuki Y, Kuzuya M. Accumulation of geriatric conditions is associated with poor nutritional status in dependent older people living in the community and in nursing homes. Geriatrics & Gerontology International. 2014;**14**:198-205. DOI: 10.1111/ggi.12079

[2] Ferguson ML, Bauer J, Gallagher B, Capra S, Christie DR, Mason BR. Validation of a malnutrition screening tool for patients receiving radiotherapy. Australasian Radiology. 1999;**43**:325-327. DOI: 10.1046/j. 1440-1673.1999.433665.x

[3] MAG. Malnutrition Action Group (MAG) (a standing committee of the British Association for Parenteral and Enteral Nutrition): The" MUST" explanatory booklet. [Internet]. 2011. Available from: http://www.bapen. org.uk/pdfs/must/must\_explan.pdf [Accessed March 11, 2021]

[4] Kondrup J, Rasmussen HH, Hamberg O, Stanga Z, Ad Hoc ESPEN Working Group. Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials. Clinical Nutrition. 2003;**22**:321- 336. DOI: 10.1016/s0261-5614(02) 00214-5

[5] Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature: What does it tell us? The Journal of Nutrition, Health & Aging. 2006;**10**:466-485

[6] Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): A practical tool for identification of nutritional status. The Journal of

Nutrition, Health & Aging. 2009;**13**:782- 788. DOI: 10.1007/s12603-009-0214-7

[7] Johnson S, Siddique A, Hyer K. Review and analysis of indicators in nutrition screening tools that identify malnutrition among long term care residents. Journal of Nursing Home Research. 2017;**3**:88-98. DOI.org/10.14283/jnhrs.2017.14

[8] Cederholm T, Jensen GL, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition: A consensus report from the global clinical nutrition community. Clinical Nutrition. 2019;**38**:1-9. DOI: 10.1016/j.clnu.2018.08.002

[9] Kalyani RR, Corriere M, Ferrucci L. Age-related and disease-related muscle loss: The effect of diabetes, obesity, and other diseases. The Lancet Diabetes and Endocrinology. 2014;**2**:819-829. DOI: 10.1016/S2213-8587(14)70034-8

[10] Neelemaat F, Meijers J, Kruizenga H, van Ballegooijen H, Schueren M. Comparison of five malnutrition screening tools in one hospital inpatient sample. Journal of Clinical Nursing. 2011;**20**:2144-2152. DOI: 10.1111/j.1365-2702.2010.03667.x

[11] Graeb F, Wolke R, Reiber P. Gewichtsverluste und Mangelernährungsrisiko bei geriatrischen PatientInnen [Weight loss and malnutrition risk in geriatric patients]. Zeitschrift für Gerontologie und Geriatrie. 2021;**54**:789-794

[12] Lahmann NA, Tannen A, Suhr R. Underweight and malnutrition in home care: A multicenter study. Clinical Nutrition. 2016;**35**:1140-1146. DOI: 10.1016/j.clnu.2015.09.008

[13] J-Stage. [Internet]. 2021. Available from: https://www.jstage.jst.go.jp/ browse/-char/en [Accessed March 11, 2021]

[14] Schueren MA, Guaitoli PR, Jansma EP, de Vet HC. Nutrition screening tools: Does one size fit all? A systematic review of screening tools for the hospital setting. Clinical Nutrition. 2014;**33**:39-58. DOI: 10.1016/j. clnu.2013.04.008

[15] Kostka J, Borowiak E, Kostka T. Validation of the modified mini nutritional assessment short-forms in different populations of older people in Poland. The Journal of Nutrition, Health & Aging. 2014;**18**:366-371. DOI: 10.1007/ s12603-013-0393-0

[16] Henriksen C, Gjelstad IM, Nilssen H, Blomhoff R. A low proportion of malnourished patients receive nutrition treatment—Results from nutritionDay. Food & Nutrition Research. 2017;**61**:1391667. DOI: 10.1080/16546628.2017.1391667

[17] Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, et al. Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clinical Nutrition. 2015;**34**:335-340. DOI: 10.1016/j.clnu.2015.03.001

[18] Ostrowska J, Sulz I, Tarantino S, Hiesmayr M, Szostak-Węgierek D. Hospital malnutrition, nutritional risk factors, and elements of nutritional care in Europe: Comparison of Polish results with all European countries participating in the nDay Survey. Nutrients. 2021;**13**:263. DOI: 10.3390/nu13010263

[19] Torbahn G, Sulz I, Großhauser F, Hiesmayr MJ, Kiesswetter E, Schindler K, et al. Predictors of incident malnutrition-a nutritionDay analysis in 11,923 nursing home residents. European Journal of

