**Chapter 3**

*Malnutrition*

[62] De Steur H, Wesana J,

2017b;**1390**:34-46

2014;**19**:724-742

Blancquaert D, van der Straeten D, Gellynck X. Methods matter: A metaregression on the determinants of willingness-to-pay studies on biofortified foods. Annals of the New York Academy of Sciences.

[63] Wesseler J, Zilberman D. The economic power of the Golden Rice opposition. Environment and Development Economics.

**20**

## Vitamins

*Mohanad Mousa Kareem and Majid S. Jabir*

### **Abstract**

This chapter is going to explain a part of the nutrients the human body needs. They are organic compounds called vitamins. Those compounds will be clarified, as well as their benefits, deficiencies, chemical structure, and why the body needs them crucially. Vitamins is an exceptionally vital recognized name required in certain amounts in the body, some of them exist as a complicated natural compounds found in herbal meals. It plays a key function in regular metabolism, the absence of which in the diet causes deficiency and several diseases. Vitamins are differentiated from the trace elements, also found in the weight-reduction plan in small quantities for health, growth, replica, and other crucial metabolism.

**Keywords:** vitamins, water-soluble vitamins, fat-soluble vitamins, deficiency, benefits, dosage

### **1. Introduction**

The human body is a magnificent machine, and to function well, the body needs certain supplements. Vitamins are one of the most essential elements for the body. There are nutrients that the body can make on its own, and there are others that the body is not able to make. Vitamins are one of the nutrients that the body is unable to make, so they must be consumed from aliments. Vitamins are an organic molecule, which is an essential micronutrient that an organism needs for its metabolism to function. They are divided into two groups, fat-soluble vitamins and water-soluble vitamins. The first group contains vitamins A, D, E, and K, while the second consists of thiamin (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxal, pyridoxamine, pyridoxine (B6), biotin-cobalamin (B12), folic acid, and ascorbic acid [1–10].

### **2. Fat-soluble vitamins**

They are a type that is absorbed well into the blood stream via fatty nourishments and are stored in limited amounts; they can be easy to separate and disposed out from the body through urine [8–10].

#### **2.1 Vitamin A**

Vitamin A is a yellow viscous liquid alicyclic alcohol C20H30O that contains one more double bond in a molecule than vitamin A1 and is less active biologically in mammals and that occurs especially in the liver oil of freshwater fish. It consists of three biologically active molecules, retinol, retinal (retinaldehyde), and retinoic acid, all derived from the plant precursor molecule, β-carotene (**Figure 1**) [11, 12].

**Figure 1.** *Types of vitamin A.*

Retinol also functions in the synthesis of certain glycoproteins and mucopolysaccharides necessary for mucous production and normal growth regulation. Retinol is the predominant, active form of vitamin A found in the blood. Retinyl palmitate is the storage form of the vitamin [13].

This vitamin is important to the body for playing an effective role in growth and development, the visual system, immunity, and reproduction as well as supplying epithelial cellular integrity. Most of the vitamin A is stored in the liver in the form of retinyl esters. Sources of vitamin A vary from vegetables to fruits and are found in animal-sourced foods, such as eggs, oily fish, liver, cheese, and butter. The lack of this vitamin can leave severe effects on the function of the body such as night blindness, decreased resistance to infections, and extremely dry skin, hair, or nails. Just deficiency can be harmful; the overuse of vitamin A can be toxic and lead to hypervitaminosis. An average dose of this vitamin needed for the body is 0.7 mg for men and 0.6 mg for women on a daily diet. Women who have been through menopause and older men, who are more at risk of osteoporosis, should avoid having more than 1.5 mg of vitamin A per day from food and supplements [7, 13, 14].

#### **2.2 Vitamin D**

Vitamin D is a steroid vitamin, which promotes the intestinal absorption and metabolism of calcium and phosphorus. There are two main types of vitamin D, Vitamin D2, which is synthesized by plants and is not created by the human body. Vitamin D3, which is made in large amounts in the skin when daylight strikes uncovered skin. Moreover, it can be ingested from animal sources. As well as there other types like ergosterol, dehydrocholesterol, and the biologically active form of the hormone 1,25-dihydroxy vitamin D3 termed calcitriol.

**23**

**Figure 2.** *Types of vitamin D.*

*Vitamins*

*DOI: http://dx.doi.org/10.5772/intechopen.92074*

tion and transport [15–17] (**Figure 2**).

Vitamin D is not active itself (it is a prohormone); it is modified to yield biologically active forms, such as calcitriol. Calcitriol (derived from vitamin D) is a transcription factor, influencing expression of proteins involved in calcium absorp-

Vitamin D is required to maintain normal blood levels of calcium and phosphate, which in turn is needed for the normal mineralization of the bone, muscle contraction, nerve conduction, general cellular function in all cells of the body and supporting lung function, and cardiovascular health. It may also protect against a range of diseases and conditions, such as type 1 diabetes. Vitamin D also modulates the transcription of cell cycle proteins, which decrease cell proliferation and increase cell differentiation of a number of specialized cells of the body (e.g., osteoclastic precursors, enterocytes, and keratinocytes). This property may explain the actions of vitamin D in bone resorption, intestinal calcium transport, and skin. Vitamin D also possesses immunomodulatory properties that may alter responses to infections in vivo. These cell-differentiating and immunomodulatory properties underlie the reason why vitamin D derivatives now are in use successfully in the treatment of psoriasis and other skin disorders. Oily fish, such as salmon, sardines, herring, and mackerel, contain a fair amount of vitamin D as well as red meat, liver, egg yolks, and fortified foods, such as most fat spreads and some breakfast cereals.

The simplest way to get all the vitamin D the body needs is from direct sunlight. The absence of this very vitamin in an adult daily diet can result in hypovitaminosis

Another source of vitamin D is dietary supplements [15–18].

#### *Vitamins DOI: http://dx.doi.org/10.5772/intechopen.92074*

*Malnutrition*

Retinol also functions in the synthesis of certain glycoproteins and mucopolysaccharides necessary for mucous production and normal growth regulation. Retinol is the predominant, active form of vitamin A found in the blood. Retinyl

This vitamin is important to the body for playing an effective role in growth and development, the visual system, immunity, and reproduction as well as supplying epithelial cellular integrity. Most of the vitamin A is stored in the liver in the form of retinyl esters. Sources of vitamin A vary from vegetables to fruits and are found in animal-sourced foods, such as eggs, oily fish, liver, cheese, and butter. The lack of this vitamin can leave severe effects on the function of the body such as night blindness, decreased resistance to infections, and extremely dry skin, hair, or nails. Just deficiency can be harmful; the overuse of vitamin A can be toxic and lead to hypervitaminosis. An average dose of this vitamin needed for the body is 0.7 mg for men and 0.6 mg for women on a daily diet. Women who have been through menopause and older men, who are more at risk of osteoporosis, should avoid having more than 1.5 mg of vitamin A per day from food and supplements [7, 13, 14].

Vitamin D is a steroid vitamin, which promotes the intestinal absorption and metabolism of calcium and phosphorus. There are two main types of vitamin D, Vitamin D2, which is synthesized by plants and is not created by the human body. Vitamin D3, which is made in large amounts in the skin when daylight strikes uncovered skin. Moreover, it can be ingested from animal sources. As well as there other types like ergosterol, dehydrocholesterol, and the biologically active form of

the hormone 1,25-dihydroxy vitamin D3 termed calcitriol.

palmitate is the storage form of the vitamin [13].

**22**

**2.2 Vitamin D**

**Figure 1.** *Types of vitamin A.*

Vitamin D is not active itself (it is a prohormone); it is modified to yield biologically active forms, such as calcitriol. Calcitriol (derived from vitamin D) is a transcription factor, influencing expression of proteins involved in calcium absorption and transport [15–17] (**Figure 2**).

Vitamin D is required to maintain normal blood levels of calcium and phosphate, which in turn is needed for the normal mineralization of the bone, muscle contraction, nerve conduction, general cellular function in all cells of the body and supporting lung function, and cardiovascular health. It may also protect against a range of diseases and conditions, such as type 1 diabetes. Vitamin D also modulates the transcription of cell cycle proteins, which decrease cell proliferation and increase cell differentiation of a number of specialized cells of the body (e.g., osteoclastic precursors, enterocytes, and keratinocytes). This property may explain the actions of vitamin D in bone resorption, intestinal calcium transport, and skin. Vitamin D also possesses immunomodulatory properties that may alter responses to infections in vivo. These cell-differentiating and immunomodulatory properties underlie the reason why vitamin D derivatives now are in use successfully in the treatment of psoriasis and other skin disorders. Oily fish, such as salmon, sardines, herring, and mackerel, contain a fair amount of vitamin D as well as red meat, liver, egg yolks, and fortified foods, such as most fat spreads and some breakfast cereals. Another source of vitamin D is dietary supplements [15–18].

The simplest way to get all the vitamin D the body needs is from direct sunlight. The absence of this very vitamin in an adult daily diet can result in hypovitaminosis

**Figure 2.** *Types of vitamin D.*

D, which leads to loss of bone density, which can contribute to osteoporosis and fractures (broken bones). In children, a severe vitamin D deficiency can cause delays in growth as well as rickets, a disease where the bones become soft and bend. Furthermore, vitamin D deficiency has been in link with several cancers, type 1 diabetes, multiple sclerosis, high blood pressure, and thyroid problems. A daily dose of vitamin D 1000 IU should prevent very low vitamin D levels and should be sufficient to help most aging adults get the benefit [17–19].

#### **2.3 Vitamin E**

Vitamin E is a major lipid-soluble antioxidant in the cell's antioxidant defense system and is exclusively obtained from the diet. The term "vitamin E" refers to a family of eight naturally occurring homologs synthesized by plants from homogentisic acid. All are derivatives of 6-chromanol and differ in the number and position of methyl groups on the ring structure known as tocopherols (**Figure 3**) [20].

This particular vitamin plays a huge role in protecting cell membranes and other fat-soluble parts of the body (LDL cholesterol) from oxidation; it also may reduce the risk of heart disease, discourage development of some types of cancer, promote normal growth and development, and promote normal red blood cell formation. It can also act as an anti-blood clotting agent and plays some role in the body's ability to process glucose. In addition, it is recognized to aid the process of wound healing. This vitamin is found in wheat germ oil, vegetable oils, nuts and seeds, whole grains, and egg yolk, in addition to leafy green vegetables [21, 22].

Vitamin E is mainly stored in the liver before released into the blood stream for use. Vitamin E is essential to the central nervous system. It is among the body's main antioxidants, and a deficiency results in oxidative stress, which can lead to muscle weakness. A deficiency can cause certain neurons, called the Purkinje neurons, to break down, harming their ability to transmit signals, which causes walking difficulties. Numbing and tingling also is a sign of deficiency, and the damage to nerve fibers can prevent the nerves from transmitting signals correctly, resulting in these sensations, which is also called peripheral neuropathy. The deficiency can also cause weakness of light receptors in the retina and other cells in the eye, and this can lead to loss of vision over time as well as immune system problems. The recommended daily dosage of this vitamin for males is 30 IU and for females 24 IU [22–24].

**Figure 3.** *Vitamin E.*

#### **2.4 Vitamin K**

Vitamin K refers to a group of chemically similar fat-soluble compounds called naphthoquinones: vitamin K1 (phytonadione) is found in plants and is the primary source of vitamin K for humans through dietary consumption, vitamin K2 compounds (menaquinones) are made by bacteria in the human gut, and vitamin K3 (menadione) is a water-soluble preparation available for adults only (**Figure 4**).

**25**

**3. Water-soluble vitamins**

**3.1 Thiamin (B1)**

*Vitamins*

**Figure 4.** *Types of vitamin K.*

*DOI: http://dx.doi.org/10.5772/intechopen.92074*

Vitamin K is necessary for the liver to produce the coagulation factors II, VII, IX, and X as well as the clotting factors protein C, protein S, and protein Z [25, 26]. The body needs vitamin K to produce prothrombin, a protein and clotting factor that is important in blood clotting and bone metabolism. Vitamin K1, or phylloquinone, comes from plants. It is the main type of dietary vitamin K. A lesser source is vitamin K2, or menaquinones, which occurs in some animal-based and fermented foods. The body is in need for both types of vitamin K to produce prothrombin, a protein that plays crucial roles in blood clotting, bone metabolism, and heart health. Vitamin K also helps facilitate energy production in the mitochondria of cells. Vitamin K has antioxidant properties. It protects cellular membranes from damage due to excess free radicals, in a process known as peroxidation. It is in use in synthesizing gamma-carboxyglutamate, a posttranslationally modified amino acid in prothrombin. Green vegetables contain the highest amounts of vitamin K like kale, spinach, turnip greens, collards, and green leaf lettuce vegetables, but there are many other good sources like fish, liver, meat, eggs, and cereals (contain smaller amounts). Vitamin K is made as well by the bacteria in the lower intestinal tract. Vitamin K deficiency is very rare. It occurs when the body does not properly absorb the vitamin from the intestinal tract. Vitamin K deficiency can also occur after long-term treatment with antibiotics. In adults, primary vitamin K-deficient states that manifest as bleeding are almost unknown, except when the absorption of the vitamin is impaired, resulting in an underlying pathology. Vitamin K deficiency bleeding is a problem that occurs in some newborns. It happens during the first few days of life. This condition used to be named hemorrhagic disease of the newborn. About toxicity, natural vitamin K seems free of toxic side effects. This apparent safety is designated out by the common clinical administration of phylloquinone at doses of 10–20 mg or greater. The recommended daily dosage for male adults is 120 mcg and for female adults is 90 mcg [26–29].

Thiamin is one of the B vitamins. The B vitamins are a group of water-soluble vitamins that are part of many of the chemical reactions in the body. It plays a role by

#### **Figure 4.** *Types of vitamin K.*

*Malnutrition*

**2.3 Vitamin E**

D, which leads to loss of bone density, which can contribute to osteoporosis and fractures (broken bones). In children, a severe vitamin D deficiency can cause delays in growth as well as rickets, a disease where the bones become soft and bend. Furthermore, vitamin D deficiency has been in link with several cancers, type 1 diabetes, multiple sclerosis, high blood pressure, and thyroid problems. A daily dose of vitamin D 1000 IU should prevent very low vitamin D levels and should be

Vitamin E is a major lipid-soluble antioxidant in the cell's antioxidant defense system and is exclusively obtained from the diet. The term "vitamin E" refers to a family of eight naturally occurring homologs synthesized by plants from homogentisic acid. All are derivatives of 6-chromanol and differ in the number and position of methyl groups on the ring structure known as tocopherols (**Figure 3**) [20].

This particular vitamin plays a huge role in protecting cell membranes and other fat-soluble parts of the body (LDL cholesterol) from oxidation; it also may reduce the risk of heart disease, discourage development of some types of cancer, promote normal growth and development, and promote normal red blood cell formation. It can also act as an anti-blood clotting agent and plays some role in the body's ability to process glucose. In addition, it is recognized to aid the process of wound healing. This vitamin is found in wheat germ oil, vegetable oils, nuts and seeds, whole

Vitamin E is mainly stored in the liver before released into the blood stream for use. Vitamin E is essential to the central nervous system. It is among the body's main antioxidants, and a deficiency results in oxidative stress, which can lead to muscle weakness. A deficiency can cause certain neurons, called the Purkinje neurons, to break down, harming their ability to transmit signals, which causes walking difficulties. Numbing and tingling also is a sign of deficiency, and the damage to nerve fibers can prevent the nerves from transmitting signals correctly, resulting in these sensations, which is also called peripheral neuropathy. The deficiency can also cause weakness of light receptors in the retina and other cells in the eye, and this can lead to loss of vision over time as well as immune system problems. The recommended daily dosage of this vitamin for males is 30 IU and for females 24 IU [22–24].

Vitamin K refers to a group of chemically similar fat-soluble compounds called naphthoquinones: vitamin K1 (phytonadione) is found in plants and is the primary source of vitamin K for humans through dietary consumption, vitamin K2 compounds (menaquinones) are made by bacteria in the human gut, and vitamin K3 (menadione) is a water-soluble preparation available for adults only (**Figure 4**).

sufficient to help most aging adults get the benefit [17–19].

grains, and egg yolk, in addition to leafy green vegetables [21, 22].

**24**

**2.4 Vitamin K**

**Figure 3.** *Vitamin E.* Vitamin K is necessary for the liver to produce the coagulation factors II, VII, IX, and X as well as the clotting factors protein C, protein S, and protein Z [25, 26].

The body needs vitamin K to produce prothrombin, a protein and clotting factor that is important in blood clotting and bone metabolism. Vitamin K1, or phylloquinone, comes from plants. It is the main type of dietary vitamin K. A lesser source is vitamin K2, or menaquinones, which occurs in some animal-based and fermented foods. The body is in need for both types of vitamin K to produce prothrombin, a protein that plays crucial roles in blood clotting, bone metabolism, and heart health. Vitamin K also helps facilitate energy production in the mitochondria of cells. Vitamin K has antioxidant properties. It protects cellular membranes from damage due to excess free radicals, in a process known as peroxidation. It is in use in synthesizing gamma-carboxyglutamate, a posttranslationally modified amino acid in prothrombin. Green vegetables contain the highest amounts of vitamin K like kale, spinach, turnip greens, collards, and green leaf lettuce vegetables, but there are many other good sources like fish, liver, meat, eggs, and cereals (contain smaller amounts). Vitamin K is made as well by the bacteria in the lower intestinal tract. Vitamin K deficiency is very rare. It occurs when the body does not properly absorb the vitamin from the intestinal tract. Vitamin K deficiency can also occur after long-term treatment with antibiotics. In adults, primary vitamin K-deficient states that manifest as bleeding are almost unknown, except when the absorption of the vitamin is impaired, resulting in an underlying pathology. Vitamin K deficiency bleeding is a problem that occurs in some newborns. It happens during the first few days of life. This condition used to be named hemorrhagic disease of the newborn. About toxicity, natural vitamin K seems free of toxic side effects. This apparent safety is designated out by the common clinical administration of phylloquinone at doses of 10–20 mg or greater. The recommended daily dosage for male adults is 120 mcg and for female adults is 90 mcg [26–29].

#### **3. Water-soluble vitamins**

#### **3.1 Thiamin (B1)**

Thiamin is one of the B vitamins. The B vitamins are a group of water-soluble vitamins that are part of many of the chemical reactions in the body. It plays a role by producing energy from carbohydrates and helping in proper nerve function as well as stabilizing the appetite and promoting growth and good muscle tone. It is also involved in the flow of electrolytes into and out of muscle and nerve cells. Thiamin is rapidly converted to its active form, thiamin pyrophosphate (TPP) (**Figure 5**), in the brain and liver by specific enzymes, thiamine phosphotransferase [30, 31].

There are many natural ways to add thiamine-rich foods to an everyday diet. Food sources of thiamine include beef, liver, dried milk, nuts, oats, oranges, pork, eggs, seeds, legumes, peas, and yeast. Foods also are fortified with thiamine. Some foods that are fortified with B1 are rice, pasta, breads, cereals, and flour. The relieving thing about thiamin is that it's non-toxic even at high dosage. However, the deficiency can be worrying because it leads to loss of appetite, weakness, and tiredness. Also causes insomnia, loss of weight, in addition to depression and gastrointestinal problems. Moreover, the deficiency leads to neurological problems and beriberi, which is a muscle atrophy. Furthermore, we must mention Wernicke-Korsakoff syndrome, which is a disease most commonly found in chronic alcoholics due to their poor dietetic lifestyles. A recommended daily dosage of thiamin for body requirement is 1.0–1.5 mg for normal adults [32–34].

**Figure 5.** *Types of vitamin B1.*

#### **3.2 Riboflavin (B2)**

Vitamin B2 is an organic compound that is not stored by the body except in insignificant amounts. It must be replenished daily. It is the precursor of coenzymes flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD) (**Figure 6**). The enzymes that require FMN or FAD and FADH2 as cofactors are termed flavoproteins. Several flavoproteins also contain metal ions, termed metalloflavoproteins. It contributes in energy production carbohydrate, fat, and protein metabolism and also in the formation of antibodies and red blood cells, not to mention respiration and maintenance of good vision and alleviating skin, nails, and hair, plus improving eye fatigue [35–37].

**27**

**3.3 Niacin (B3)**

**Figure 6.** *Types of vitamin B2.*

*Vitamins*

*DOI: http://dx.doi.org/10.5772/intechopen.92074*

Riboflavin decomposes when exposed to visible light. This characteristic can lead to riboflavin deficiencies in newborns treated for hyperbilirubinemia by phototherapy. Sources of riboflavin are present in large amounts in meat, fish, eggs, vegetables, dairy foods, and grain products. The deficiency of B2 is common due to poor diet. The resulting side effects of the deficiency of riboflavin are itching, burning eyes, cracks and sores in mouth and lips. In addition to bloodshot eyes, dermatitis, oily skin, and digestive disturbances. Moreover, normocytic anemia is associated with pure red cytoplasia of the bone marrow. The toxicity of this vitamin is not an issue due to limited intestinal absorption. The required daily dosage of B2

Niacin (nicotinic acid and nicotinamide), or known as vitamin B3, is required for the synthesis of the active forms of vitamin B3, nicotinamide adenine dinucleotide (NAD+), and nicotinamide adenine dinucleotide phosphate (NADP+).

for adolescent and adults is 1.0–1.3 mg [10, 37, 38].

*Malnutrition*

producing energy from carbohydrates and helping in proper nerve function as well as stabilizing the appetite and promoting growth and good muscle tone. It is also involved in the flow of electrolytes into and out of muscle and nerve cells. Thiamin is rapidly converted to its active form, thiamin pyrophosphate (TPP) (**Figure 5**), in the

There are many natural ways to add thiamine-rich foods to an everyday diet. Food sources of thiamine include beef, liver, dried milk, nuts, oats, oranges, pork, eggs, seeds, legumes, peas, and yeast. Foods also are fortified with thiamine. Some foods that are fortified with B1 are rice, pasta, breads, cereals, and flour. The relieving thing about thiamin is that it's non-toxic even at high dosage. However, the deficiency can be worrying because it leads to loss of appetite, weakness, and tiredness. Also causes insomnia, loss of weight, in addition to depression and gastrointestinal problems. Moreover, the deficiency leads to neurological problems and beriberi, which is a muscle atrophy. Furthermore, we must mention Wernicke-Korsakoff syndrome, which is a disease most commonly found in chronic alcoholics due to their poor dietetic lifestyles. A recommended daily dosage of thiamin for

Vitamin B2 is an organic compound that is not stored by the body except in insignificant amounts. It must be replenished daily. It is the precursor of coenzymes flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD) (**Figure 6**). The enzymes that require FMN or FAD and FADH2 as cofactors are termed flavoproteins. Several flavoproteins also contain metal ions, termed metalloflavoproteins. It contributes in energy production carbohydrate, fat, and protein metabolism and also in the formation of antibodies and red blood cells, not to mention respiration and maintenance of good vision and alleviating skin, nails, and hair, plus

brain and liver by specific enzymes, thiamine phosphotransferase [30, 31].

body requirement is 1.0–1.5 mg for normal adults [32–34].