Clinical Nutrition. 2022;**76**:382-388. DOI: 10.1038/s41430-021-00964-9

[20] Nakamura T, Yabe A, Imai S, Fujimura Y, Mizokami Y, Nakayama N, et al. Effects of weight loss as a nutrition screening tool parameter on nutrition risk assessment in day care facilities: A cross-sectional study. Journal of the Japan Dietetic Association. 2021;**64**:97- 104. DOI: 10.11379/jjda.64.97

[21] Mikkelsen S, Geisler L, Holst M. Healthcare professionals' experiences with practice for managing diseaserelated malnutrition in general practice and proposals for improvement: A qualitative study. Scandinavian Journal of Caring Sciences. 2021. Online ahead of print. DOI: 10.1111/scs.13033

[22] Cereda E, Lucchin L, Pedrolli C, D'Amicis A, Gentile MG, Battistini NC, et al. Nutritional care routines in Italy: Results from the PIMAI (Project: Iatrogenic MAlnutrition in Italy) study. European Journal of Clinical Nutrition. 2010;**64**:894-898. DOI: 10.1038/ ejcn.2010.85

[23] Allmark G, Calder PC, Marino LV. Research identified variation in nutrition practice by community prescribing dietitians with regards to the identification and management of malnutrition amongst community dwelling adults. Nutrition Research. 2020;**76**:94-105. DOI: 10.1016/j. nutres.2019.10.005

[24] Caccialanza R, Cereda E, Pinto C, Cotogni P, Farina G, Gavazzi C, et al. Awareness and consideration of malnutrition among oncologists: Insights from an exploratory survey. Nutrition. 2016;**32**:1028-1032. DOI: 10.1016/j. nut.2016.02.005

[25] Deftereos I, Kiss N, Brown T, Carey S, Carter VM, Usatoff V, et al. *Perspective Chapter: Early Diagnosis of Malnutrition DOI: http://dx.doi.org/10.5772/intechopen.104655*

Awareness and perceptions of nutrition support in upper gastrointestinal cancer surgery: A national survey of multidisciplinary clinicians. Clinical Nutrition ESPEN. 2021;**46**:343-349. DOI: 10.1016/j.clnesp.2021.09.734

[26] Morimoto T, Machii K, Matsumoto H, Takai S. Web questionnaire survey on appetite loss and weight loss associated with cancer cachexia Japanese Evidence for Patients Of Cancer Cachexia (J-EPOCC)-The problem awareness of appetite loss and weight loss. Gan to Kagaku Ryoho. 2020;**47**:947-953

[27] Avgerinou C, Bhanu C, Walters K, Croker H, Liljas A, Rea J, et al. Exploring the views and dietary practices of older people at risk of malnutrition and their carers: A qualitative study. Nutrients. 2019;**11**:1281. DOI: 10.3390/nu11061281

[28] Everink IHJ, van Haastregt JCM, Manders M, van der Schueren MAE, Schols JMGA. Malnutrition prevalence rates among Dutch nursing home residents: What has changed over one decade? A comparison of the years 2009, 2013 and 2018. The Journal of Nutrition, Health & Aging;**2021**(25):999-1005. DOI: 10.1007/s12603-021-1668-5

[29] Charlton K, Walton K, Brumerskyj K, Halcomb E, Hull A, Comerford T, et al. Model of nutritional care in older adults: Improving the identification and management of malnutrition using the Mini Nutritional Assessment-Short Form (MNA®-SF) in general practice. Australian Journal of Primary Health. 2022;**28**:23-32. DOI: 10.1071/PY21053

[30] Beattie E, O'Reilly M, Strange E, Franklin S, Isenring E. How much do residential aged care staff members know about the nutritional needs of residents? International Journal of Older People Nursing. 2014;**9**:54-64. DOI: 10.1111/ opn.12016

[31] Khor PY, Vearing RM, Charlton KE. The effectiveness of nutrition interventions in improving frailty and its associated constructs related to malnutrition and functional decline among community-dwelling older adults: A systematic review. Journal of Human Nutrition and Dietetics. 2021. Online ahead of print. DOI: 10.1111/ jhn.12943

[32] Imamura H, Matsuyama J, Nishikawa K, Endo S, Kawase T, Kimura Y, et al. Osaka Gastrointestinal Cancer Chemotherapy Study Group (OGSG). Effects of an oral elemental nutritional supplement in gastric cancer patients with adjuvant S-1 chemotherapy after gastrectomy: Amulticenter, open-label, single-arm, prospective phase II study (OGSG1108). Annals of Gastroenterological Surgery. 2021;**5**:776- 784. DOI: 10.1002/ags3.12487

## **Chapter 9**