**26**

**3.2 Riboflavin (B2)**

*Types of vitamin B1.*

**Figure 5.**

improving eye fatigue [35–37].

Riboflavin decomposes when exposed to visible light. This characteristic can lead to riboflavin deficiencies in newborns treated for hyperbilirubinemia by phototherapy. Sources of riboflavin are present in large amounts in meat, fish, eggs, vegetables, dairy foods, and grain products. The deficiency of B2 is common due to poor diet. The resulting side effects of the deficiency of riboflavin are itching, burning eyes, cracks and sores in mouth and lips. In addition to bloodshot eyes, dermatitis, oily skin, and digestive disturbances. Moreover, normocytic anemia is associated with pure red cytoplasia of the bone marrow. The toxicity of this vitamin is not an issue due to limited intestinal absorption. The required daily dosage of B2 for adolescent and adults is 1.0–1.3 mg [10, 37, 38].

#### **3.3 Niacin (B3)**

Niacin (nicotinic acid and nicotinamide), or known as vitamin B3, is required for the synthesis of the active forms of vitamin B3, nicotinamide adenine dinucleotide (NAD+), and nicotinamide adenine dinucleotide phosphate (NADP+).

Both NAD+ and NADP+, also known as NADPH (reduced form), function as cofactors for numerous dehydrogenases (**Figure 7**) [38, 39].

Niacin is an essential nutrient required for normal metabolism, energy production, maintenance of skin and tongue, and also improvement of circulation and maintenance of nervous system as well as the health of the digestive tract. This vitamin is divided into two types, nicotinic acid and niacinamide (nicotinamide) (**Figure 8**). It helps build proteins in the skin and lock in moisture to prevent environmental damage. The use is frequent in cosmetics and personal care products due to its wonderful effectiveness and treatments to skin and hair flaws and problems. It is important to mention that niacin is highly toxic in large doses and can lead to no good; doses of only 50–100 mg nicotinic acid can cause dilation of blood vessels and potentially painful tingling ("niacin flush"), diarrhea, nausea, vomiting, and longterm liver damage. In spite of the danger, nicotonic acid regulates the cholesterol with the assistance of inositol hexaniacinate, which is a supplement that regulates cholesterol without high toxicity. Nicotinamide is nearly always safe to take, although a few cases of liver damage have been in report due to doses of over 1000 mg/day [10, 39].

This vitamin is consumed through meat like liver, fish, and pork and peanuts, whole wheat, brown rice, mushrooms, and vegetables like green peas and potatoes, as well as fruits that are enriched in B3 like avocado. Deficiency can lead to pellagra, which is a dangerous disease. The symptoms are marked by dementia,

**Figure 7.** *Structures of NADH, NAD<sup>+</sup> , NADPH, and NADP<sup>+</sup> .*

**29**

**Figure 9.** *Vitamin B5.*

cal reaction [38, 45].

*Vitamins*

*DOI: http://dx.doi.org/10.5772/intechopen.92074*

females +14 years 14 mg/day [39–41].

**3.4 Pantothenic acid (B5)**

diarrhea, and dermatitis, also known as "the three Ds." If left untreated, pellagra can be fatal. Besides pellagra, deficiency causes gastrointestinal disturbance, loss of appetite, headache, insomnia, and mental depression. Moreover, it can be the reason of fatigue, aches, pains, nervousness, and irritability. The recommended daily dosage of a stable diet for vitamin B3 is 16 mg/day for males +14 years and for

Pantothenic acid (**Figure 9**) is vitamin B5. The word pantothenic comes from the Greek "pantou," meaning everywhere. Nearly all foods contain small quantities of pantothenic acid. It is one of the eight water-soluble B vitamins, which enables the body to break down carbohydrates into glucose to produce energy and to make red blood cells. This acid is formed from ß-alanine and pantoic acid. Pantothenic acid is required for the synthesis of coenzyme A (CoA) and component of the acyl carrier protein (ACP) domain of fatty acid synthase, in addition to its need for the metabo-

lism of carbohydrate by the TCA cycle and all fats and proteins [38, 42].

**3.5 Pyridoxal, pyridoxamine, and pyridoxine (B6)**

Pyridoxine is one of the vitamin B6 groups which also includes pyridoxal and pyridoxamine; all three compounds are efficiently converted by pyridoxal kinase to the biologically active form of vitamin B6, which is pyridoxal phosphate (**Figure 10**). Pyridoxal phosphate functions as a coenzyme, a substance that enhances the action of an enzyme and thereby helps catalyze and speed a biochemi-

Moreover, vitamin B5 also takes action in converting food into glucose, synthesizing cholesterol and forming sex and stress-related hormones in the adrenal glands. In addition, vitamin B5 helps maintain healthy skin, hair, eyes, and digestive system and also assists the body in using other vitamins. Furthermore, it can be in use for skin care as some studies have shown that vitamin B5 works as a moisturizer on the skin and enhances the healing process of skin wounds and acne. In addition, some studies suggest that vitamin B5 intake can help lower cholesterol and levels of blood triglycerides or fats. Almost all plant- and animal-based foods contain pantothenic acid in varying amounts, though food processing can cause a significant loss. Vitamin B5 is mainly found in members of the cabbage family, poultry, white and sweet potatoes, whole-grain cereals, and yeast, in addition to milk, lentils, and legumes. Deficiency is rare but can cause symptoms like headache, fatigue, irritability, impaired muscle coordination, gastrointestinal problems, and paresthesia, which is a tingling and numbing feeling in the feet, hands, legs, and other parts of the body. The recommended daily intake for this acid is 1.7–5.0 mg; large doses of pantothenic acid do not cause symptoms, other than possible diarrhea [43, 44].

**Figure 8.** *Types of B3.*

#### *Vitamins DOI: http://dx.doi.org/10.5772/intechopen.92074*

diarrhea, and dermatitis, also known as "the three Ds." If left untreated, pellagra can be fatal. Besides pellagra, deficiency causes gastrointestinal disturbance, loss of appetite, headache, insomnia, and mental depression. Moreover, it can be the reason of fatigue, aches, pains, nervousness, and irritability. The recommended daily dosage of a stable diet for vitamin B3 is 16 mg/day for males +14 years and for females +14 years 14 mg/day [39–41].

#### **3.4 Pantothenic acid (B5)**

*Malnutrition*

Both NAD+ and NADP+, also known as NADPH (reduced form), function as

Niacin is an essential nutrient required for normal metabolism, energy production, maintenance of skin and tongue, and also improvement of circulation and maintenance of nervous system as well as the health of the digestive tract. This vitamin is divided into two types, nicotinic acid and niacinamide (nicotinamide) (**Figure 8**). It helps build proteins in the skin and lock in moisture to prevent environmental damage. The use is frequent in cosmetics and personal care products due to its wonderful effectiveness and treatments to skin and hair flaws and problems. It is important to mention that niacin is highly toxic in large doses and can lead to no good; doses of only 50–100 mg nicotinic acid can cause dilation of blood vessels and potentially painful tingling ("niacin flush"), diarrhea, nausea, vomiting, and longterm liver damage. In spite of the danger, nicotonic acid regulates the cholesterol with the assistance of inositol hexaniacinate, which is a supplement that regulates cholesterol without high toxicity. Nicotinamide is nearly always safe to take, although a few cases of liver damage have been in report due to doses of over 1000 mg/day [10, 39]. This vitamin is consumed through meat like liver, fish, and pork and peanuts, whole wheat, brown rice, mushrooms, and vegetables like green peas and potatoes, as well as fruits that are enriched in B3 like avocado. Deficiency can lead to pellagra, which is a dangerous disease. The symptoms are marked by dementia,

cofactors for numerous dehydrogenases (**Figure 7**) [38, 39].

**28**

**Figure 8.** *Types of B3.*

**Figure 7.**

*Structures of NADH, NAD<sup>+</sup>*

*, NADPH, and NADP+*

*.*

Pantothenic acid (**Figure 9**) is vitamin B5. The word pantothenic comes from the Greek "pantou," meaning everywhere. Nearly all foods contain small quantities of pantothenic acid. It is one of the eight water-soluble B vitamins, which enables the body to break down carbohydrates into glucose to produce energy and to make red blood cells. This acid is formed from ß-alanine and pantoic acid. Pantothenic acid is required for the synthesis of coenzyme A (CoA) and component of the acyl carrier protein (ACP) domain of fatty acid synthase, in addition to its need for the metabolism of carbohydrate by the TCA cycle and all fats and proteins [38, 42].

Moreover, vitamin B5 also takes action in converting food into glucose, synthesizing cholesterol and forming sex and stress-related hormones in the adrenal glands. In addition, vitamin B5 helps maintain healthy skin, hair, eyes, and digestive system and also assists the body in using other vitamins. Furthermore, it can be in use for skin care as some studies have shown that vitamin B5 works as a moisturizer on the skin and enhances the healing process of skin wounds and acne. In addition, some studies suggest that vitamin B5 intake can help lower cholesterol and levels of blood triglycerides or fats. Almost all plant- and animal-based foods contain pantothenic acid in varying amounts, though food processing can cause a significant loss. Vitamin B5 is mainly found in members of the cabbage family, poultry, white and sweet potatoes, whole-grain cereals, and yeast, in addition to milk, lentils, and legumes. Deficiency is rare but can cause symptoms like headache, fatigue, irritability, impaired muscle coordination, gastrointestinal problems, and paresthesia, which is a tingling and numbing feeling in the feet, hands, legs, and other parts of the body. The recommended daily intake for this acid is 1.7–5.0 mg; large doses of pantothenic acid do not cause symptoms, other than possible diarrhea [43, 44].

**Figure 9.** *Vitamin B5.*

#### **3.5 Pyridoxal, pyridoxamine, and pyridoxine (B6)**

Pyridoxine is one of the vitamin B6 groups which also includes pyridoxal and pyridoxamine; all three compounds are efficiently converted by pyridoxal kinase to the biologically active form of vitamin B6, which is pyridoxal phosphate (**Figure 10**). Pyridoxal phosphate functions as a coenzyme, a substance that enhances the action of an enzyme and thereby helps catalyze and speed a biochemical reaction [38, 45].

Vitamin B6 is important to the body for it plays a huge role in the production of red blood cells, the conversion of tryptophan to niacin (B3), and the immunity and nervous system functions. Moreover, it reduces muscle spasms, cramps, and numbness as well as maintains a proper balance of sodium and phosphorus in the body. Good sources of this vitamin is just like most other vitamins, it can be found in whole-grain cereals, eggs, vegetables, soya beans, peanuts, milk, and potatoes as well as meat like poultry, pork, and fish. The risks of the deficiency are rare but can lead to nervousness, insomnia, loss of muscle control, muscle weakness, and arm and leg cramps, in addition to water retention and skin lesions. The recommended daily dosage of this vitamin is 1.4 mg a day for men and 1.2 mg a day for women [38, 45, 46].

#### **3.6 Biotin-cobalamin (B12)**

Biotin is a water-soluble B-complex vitamin that helps the body metabolize proteins and process glucose. Biotin is also known as vitamin B7 or vitamin H (**Figure 11**). It is also involved in the metabolism of fatty acids, a type of molecule found in fats and oils and leucine, an essential amino acid that humans cannot synthesize [46].

Biotin has a number of benefits to the human body like lowering cholesterol, regulating blood sugar, improving the skin health, as well as strengthening hair and

**31**

**Figure 12.**

*Vitamin B12 (cobalamin).*

*Vitamins*

*DOI: http://dx.doi.org/10.5772/intechopen.92074*

nails. A research has found that biotin can treat multiple sclerosis, a serious disease that affects the central nervous system, if taken in high doses as studies have shown. Biotin is largely found in egg yolks, cheese, legumes such as soybeans and peanuts, leafy greens, and cauliflower. Moreover, it also exists in mushrooms, nuts and nut butters, as well as animal liver and kidney. Biotinidase deficiency (BTD) is the most common cause of biotin deficiency. BTD is a rare inherited disorder where the body is not able to use biotin and leads to biotin deficiency, which developed by a mutation in the BTD gene. This gene instructs the body on how to make the enzyme biotinidase, which the body needs to extract biotin from food. Biotin deficiency includes thinning hair, progressing to loss of hair across the body, and a scaly, red rash around body openings, including the eyes, nose, mouth, and anus, as well as development of conjunctivitis. The daily requirement of this vitamin is within 5–30 mcg, for both men and women; the dosage differs according to age [47, 48]. Cobalamin is an essential nutrient and natural water-soluble vitamin of the B-complex family that must combine with an intrinsic factor for absorption by the intestine; vitamin B12 (cyanocobalamin) (**Figure 12**) is necessary for

**Figure 11.** *Vitamin B12 (biotin).*

#### *Vitamins DOI: http://dx.doi.org/10.5772/intechopen.92074*

*Malnutrition*

**Figure 10.** *Types of vitamin B6.*

Vitamin B6 is important to the body for it plays a huge role in the production of red blood cells, the conversion of tryptophan to niacin (B3), and the immunity and nervous system functions. Moreover, it reduces muscle spasms, cramps, and numbness as well as maintains a proper balance of sodium and phosphorus in the body. Good sources of this vitamin is just like most other vitamins, it can be found in whole-grain cereals, eggs, vegetables, soya beans, peanuts, milk, and potatoes as well as meat like poultry, pork, and fish. The risks of the deficiency are rare but can lead to nervousness, insomnia, loss of muscle control, muscle weakness, and arm and leg cramps, in addition to water retention and skin lesions. The recommended daily dosage of this vitamin is 1.4 mg a day for men and 1.2 mg a day for women [38, 45, 46].

Biotin is a water-soluble B-complex vitamin that helps the body metabolize proteins and process glucose. Biotin is also known as vitamin B7 or vitamin H (**Figure 11**). It is also involved in the metabolism of fatty acids, a type of molecule found in fats and

Biotin has a number of benefits to the human body like lowering cholesterol, regulating blood sugar, improving the skin health, as well as strengthening hair and

oils and leucine, an essential amino acid that humans cannot synthesize [46].

**30**

**Figure 11.**

*Vitamin B12 (biotin).*

**3.6 Biotin-cobalamin (B12)**

nails. A research has found that biotin can treat multiple sclerosis, a serious disease that affects the central nervous system, if taken in high doses as studies have shown. Biotin is largely found in egg yolks, cheese, legumes such as soybeans and peanuts, leafy greens, and cauliflower. Moreover, it also exists in mushrooms, nuts and nut butters, as well as animal liver and kidney. Biotinidase deficiency (BTD) is the most common cause of biotin deficiency. BTD is a rare inherited disorder where the body is not able to use biotin and leads to biotin deficiency, which developed by a mutation in the BTD gene. This gene instructs the body on how to make the enzyme biotinidase, which the body needs to extract biotin from food. Biotin deficiency includes thinning hair, progressing to loss of hair across the body, and a scaly, red rash around body openings, including the eyes, nose, mouth, and anus, as well as development of conjunctivitis. The daily requirement of this vitamin is within 5–30 mcg, for both men and women; the dosage differs according to age [47, 48].

Cobalamin is an essential nutrient and natural water-soluble vitamin of the B-complex family that must combine with an intrinsic factor for absorption by the intestine; vitamin B12 (cyanocobalamin) (**Figure 12**) is necessary for

**Figure 12.** *Vitamin B12 (cobalamin).*

#### *Malnutrition*

hematopoiesis, which is the process by which blood cells are formed and neural, in addition to metabolism, DNA and RNA production, as well as carbohydrate, fat, and protein metabolism. B12 improves iron functions in the metabolic cycle and assists folic acid in choline synthesis. B12 metabolism is interconnected with that of folic acid. This vitamin is mainly found in meat, for instance, fish, clams, beef, animal liver and kidney, as well as in eggs, dairies, and fortified nutritional yeast. Deficiency of cobalamin results to anemia, nerve damage, and hypersensitive skin. The recommended daily requirement of this vitamin for men and women of +14 of age is 2–3 mcg/day [47–49].

#### **3.7 Folic acid (B9)**

Folic acid is a form of vitamin B9 that can dissolve in water. It is a key ingredient in the making of the nucleic acid, which forms part of all genetic material. Its main functions are synthesis and repair of DNA and RNA, aiding rapid cell division and growth, enhancing brain health, and age-related hearing loss (**Figure 13**) [50].

Folic acid is essential to the body, and the deficiency of it can cause anemia, diseases of the heart and blood vessels and defects in the brain and spinal cord in a fetus. Folic acid is added to be in study with vitamin B12 in the prevention and treatment of cancer. It is also called folate. In addition, it is in consideration that folic acid plays a preventive role in a number of conditions like autism; a recent study connected folic acid deficiency with autism. It is fair to mention that folic acid is often used to support a methotrexate prescription for rheumatoid arthritis, which is a long-term, progressive, and disabling autoimmune disease. It causes inflammation, swelling, and pain in and around the joints and other body organs. This vitamin can be consumed through legumes, eggs, leafy greens, asparagus, beetroot, citrus fruits, beef liver, wheat germ-fortified grains, and others. The required daily dosage for the body is 0.1–0.4 mg [51, 52].

**Figure 13.** *Vitamin B9.*

#### **3.8 Ascorbic acid (vitamin C)**

Vitamin C is also known as ascorbic acid, a water-soluble vitamin, one that is not able to be in storage by the body except in insignificant amounts. It must be replenished daily. It helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin, and blood vessels. Vitamin C is a powerful antioxidant that protects your cells from damage by free radicals produced by cigarette smoke, air pollution, excessive sunlight, and normal metabolism (**Figure 14**). Free radicals are considered to play a role in rapid aging and diseases such as cancer and heart disease [53–55].

**33**

*Vitamins*

**Figure 14.** *Vitamin C.*

**4. Conclusions**

*DOI: http://dx.doi.org/10.5772/intechopen.92074*

It known that vitamin C helps metabolize proteins and its antioxidant activity may have a chance of reducing the risk of some cancers. Scurvy is the name for a vitamin C deficiency which results in anemia, fatigue, depression, and connective tissue defects like internal bleeding, petechiae, impaired wound healing, and gingivitis. Vitamin C is mainly found in citrus fruits such as orange, kiwi, lemon, guava, and grapefruit, and vegetables such as broccoli, cauliflower, Brussels sprouts, and capsicums are rich, natural sources of vitamin C. Other vitamin C-rich fruits include papaya, cantaloupe, and strawberries. The required intake of the vitamin is 45–60 mg for male and female, and the dosage differs according to age [54–58].

In conclusion, there are two types of vitamins, which are essential to the body, water-soluble vitamins and fat-soluble vitamins; both types play an effective part in the human body. Nobody can deny the necessity of these vitamins to the body in all ages, and the lack of it can result in severe damage in certain parts of the body according to which vitamin and age as well as the health status of each person.

**Figure 14.** *Vitamin C.*

*Malnutrition*

age is 2–3 mcg/day [47–49].

dosage for the body is 0.1–0.4 mg [51, 52].

**3.8 Ascorbic acid (vitamin C)**

**3.7 Folic acid (B9)**

hematopoiesis, which is the process by which blood cells are formed and neural, in addition to metabolism, DNA and RNA production, as well as carbohydrate, fat, and protein metabolism. B12 improves iron functions in the metabolic cycle and assists folic acid in choline synthesis. B12 metabolism is interconnected with that of folic acid. This vitamin is mainly found in meat, for instance, fish, clams, beef, animal liver and kidney, as well as in eggs, dairies, and fortified nutritional yeast. Deficiency of cobalamin results to anemia, nerve damage, and hypersensitive skin. The recommended daily requirement of this vitamin for men and women of +14 of

Folic acid is a form of vitamin B9 that can dissolve in water. It is a key ingredient in the making of the nucleic acid, which forms part of all genetic material. Its main functions are synthesis and repair of DNA and RNA, aiding rapid cell division and growth, enhancing brain health, and age-related hearing loss (**Figure 13**) [50]. Folic acid is essential to the body, and the deficiency of it can cause anemia, diseases of the heart and blood vessels and defects in the brain and spinal cord in a fetus. Folic acid is added to be in study with vitamin B12 in the prevention and treatment of cancer. It is also called folate. In addition, it is in consideration that folic acid plays a preventive role in a number of conditions like autism; a recent study connected folic acid deficiency with autism. It is fair to mention that folic acid is often used to support a methotrexate prescription for rheumatoid arthritis, which is a long-term, progressive, and disabling autoimmune disease. It causes inflammation, swelling, and pain in and around the joints and other body organs. This vitamin can be consumed through legumes, eggs, leafy greens, asparagus, beetroot, citrus fruits, beef liver, wheat germ-fortified grains, and others. The required daily

Vitamin C is also known as ascorbic acid, a water-soluble vitamin, one that is not able to be in storage by the body except in insignificant amounts. It must be replenished daily. It helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin, and blood vessels. Vitamin C is a powerful antioxidant that protects your cells from damage by free radicals produced by cigarette smoke, air pollution, excessive sunlight, and normal metabolism (**Figure 14**). Free radicals are considered to play a role in rapid

aging and diseases such as cancer and heart disease [53–55].

**32**

**Figure 13.** *Vitamin B9.*

It known that vitamin C helps metabolize proteins and its antioxidant activity may have a chance of reducing the risk of some cancers. Scurvy is the name for a vitamin C deficiency which results in anemia, fatigue, depression, and connective tissue defects like internal bleeding, petechiae, impaired wound healing, and gingivitis. Vitamin C is mainly found in citrus fruits such as orange, kiwi, lemon, guava, and grapefruit, and vegetables such as broccoli, cauliflower, Brussels sprouts, and capsicums are rich, natural sources of vitamin C. Other vitamin C-rich fruits include papaya, cantaloupe, and strawberries. The required intake of the vitamin is 45–60 mg for male and female, and the dosage differs according to age [54–58].

### **4. Conclusions**

In conclusion, there are two types of vitamins, which are essential to the body, water-soluble vitamins and fat-soluble vitamins; both types play an effective part in the human body. Nobody can deny the necessity of these vitamins to the body in all ages, and the lack of it can result in severe damage in certain parts of the body according to which vitamin and age as well as the health status of each person.

*Malnutrition*

#### **Author details**

Mohanad Mousa Kareem1 \* and Majid S. Jabir2

1 Department of Chemistry, College of Science, University of Babylon, Iraq

2 Division of Biotechnology, Department of Applied Science, University of Technology, Baghdad, Iraq

\*Address all correspondence to: sci.mohanad.mousa@uobabylon.edu.iq

© 2020 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.

**35**

*Vitamins*

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Co.; 1981

Smith)

Academic Press; 1954

*DOI: http://dx.doi.org/10.5772/intechopen.92074*

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[12] Olson JA. Needs and sources of carotenoids and vitamin A. Nutrition Reviews. 1994;**52**(2II):S67-S73

[13] Ong DE. Absorption of vitamin A. In: Blomhoff R, editor. Vitamin A in Health and Disease. New York, NY: Marcel Dekker; 1994. pp. 37-72

[14] Stephensen CB et al. Vitamin A is excreted in the urine during acute infection. American Journal of Clinical

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### **References**

*Malnutrition*

**34**

**Author details**

Mohanad Mousa Kareem1

Technology, Baghdad, Iraq

provided the original work is properly cited.

\* and Majid S. Jabir2

1 Department of Chemistry, College of Science, University of Babylon, Iraq

2 Division of Biotechnology, Department of Applied Science, University of

© 2020 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,

\*Address all correspondence to: sci.mohanad.mousa@uobabylon.edu.iq

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[3] FDA. Consumer: Nutrition Group Warns on Vitamin Overuse. U.S. Department of Health, Education, and Welfare, Public Health Service, Food and Drug Administration; 1978;**12**:3

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[13] Ong DE. Absorption of vitamin A. In: Blomhoff R, editor. Vitamin A in Health and Disease. New York, NY: Marcel Dekker; 1994. pp. 37-72

[14] Stephensen CB et al. Vitamin A is excreted in the urine during acute infection. American Journal of Clinical Nutrition. 1994;**60**:388-392

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[16] Feldman D, Glorieux FH, Pike JW. Vitamin D. New York, NY: Academic Press; 1997

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preeclampsia. International Journal of Gynaecology and Obstetrics. 2006;**93**:136-137

*Malnutrition*

[20] Traber MG. Vitamin E. In: Shils ME, Shike M, Ross AC,

& Wilkins; 2006. pp. 396-411

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[22] Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Vitamin C,

Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy

[23] Hathcock JN, Azzi A, Blumberg J, Bray T, Dickinson A, Frei B, et al. Vitamins E and C are safe across a broad range of intakes. The American Journal of Clinical Nutrition. 2005;**81**:736-745

[24] Horwitt MK. Interpretation of human requirements for vitamin E. In: Machlin L, editor. Vitamin E, A Comprehensive Treatise. New York, NY: Marcel Dekker; 1980. pp. 621-636

[25] Ferland G. Vitamin K. In:

10th ed. Washington, DC: Wiley-Blackwell; 2012. pp. 230-247

[27] U.S. Department of Agriculture USDHHS. Dietary

Erdman JW, Macdonald IA, Zeisel SH, editors. Present Knowledge in Nutrition.

[26] Shearer MJ. Fat-soluble vitamins: Vitamin K. Lancet. 1995;**345**:229-234

Guidelines for Americans. Washington, DC: U.S. Government Printing Office;

Sadowski JA. Food sources and dietary intakes of vitamin K-1 (phylloquinone)

[28] Booth SL, Pennington JAT,

in the American diet: Data from the FDA total diet study. Journal of the American Dietetic Association.

2006;**78**:2088-2098

Press; 2000

Caballero B, Cousins R, editors. Modern Nutrition in Health and Disease. 10th ed. Baltimore, MD: Lippincott Williams

[29] Conly JM, Stein K. Quantitative and qualitative measurements of K vitamins in human intestinal contents. The American Journal of Gastroenterology.

[30] Said HM. Thiamin. In: Coates PM, Betz JM, Blackman MR, et al., editors. Encyclopedia of Dietary Supplements. 2nd ed. Informa Healthcare: London and New York; 2010. pp. 748-753

[31] Bemeur C, Butterworth RF. Thiamin. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, editors. Modern Nutrition in Health and Disease. 11th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2014.

[32] Gibson GE, Blass JP. Thiaminedependent processes and treatment strategies in neurodegeneration. Antioxidants & Redox Signaling.

[33] McCormick DB. Thiamin. In: Shils ME, Young VR, editors. Modern Nutrition in Health and Disease. 6th ed. Philadelphia, PA: Lea & Febiger; 1988.

[34] Bailey AL et al. Thiamin intake, erythrocyte transketolase (EC 2.2.1.1) activity and total erythrocyte thiamin in adolescents. British Journal of Nutrition.

[35] Rivlin RS. Riboflavin. In: Coates PM, Betz JM, Blackman MR, et al., editors. Encyclopedia of Dietary Supplements. 2nd ed. Informa Healthcare: London and New York; 2010. pp. 691-699

[36] Said HM, Ross AC. Riboflavin. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, editors. Modern Nutrition in Health and Disease. 11th ed. Baltimore, MD: Lippincott Williams &

[37] Neugebauer J, Zanre Y, Wacker J. Riboflavin supplementation and

Wilkins; 2014. pp. 325-330

1992;**87**:311-316

pp. 317-324

2007;**9**:1605-1619

pp. 355-361

1994;**72**:111-125

**36**

1996;**96**:149-154

2010

[38] Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic acid, Biotin, and Choline. Washington, DC: National Academy Press; 1998

[39] Penberthy WT, Kirkland JB. Niacin. In: Erdman JW, Macdonald IA, Zeisel SH, editors. Present Knowledge in Nutrition. 10th ed. Washington, DC: Wiley-Blackwell; 2012. pp. 293-306

[40] Kirkland JB. Niacin. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, editors. Modern Nutrition in Health and Disease. 11th ed. Baltimore, MD: Williams & Wilkins; 2014. pp. 331-340

[41] MacKay D, Hathcock J, Guarneri. Niacin: Chemical forms, bioavailability, and health effects. Nutrition Reviews. 2012;**70**:357-366

[42] Miller JW, Rucker RB. Pantothenic acid. In: Erdman JW, Macdonald IA, Zeisel SH, editors. Present Knowledge in Nutrition. 10th ed. Washington, DC: Wiley-Blackwell; 2012. pp. 375-390

[43] Sweetman L. Pantothenic acid. In: Coates PM, Betz JM, Blackman MR, et al., editors. Encyclopedia of Dietary Supplements. 2nd ed. Informa Healthcare: London and New York; 2010. pp. 604-611

[44] Trumbo PR. Pantothenic acid. In: Ross AC, Caballero B, Cousins RJ, et al., editors. Modern Nutrition in Health and Disease. 11th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2014. pp. 351-357

[45] Mackey A, Davis S, Gregory J. Vitamin B6. In: Shils M, Shike M, Ross A, Caballero B, Cousins R, editors. Modern Nutrition in Health and

Disease. 10th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005

[46] Riggs KM, Spiro A 3rd, Tucker K, Rush D. Relations of vitamin B-12, vitamin B-6, folate, and homocysteine to cognitive performance in the normative aging study. The American Journal of Clinical Nutrition. 1996;**63**:306-314

[47] Herbert V. Vitamin B12 in Present Knowledge in Nutrition. 17th ed. Washington, DC: International Life Sciences Institute Press; 1996

[48] Herbert V, Das K. Vitamin B12 in Modern Nutrition in Health and Disease. 8th ed. Baltimore, MD: Williams & Wilkins; 1994

[49] Combs G. Vitamin B12 in the Vitamins. New York: Academic Press, Inc.; 1992

[50] Bailey LB, Caudill MA. Folate. In: Erdman JW, Macdonald IA, Zeisel SH, editors. Present Knowledge in Nutrition. 10th ed. Washington, DC: Wiley-Blackwell; 2012. pp. 321-342

[51] Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 1998

[52] Scott JM, Weir DG. Folate/vitamin B12 interrelationships. Essays in Biochemistry. 1994;**28**:63-72

[53] Gershoff SN. Vitamin C (ascorbic acid): New roles, new requirements? Nutrition Reviews. 1993;**51**:313-326

[54] Rebouche CJ. Ascorbic acid and carnitine biosynthesis. American Journal of Clinical Nutrition. 1991;**54**(Suppl):S1147-S1152

[55] McCormick DB, Zhang Z. Cellular assimilation of water-soluble vitamins in the mammal: Riboflavin, B6, biotin and C. Proceedings of the Society of Experimental Biology and Medicine. 1993;**202**:265-270

**Chapter 4**

**Abstract**

*Joseph Kiprop Choge*

optimization, universal healthcare

**1. Introduction**

**39**

Malnutrition: Current Challenges

Achievement of good nutrition is important in Universal Healthcare; hence, all stakeholders should be updated regarding management of malnutrition and challenges encountered, especially in resource-constrained societies of the world. Coexistence of multiple predisposing factors of malnutrition therefore compounds its diagnosis and management. It is of paramount importance therefore that the vulnerable population should be provided with adequate knowledge to alleviate the nutritional challenges they encounter. Capacity building of the healthcare personnel that are entrusted to serve such vulnerable societies should be improved appropri-

ately. Healthy nutrition policy makers, implementers, and evaluators in all

urgently be addressed through appropriate and widespread counseling.

**Keywords:** breastfeeding, challenges, counseling, fortification, innovative lipid-based nutrient supplements, malnutrition, nixtamalization, nutrition,

Malnutrition has been clearly described by the World Health Organization, among other entities dealing with the professional aspects of the subject matter [1, 2]. The nutritional imbalance can be classified in various ways, especially for purposes of proper and adequate management. Currently, the categories of malnutrition include undernutrition, overweight, and obesity, among others that will be substantiated shortly. The study of malnutrition, especially in developing countries, will remain important for a long time to come. This is because vulnerable communities, families, and/or individuals therein are likely to be adversely affected, with consequences of morbidity and mortality. Significantly large proportions (about 50%) of children aged five and below die from malnutrition and its complications, including infections. The severity, prevalence, and incidence of such infections may

healthcare sectors should be conversant with new developments in management of malnutrition and challenges including those encountered in case studies, such as one recently encountered in Kenya, during the management of isoniazid induced pellagra (IPT) in a TB patient also on antiretroviral therapy. Food fortification, nixtamalization, provision of ready-to-use therapy foods (RUTFs), and innovative lipid-based nutrient supplements are relatively new areas whose nutrition policy makers, implementers, and evaluators should be well updated in. As part of nutrition optimization among those at risk, the nonadherence to exclusive breastfeeding for at least 6 months, which globally remains unacceptably high (59%), should

and Future Perspectives

[56] Bates CJ. Bioavailability of vitamin C. European Journal of Clinical Nutrition. 1997;**51**(Suppl 1):S28-S33

[57] Kareem MM, Baqir SJ, Aowda SA, Hussein FA. Determination of vitamin C (ascorbic acid) concentration in some of commercial products, by redox titration. UOB Journal of Pure & Applied Sciences. 2010;**3**:18

[58] Kareem MM. Chemistry of Fruits. Jordan: DAR SAFA Publishing-Distributing; 2020. ISBN: 978-9923-28-014-0

#### **Chapter 4**

*Malnutrition*

1993;**202**:265-270

in the mammal: Riboflavin, B6, biotin and C. Proceedings of the Society of Experimental Biology and Medicine.

[56] Bates CJ. Bioavailability of vitamin C. European Journal of Clinical Nutrition. 1997;**51**(Suppl 1):S28-S33

[57] Kareem MM, Baqir SJ, Aowda SA, Hussein FA. Determination of vitamin C (ascorbic acid) concentration in some of commercial products, by redox titration. UOB Journal of Pure &

Publishing-Distributing; 2020. ISBN:

Applied Sciences. 2010;**3**:18

[58] Kareem MM. Chemistry of Fruits. Jordan: DAR SAFA

978-9923-28-014-0

**38**

## Malnutrition: Current Challenges and Future Perspectives

*Joseph Kiprop Choge*

#### **Abstract**

Achievement of good nutrition is important in Universal Healthcare; hence, all stakeholders should be updated regarding management of malnutrition and challenges encountered, especially in resource-constrained societies of the world. Coexistence of multiple predisposing factors of malnutrition therefore compounds its diagnosis and management. It is of paramount importance therefore that the vulnerable population should be provided with adequate knowledge to alleviate the nutritional challenges they encounter. Capacity building of the healthcare personnel that are entrusted to serve such vulnerable societies should be improved appropriately. Healthy nutrition policy makers, implementers, and evaluators in all healthcare sectors should be conversant with new developments in management of malnutrition and challenges including those encountered in case studies, such as one recently encountered in Kenya, during the management of isoniazid induced pellagra (IPT) in a TB patient also on antiretroviral therapy. Food fortification, nixtamalization, provision of ready-to-use therapy foods (RUTFs), and innovative lipid-based nutrient supplements are relatively new areas whose nutrition policy makers, implementers, and evaluators should be well updated in. As part of nutrition optimization among those at risk, the nonadherence to exclusive breastfeeding for at least 6 months, which globally remains unacceptably high (59%), should urgently be addressed through appropriate and widespread counseling.

**Keywords:** breastfeeding, challenges, counseling, fortification, innovative lipid-based nutrient supplements, malnutrition, nixtamalization, nutrition, optimization, universal healthcare

#### **1. Introduction**

Malnutrition has been clearly described by the World Health Organization, among other entities dealing with the professional aspects of the subject matter [1, 2]. The nutritional imbalance can be classified in various ways, especially for purposes of proper and adequate management. Currently, the categories of malnutrition include undernutrition, overweight, and obesity, among others that will be substantiated shortly. The study of malnutrition, especially in developing countries, will remain important for a long time to come. This is because vulnerable communities, families, and/or individuals therein are likely to be adversely affected, with consequences of morbidity and mortality. Significantly large proportions (about 50%) of children aged five and below die from malnutrition and its complications, including infections. The severity, prevalence, and incidence of such infections may delay recuperation. Stunted growth and impaired cognitive and other aspects of child development may adversely affect learning of children during their first few years (more so the first 1000 days of life).

countries, where small-scale subsistence farming is practiced. The most notable of these are good agricultural practices, good and vibrant economy, healthy enabling environment, healthy social and family life, good antenatal and perinatal care, and early screening and control of preventable diseases. We shall now revisit each of

Parents and household heads need to take responsibility in ensuring good agricultural practices (especially clearing farm land at the right time, planting sufficient good crops, using irrigation and fertilizer where necessary, getting appropriate advice from agricultural extension workers, harvesting at the right time, and safe storing the food to avoid losses through pests, a good transport and distribution system to get enough good food to all regions) are done appropriately. Chronic and irresponsible alcoholism by those charged with providing for the family, for example, may lead to poor (or inadequately productive) agricultural practices that will lead to loss of family income, poverty, and family neglect and may lead to malnutrition, among other health challenges in the family. Improvement of nutrition and prevention of malnutrition require energetic and cooperative efforts directed

Those in influential leadership and governance of societies should on priority basis ensure there is a good economy in place. This should guarantee sufficient resources allocated to support adequate food and fuel/energy, health and education, and good education, among other society needs. Unfortunately, this is not always

Each country should ensure there is equitable availability and distribution of safe and sufficient water for drinking, cooking, cleaning, and other uses. Environmental sanitation and sewage treatment and management should also be appropriate. If this kind of environment is lacking, then the affected society will be vulnerable to many

Provision of appropriate and adequate knowledge on good nutrition and child health to the societies is critical. In most developing countries, this can effectively be done by those charged with the responsibility of disseminating such knowledge to schools, families, and any other modes of communication to large populations. Through good health education, the right attitudes and practices that promote good nutrition to the most vulnerable groups (especially children and mothers) will be

Dissemination of adequate knowledge on family planning matters, at the right time to the right audience, is important. The right size of and the availability of adequate resources to the family and the presence of a health social environment in a family are paramount. This will ensure adequacy of food and attention to the

the case in many parts of the world, especially in developing countries.

health problems, including related nutrition challenges.

these factors.

**3.1 Good agricultural practices**

*Malnutrition: Current Challenges and Future Perspectives*

*DOI: http://dx.doi.org/10.5772/intechopen.92007*

toward all these factors.

**3.4 Good education**

guaranteed.

**41**

**3.2 Good and vibrant economy**

**3.3 Healthy enabling environment**

**3.5 Healthy social and family life**

#### **2. Worrying global prevalence trends of malnutrition**

According to 2019 statistics from the World Health Organization and UNICEF [1–3], malnutrition is cosmopolitan, and its prevalence remains unacceptably high, consequently impacting negatively on the lives of the affected children. Approximately one third of women of reproductive age had anemia, while obesity affected a slightly higher proportion (39%) of the world's adult population. Underweight babies constitute a further 20 million, despite a noted slow decline in stunted growth. In 2018, just over a fifth (21.9%) of the world's children aged five had stunted growth, despite its overall global prevalence decline from 32.5% during the period between the years 2000 and 2018. During the same period, the population of stunted children decreased in terms of millions (from 198.2 to 149.0). Of this proportion, nearly 40% lived in South Asia, and a similar proportion lived in Africa south of Sahara (SSA), although an alarming proportional increase has been noted from west and central Africa (22.4 million to 28.9 million). Earlier in 2010, 49 million children aged five and below were wasted, while a further 17 million suffered from severe wasting thus translating to 7.3 and 2.4%, respectively. One worrying global trend is the fact that about 45% of mortality among children aged five and below is linked to malnutrition, the bulk of these occurring in low- and middleincome countries. A further global trend is that 528 million (29%) of reproductiveage women are vulnerable to anemia occasioned by inadequate dietary iron supplementation. In the low and middle - income Countries, the rates of childhood obesity and overweight were on the rise, estimated to nearly threefold rise in prevalence during the period between the years 2000 and 2018 alone, in Eastern Europe, Central Asia, the Middle East, and Northern Africa. The prevalence in these regions ranges between 8.8 and 11.2%, respectively. Eastern and south-east Asia, the Pacific, and northern Africa account for more than a third of the world's overweight children. The gender distribution of these statistics tends to show higher stunting rates among boys than girls. This is thought to be due to the fact that boys have relatively higher risk of low birth weight and preterm birth than girls. These disparities were noted to be prevalent in Latin America, South-ease Asia, and the Caribbean. More attention should then be placed on these regions by those dealing with intervention measures. WHO [3] report also cites that those who are at risk of malnutrition include infants, children, women, and adolescents and that optimization of nutrition early in life (specifically within the first 1000 days of life) will ensure the child gets the best possible start in life with its life-long benefits. Unfortunately, the nonadherence to the recommended prevalence of breastfeeding practices among many societies of the world remains relatively low and worrying, since only 41% (hence 59% non-compliance) of infants aged 6 months or less were exclusively breastfed and only 45% were continually breastfed for at most 2 years in 2017 [4].

#### **3. Factors contributing to good nutrition**

Before we consider the factors that predispose to malnutrition, let us first discuss the factors that contribute to good nutrition. These factors play an important role, especially in places where the resources are inadequate for the affected society and/ or families [5]. Many of these factors are intertwined, especially in developing

countries, where small-scale subsistence farming is practiced. The most notable of these are good agricultural practices, good and vibrant economy, healthy enabling environment, healthy social and family life, good antenatal and perinatal care, and early screening and control of preventable diseases. We shall now revisit each of these factors.

#### **3.1 Good agricultural practices**

delay recuperation. Stunted growth and impaired cognitive and other aspects of child development may adversely affect learning of children during their first few

According to 2019 statistics from the World Health Organization and UNICEF [1–3], malnutrition is cosmopolitan, and its prevalence remains unacceptably high, consequently impacting negatively on the lives of the affected children. Approximately one third of women of reproductive age had anemia, while obesity affected a slightly higher proportion (39%) of the world's adult population. Underweight babies constitute a further 20 million, despite a noted slow decline in stunted growth. In 2018, just over a fifth (21.9%) of the world's children aged five had stunted growth, despite its overall global prevalence decline from 32.5% during the period between the years 2000 and 2018. During the same period, the population of stunted children decreased in terms of millions (from 198.2 to 149.0). Of this proportion, nearly 40% lived in South Asia, and a similar proportion lived in Africa south of Sahara (SSA), although an alarming proportional increase has been noted from west and central Africa (22.4 million to 28.9 million). Earlier in 2010, 49 million children aged five and below were wasted, while a further 17 million suffered from severe wasting thus translating to 7.3 and 2.4%, respectively. One worrying global trend is the fact that about 45% of mortality among children aged five and below is linked to malnutrition, the bulk of these occurring in low- and middleincome countries. A further global trend is that 528 million (29%) of reproductiveage women are vulnerable to anemia occasioned by inadequate dietary iron supplementation. In the low and middle - income Countries, the rates of childhood obesity and overweight were on the rise, estimated to nearly threefold rise in prevalence during the period between the years 2000 and 2018 alone, in Eastern Europe, Central Asia, the Middle East, and Northern Africa. The prevalence in these regions ranges between 8.8 and 11.2%, respectively. Eastern and south-east Asia, the Pacific, and northern Africa account for more than a third of the world's overweight children. The gender distribution of these statistics tends to show higher stunting rates among boys than girls. This is thought to be due to the fact that boys have relatively higher risk of low birth weight and preterm birth than girls. These disparities were noted to be prevalent in Latin America, South-ease Asia, and the Caribbean. More attention should then be placed on these regions by those dealing with intervention measures. WHO [3] report also cites that those who are at risk of malnutrition include infants, children, women, and adolescents and that optimization of nutrition early in life (specifically within the first 1000 days of life) will ensure the child gets the best possible start in life with its life-long benefits. Unfortunately, the nonadherence to the recommended prevalence of breastfeeding practices among many societies of the world remains relatively low and worrying, since only 41% (hence 59% non-compliance) of infants aged 6 months or less were exclusively breastfed and only 45% were continually breastfed for at most 2 years in 2017 [4].

years (more so the first 1000 days of life).

*Malnutrition*

**3. Factors contributing to good nutrition**

**40**

Before we consider the factors that predispose to malnutrition, let us first discuss the factors that contribute to good nutrition. These factors play an important role, especially in places where the resources are inadequate for the affected society and/ or families [5]. Many of these factors are intertwined, especially in developing

**2. Worrying global prevalence trends of malnutrition**

Parents and household heads need to take responsibility in ensuring good agricultural practices (especially clearing farm land at the right time, planting sufficient good crops, using irrigation and fertilizer where necessary, getting appropriate advice from agricultural extension workers, harvesting at the right time, and safe storing the food to avoid losses through pests, a good transport and distribution system to get enough good food to all regions) are done appropriately. Chronic and irresponsible alcoholism by those charged with providing for the family, for example, may lead to poor (or inadequately productive) agricultural practices that will lead to loss of family income, poverty, and family neglect and may lead to malnutrition, among other health challenges in the family. Improvement of nutrition and prevention of malnutrition require energetic and cooperative efforts directed toward all these factors.

#### **3.2 Good and vibrant economy**

Those in influential leadership and governance of societies should on priority basis ensure there is a good economy in place. This should guarantee sufficient resources allocated to support adequate food and fuel/energy, health and education, and good education, among other society needs. Unfortunately, this is not always the case in many parts of the world, especially in developing countries.

#### **3.3 Healthy enabling environment**

Each country should ensure there is equitable availability and distribution of safe and sufficient water for drinking, cooking, cleaning, and other uses. Environmental sanitation and sewage treatment and management should also be appropriate. If this kind of environment is lacking, then the affected society will be vulnerable to many health problems, including related nutrition challenges.

#### **3.4 Good education**

Provision of appropriate and adequate knowledge on good nutrition and child health to the societies is critical. In most developing countries, this can effectively be done by those charged with the responsibility of disseminating such knowledge to schools, families, and any other modes of communication to large populations. Through good health education, the right attitudes and practices that promote good nutrition to the most vulnerable groups (especially children and mothers) will be guaranteed.

#### **3.5 Healthy social and family life**

Dissemination of adequate knowledge on family planning matters, at the right time to the right audience, is important. The right size of and the availability of adequate resources to the family and the presence of a health social environment in a family are paramount. This will ensure adequacy of food and attention to the

whole family, especially younger children who usually need more care. Arrangements to ensure adequate resources for food, shelter, and other needs are maintained even if either or both parents have to work and a caretaker has to look after the children in their absence. Good supervision to ensure children get adequate and appropriate food should be in place at all times (at home, in day-care centers, and other such places); otherwise, some children might become malnourished. Care for children from broken or incomplete families directly affects nutritional status, especially if the social integration and communal care are lacking.

limited available resources to support the families. Poor personal and environmental hygiene, due to inadequate sanitation, may aggravate situation by encouraging food contamination during food handling, preparation, and consumption. Consequently, the affected individuals will suffer from inherent risks of dangerous infectious diseases that will increase nutritional losses and/or altered metabolic demands. This scenario is likely to lead to repeated infections if the infrastructure lacks wellmaintained sewage and sanitation facilities and/or supply of adequate clean water. Constant or frequent exposure to infection/infestation with intestinal and other worms such as hook worms and fish tape worms, among others will also predispose to nutritional iron deficiency anemia. Many people living under deplorable health conditions will also be exposed to many other parasites, including ascariasis, which

**Chronic disease conditions and illnesses are important etiological factors of malnutrition:** [5, 6]. This is especially more so in developed countries. People with chronic illnesses (especially children) are at relatively higher risk of nutritional problems. Some of the contributing factors include the following: chronic illnesses are frequently associated with loss of appetite and therefore intake of inadequate food. Some chronic illnesses are also associated with increased metabolic demands, hence increasing caloric needs. Any chronic illness that adversely affects the liver, pancreas, or intestines has the potential of adversely impairing food digestion and absorption. Other chronic illnesses that are associated with malnutrition include surgical diseases (such as cleft lip and/or palate, chronic hypertrophic pyloric stenosis), malignancies, congenital heart diseases, chronic renal failure, chronic bowel inflammatory diseases (such as ulcerative colitis), neuromuscular diseases, and cystic fibrosis, among others. Furthermore, risk of nutritional deficiency may be due to prematurity, failure to thrive for whatever cause, and exposure to toxins *in*

**People with multiple food allergies (especially children) may become malnourished, due to challenges of dietary restrictions:** [5, 6]. People with active allergic symptoms may have increased calorie and protein needs. This is partly because their state of morbidity predisposes them to lack of appetite during the time of ill-health and therefore without extra dietary supplements they might become malnourished. Furthermore, the allergy to certain foods denies them the benefit of the nutrients found in the food they are allergic to. If there is lack of appropriate

dietary substitute, then the affected individuals will become malnourished

Malnutrition can be classified into different categories [3, 7], namely, undernutrition, overnutrition, micronutrient-related malnutrition, severe acute (SAM), moderate acute (MAM), and global acute malnutrition (GAM), respectively. The assessment of body mass index (BMI) is one of the major ways of differentiating some of these categories. Details of BMI will be given later in the chapter.

Undernutrition consists of stunting, wasting, underweight, and micronutrient deficiencies. Stunting refers to a situation whereby children have a lower than normal height-for-age. Wasting refers to lower than normal weight-for-height, while underweight refers to lower than normal weight-for-age. Micronutrient deficiency refers to inadequate intake of vitamins and minerals. In more technical terms, the World Health Organization [3] defines these terms as follows. Underweight is defined as weight for age < 2 standard deviations (SD) of the WHO Child Growth Standards median. Stunting is defined as height for age < 2 SD of

contribute to food deprivation.

*Malnutrition: Current Challenges and Future Perspectives*

*DOI: http://dx.doi.org/10.5772/intechopen.92007*

*utero* (e.g., alcohol intake during pregnancy).

**5. Classification of malnutrition**

with time.

**43**

#### **3.6 Good antenatal and perinatal care**

Pregnant mothers require good antenatal care, especially to ensure good nutrition during pregnancy in order to avoid giving birth to low birth weight babies and to prevent intrauterine growth retardation and prematurity.

#### **3.7 Early screening and control of preventable diseases**

Immunization and vaccinations done appropriately at the right time to the right people will ensure early detection and prevention of diseases. Early screening for congenital malformations that interfere with child's eating or food utilization (such as cleft lip/palate, congenital hypertrophic pyloric stenosis) can alleviate related health problems and their management.

#### **4. Factors predisposing to malnutrition**

**Globally, inadequate food intake is the most common cause of malnutrition:** [5, 6]. In developing countries, inadequate food intake may be due to poverty, insufficient, or inappropriate food supplies or early weaning and premature stopping of breastfeeding. Ignorance about the need to have a balanced diet (and lack of adequate knowledge about the appropriate food and the right quantities needed by each family member) and ignorance about the importance of breastfeeding may be important contributing factor(s) in some places, especially if those endowed with the responsibility of disseminating the right knowledge fail to do it appropriately. Psychosocial issues, such as premature death of a breastfeeding mother, deliberate maternal deprivation from whatever reason may also contribute to childhood malnutrition. Single mothers (due to death of a spouse, separation, or divorce) may also face the challenge of premature stoppage of breastfeeding, owing to the fact that such mothers have to constantly provide food and other needs for the family, without the help of a spouse. This challenge might also contribute to maternal deprivation of adequate food to the baby, abuse of the rights toward the baby, especially if the baby was born out of unplanned pregnancy. The introduction of breast milk banks has alleviated this problem in certain places, but adequate health education of the safety and convenience of this approach has not yet been fully embraced culturally by many societies. The fear of disease transmission through breast milk remains a hindrance of new approaches of providing breast milk to babies whose mothers are missing or are not able to produce enough breast milk. In some areas, cultural and religious food customs may play a role. For example, ignorance of what constitutes a balanced diet can contribute to malnutrition. Consequently, certain families might sell most food sources they produce and actually need for the family, in order to buy larger quantities of food supplies they do not actually need. Poor family planning is a major problem in some cultures, especially where polygamy and bearing many children are encouraged, without due regard to whole family, especially younger children who usually need more care. Arrangements to ensure adequate resources for food, shelter, and other needs are

maintained even if either or both parents have to work and a caretaker has to look after the children in their absence. Good supervision to ensure children get adequate and appropriate food should be in place at all times (at home, in day-care centers, and other such places); otherwise, some children might become malnourished. Care for children from broken or incomplete families directly affects nutritional status, especially if the social integration and communal care are lacking.

Pregnant mothers require good antenatal care, especially to ensure good nutrition during pregnancy in order to avoid giving birth to low birth weight babies and

Immunization and vaccinations done appropriately at the right time to the right people will ensure early detection and prevention of diseases. Early screening for congenital malformations that interfere with child's eating or food utilization (such as cleft lip/palate, congenital hypertrophic pyloric stenosis) can alleviate related

**Globally, inadequate food intake is the most common cause of malnutrition:**

[5, 6]. In developing countries, inadequate food intake may be due to poverty, insufficient, or inappropriate food supplies or early weaning and premature stopping of breastfeeding. Ignorance about the need to have a balanced diet (and lack of adequate knowledge about the appropriate food and the right quantities needed by each family member) and ignorance about the importance of breastfeeding may be important contributing factor(s) in some places, especially if those endowed with the responsibility of disseminating the right knowledge fail to do it appropriately. Psychosocial issues, such as premature death of a breastfeeding mother, deliberate maternal deprivation from whatever reason may also contribute to childhood malnutrition. Single mothers (due to death of a spouse, separation, or divorce) may also face the challenge of premature stoppage of breastfeeding, owing to the fact that such mothers have to constantly provide food and other needs for the family, without the help of a spouse. This challenge might also contribute to maternal deprivation of adequate food to the baby, abuse of the rights toward the baby, especially if the baby was born out of unplanned pregnancy. The introduction of breast milk banks has alleviated this problem in certain places, but adequate health education of the safety and convenience of this approach has not yet been fully embraced culturally by many societies. The fear of disease transmission through breast milk remains a hindrance of new approaches of providing breast milk to babies whose mothers are missing or are not able to produce enough breast milk. In some areas, cultural and religious food customs may play a role. For example, ignorance of what constitutes a balanced diet can contribute to malnutrition. Consequently, certain families might sell most food sources they produce and actually need for the family, in order to buy larger quantities of food supplies they do not actually need. Poor family planning is a major problem in some cultures, especially where polygamy and bearing many children are encouraged, without due regard to

**3.6 Good antenatal and perinatal care**

*Malnutrition*

health problems and their management.

**42**

**4. Factors predisposing to malnutrition**

to prevent intrauterine growth retardation and prematurity.

**3.7 Early screening and control of preventable diseases**

limited available resources to support the families. Poor personal and environmental hygiene, due to inadequate sanitation, may aggravate situation by encouraging food contamination during food handling, preparation, and consumption. Consequently, the affected individuals will suffer from inherent risks of dangerous infectious diseases that will increase nutritional losses and/or altered metabolic demands. This scenario is likely to lead to repeated infections if the infrastructure lacks wellmaintained sewage and sanitation facilities and/or supply of adequate clean water. Constant or frequent exposure to infection/infestation with intestinal and other worms such as hook worms and fish tape worms, among others will also predispose to nutritional iron deficiency anemia. Many people living under deplorable health conditions will also be exposed to many other parasites, including ascariasis, which contribute to food deprivation.

**Chronic disease conditions and illnesses are important etiological factors of malnutrition:** [5, 6]. This is especially more so in developed countries. People with chronic illnesses (especially children) are at relatively higher risk of nutritional problems. Some of the contributing factors include the following: chronic illnesses are frequently associated with loss of appetite and therefore intake of inadequate food. Some chronic illnesses are also associated with increased metabolic demands, hence increasing caloric needs. Any chronic illness that adversely affects the liver, pancreas, or intestines has the potential of adversely impairing food digestion and absorption. Other chronic illnesses that are associated with malnutrition include surgical diseases (such as cleft lip and/or palate, chronic hypertrophic pyloric stenosis), malignancies, congenital heart diseases, chronic renal failure, chronic bowel inflammatory diseases (such as ulcerative colitis), neuromuscular diseases, and cystic fibrosis, among others. Furthermore, risk of nutritional deficiency may be due to prematurity, failure to thrive for whatever cause, and exposure to toxins *in utero* (e.g., alcohol intake during pregnancy).

**People with multiple food allergies (especially children) may become malnourished, due to challenges of dietary restrictions:** [5, 6]. People with active allergic symptoms may have increased calorie and protein needs. This is partly because their state of morbidity predisposes them to lack of appetite during the time of ill-health and therefore without extra dietary supplements they might become malnourished. Furthermore, the allergy to certain foods denies them the benefit of the nutrients found in the food they are allergic to. If there is lack of appropriate dietary substitute, then the affected individuals will become malnourished with time.

#### **5. Classification of malnutrition**

Malnutrition can be classified into different categories [3, 7], namely, undernutrition, overnutrition, micronutrient-related malnutrition, severe acute (SAM), moderate acute (MAM), and global acute malnutrition (GAM), respectively. The assessment of body mass index (BMI) is one of the major ways of differentiating some of these categories. Details of BMI will be given later in the chapter.

Undernutrition consists of stunting, wasting, underweight, and micronutrient deficiencies. Stunting refers to a situation whereby children have a lower than normal height-for-age. Wasting refers to lower than normal weight-for-height, while underweight refers to lower than normal weight-for-age. Micronutrient deficiency refers to inadequate intake of vitamins and minerals. In more technical terms, the World Health Organization [3] defines these terms as follows. Underweight is defined as weight for age < 2 standard deviations (SD) of the WHO Child Growth Standards median. Stunting is defined as height for age < 2 SD of

the WHO Child Growth Standards median. Wasting is defined as weight for height < 2 SD of the WHO Child Growth Standards median. The predisposing factors to some of these are known. Low birth weight is associated with intrauterine growth retardation or restriction, prematurity, or both. This situation is likely to ultimately predispose to poor health in the vulnerable societies. These situations, in addition to aggravating growth and cognitive and chronic disease development in adulthood, also predispose to morbidity and mortality, especially of neonates. Low-birth-weight infants are 20 times more likely to die of these than healthier infants.

they have good nutrition [14]. Nevertheless, the criticism led to the establishment of a new classification of malnutrition by John Conrad Waterlow [15]. Waterlow classification therefore combines weight-for-height (indicating acute episodes of malnutrition) with height-for-age to show the stunting that results from chronic malnutrition [16]. One advantage of the Waterlow classification over the Gomez classification is the fact that weight for height can be examined even if ages are not known [15]. The World Health Organization has since modified some of these

Stunting, wasting, underweight, and overweight indicators are important for

assessing nutritional imbalance resulting in undernutrition among children, according to the World Health Organization [12]. As far as child growth is concerned, it is internationally recognized as an important indicator of health in populations. It is also important as indicator for nutritional status. The cumulative effects of malnutrition and the consequent complications among children are reflected by the percentages of children with stunting (low height for age) from and even before birth. The degree of stunting can therefore be interpreted as an indicator for the existence of poor environmental conditions that have the potential of restricting child growth. The proportion of underweight and/or wasted children also indicates acute weight loss, stunting, or both. Hence, it may be difficult to interpret 'underweight' because it is a composite indicator. Thus, underweight, even in its mildest form, indicates increased risk of childhood mortality, and this risk increases among severely underweight children. Inadequate food and recurrent childhood infections also have a tendency to increase the risk of mortality among affected children. Stunting predisposes to poor child performance in school and also to delayed developmental milestones and decreased intellectual development in terms of capacity. Childhood wasting also predisposes

to immunosuppression, subsequently leading to increased susceptibility to

**8. Importance of malnutrition classification in women**

healthcare of the mother and baby during pregnancy.

Childhood obesity may precede the same in adulthood. Overweight and obesity (especially in adolescence and childhood) increase the risk of developing short- or long-term health problems, notably cardiovascular disorders and diabetes mellitus. Also, among the risks are musculoskeletal disorders (e.g., osteoarthritis) and malignancies of the breast, colon, and/or endometrium. The assessment of nutritional status of a given population is an important indicator for moderate and/or severe

Chronic malnutrition may adversely affect the growth of bones in girls, such that those affected are likely to have abnormal short stature, with relatively smaller pelvis than women with normal growth. Thus, the affected women may get complications during child birth, which might cause obstructed labor that might be dangerous for the baby, the mother, or both. Other birth-related complications of such mothers include the birth of babies with lower weight than normal (low birth weight babies), retarded intrauterine growth, and short stature later in adult life. Their likely general maternal morbidity may also adversely affect quality of

**7. Importance of malnutrition classification in children**

*Malnutrition: Current Challenges and Future Perspectives*

*DOI: http://dx.doi.org/10.5772/intechopen.92007*

classifications [9].

infections.

malnutrition.

**45**

Overnutrition comprises obesity and overweight. These are important because they are increasingly associated with lifestyle disorders, notably diabetes mellitus and cardiovascular diseases capable of complicating to stroke and even cancer that are responsible for morbidity and mortality from noncommunicable diseases. In more technical terms, overweight is defined as weight for height > +2 SD of the WHO Child Growth Standards median. Whereas undernutrition is prevalent among societies with inadequate food and the other predisposing factors already described, overnutrition is conversely associated with more affluent societies who tend to live more sedentary lives and can afford more palatable and fast-prepared junk food. These types of food stuffs are relatively cheap and readily available to a large section of the world population. No wonder the upsurge in related nutritional disorders. Variations in nutritional status may also be seen in individual families in a given community.

Micronutrient-related malnutrition occurs due to inadequate intake of vitamins and minerals. Micronutrients enable the body to produce enzymes, hormones, and other essential substances needed for proper growth and development of the human body. Among the micronutrients most essential are iodine, vitamin A, and iron. The deficiency of these micronutrients paused major health threats especially among children and pregnant women from low socioeconomic status.

The following categories are mainly for purposes of management of malnutrition [8]. Moderate acute malnutrition (MAM) refers to weight-for-height *z*-score (WHZ) between 2 and 3 or mid-upper arm circumference (MUAC) between 115 and <125 mm. Severe acute malnutrition (SAM) refers to WHZ < 3 or MUAC <115 mm, or the presence of bilateral pitting edema, or both. Global acute malnutrition (GAM) refers to the combination of MAM and SAM and is used as a measurement of nutritional status at a population level and as an indicator of the severity of an emergency situation. The prevalence thresholds for severity of malnutrition among children aged five and below are described elsewhere [5, 9–11].

#### **6. Historical background and importance of classifying malnutrition**

Part of the documented historical background of the classifications of malnutrition dates back to 1956, when Gómez and Galvan studied the factors they thought were associated with death among malnourished children Mexico City [12]. Initially, this classification was based on first, second, and third degrees, respectively [13]. The degrees were based on weight below a specified percentage of median weight for age [9] According to this classification, the risk of death increases with increasing degree of malnutrition [13]. An adaptation of Gomez's original classification is still used today. Whereas this modification provides a way of comparing malnutrition within and between populations, this classification has been criticized as too arbitrary and does not consider overweight as a classification of malnutrition, apart from the fact that height alone may not be the best indicator of malnutrition. Children who are born prematurely may be considered short for their age even if

the WHO Child Growth Standards median. Wasting is defined as weight for height < 2 SD of the WHO Child Growth Standards median. The predisposing factors to some of these are known. Low birth weight is associated with intrauterine growth retardation or restriction, prematurity, or both. This situation is likely to ultimately predispose to poor health in the vulnerable societies. These situations, in addition to aggravating growth and cognitive and chronic disease development in adulthood, also predispose to morbidity and mortality, especially of neonates. Low-birth-weight

Overnutrition comprises obesity and overweight. These are important because they are increasingly associated with lifestyle disorders, notably diabetes mellitus and cardiovascular diseases capable of complicating to stroke and even cancer that are responsible for morbidity and mortality from noncommunicable diseases. In more technical terms, overweight is defined as weight for height > +2 SD of the WHO Child Growth Standards median. Whereas undernutrition is prevalent among societies with inadequate food and the other predisposing factors already described, overnutrition is conversely associated with more affluent societies who tend to live more sedentary lives and can afford more palatable and fast-prepared junk food. These types of food stuffs are relatively cheap and readily available to a large section of the world population. No wonder the upsurge in related nutritional disorders. Variations in nutritional status may also be seen in individual families in a given

Micronutrient-related malnutrition occurs due to inadequate intake of vitamins and minerals. Micronutrients enable the body to produce enzymes, hormones, and other essential substances needed for proper growth and development of the human body. Among the micronutrients most essential are iodine, vitamin A, and iron. The deficiency of these micronutrients paused major health threats especially among

The following categories are mainly for purposes of management of malnutrition [8]. Moderate acute malnutrition (MAM) refers to weight-for-height *z*-score (WHZ) between 2 and 3 or mid-upper arm circumference (MUAC) between 115 and <125 mm. Severe acute malnutrition (SAM) refers to WHZ < 3 or MUAC <115 mm, or the presence of bilateral pitting edema, or both. Global acute malnutrition (GAM) refers to the combination of MAM and SAM and is used as a measurement of nutritional status at a population level and as an indicator of the severity of an emergency situation. The prevalence thresholds for severity of malnutrition among children aged five and below are described else-

**6. Historical background and importance of classifying malnutrition**

Part of the documented historical background of the classifications of malnutrition dates back to 1956, when Gómez and Galvan studied the factors they thought were associated with death among malnourished children Mexico City [12]. Initially, this classification was based on first, second, and third degrees, respectively [13]. The degrees were based on weight below a specified percentage of median weight for age [9] According to this classification, the risk of death increases with increasing degree of malnutrition [13]. An adaptation of Gomez's original classification is still used today. Whereas this modification provides a way of comparing malnutrition within and between populations, this classification has been criticized as too arbitrary and does not consider overweight as a classification of malnutrition, apart from the fact that height alone may not be the best indicator of malnutrition. Children who are born prematurely may be considered short for their age even if

infants are 20 times more likely to die of these than healthier infants.

children and pregnant women from low socioeconomic status.

community.

*Malnutrition*

where [5, 9–11].

**44**

they have good nutrition [14]. Nevertheless, the criticism led to the establishment of a new classification of malnutrition by John Conrad Waterlow [15]. Waterlow classification therefore combines weight-for-height (indicating acute episodes of malnutrition) with height-for-age to show the stunting that results from chronic malnutrition [16]. One advantage of the Waterlow classification over the Gomez classification is the fact that weight for height can be examined even if ages are not known [15]. The World Health Organization has since modified some of these classifications [9].

#### **7. Importance of malnutrition classification in children**

Stunting, wasting, underweight, and overweight indicators are important for assessing nutritional imbalance resulting in undernutrition among children, according to the World Health Organization [12]. As far as child growth is concerned, it is internationally recognized as an important indicator of health in populations. It is also important as indicator for nutritional status. The cumulative effects of malnutrition and the consequent complications among children are reflected by the percentages of children with stunting (low height for age) from and even before birth. The degree of stunting can therefore be interpreted as an indicator for the existence of poor environmental conditions that have the potential of restricting child growth. The proportion of underweight and/or wasted children also indicates acute weight loss, stunting, or both. Hence, it may be difficult to interpret 'underweight' because it is a composite indicator. Thus, underweight, even in its mildest form, indicates increased risk of childhood mortality, and this risk increases among severely underweight children. Inadequate food and recurrent childhood infections also have a tendency to increase the risk of mortality among affected children. Stunting predisposes to poor child performance in school and also to delayed developmental milestones and decreased intellectual development in terms of capacity. Childhood wasting also predisposes to immunosuppression, subsequently leading to increased susceptibility to infections.

Childhood obesity may precede the same in adulthood. Overweight and obesity (especially in adolescence and childhood) increase the risk of developing short- or long-term health problems, notably cardiovascular disorders and diabetes mellitus. Also, among the risks are musculoskeletal disorders (e.g., osteoarthritis) and malignancies of the breast, colon, and/or endometrium. The assessment of nutritional status of a given population is an important indicator for moderate and/or severe malnutrition.

#### **8. Importance of malnutrition classification in women**

Chronic malnutrition may adversely affect the growth of bones in girls, such that those affected are likely to have abnormal short stature, with relatively smaller pelvis than women with normal growth. Thus, the affected women may get complications during child birth, which might cause obstructed labor that might be dangerous for the baby, the mother, or both. Other birth-related complications of such mothers include the birth of babies with lower weight than normal (low birth weight babies), retarded intrauterine growth, and short stature later in adult life. Their likely general maternal morbidity may also adversely affect quality of healthcare of the mother and baby during pregnancy.

#### **8.1 Anthropometric measurements**

The major mode of assessment of nutritional status of gravid women and children is by the use of anthropometry (the process by which anthropometric measurements are serially taken). The measurements have been developed and improved over time. These measurements taken quantitatively and involve measurements of muscle girth, bulk, and sometimes muscle power and tone if other inherent nervous system problems are suspected. Bone length and density as well as quantity of adipose tissue may also be measured. However, the main anthropometric measurements are those of weight and height, and from these two, the body mass index (BMI) may be calculated. Also important are the measurements of head circumference, waist, hip, and limb circumferences as well as the thickness of skin folds. As already discussed in the previous section, such measurements are important in assessing the nutritional status of children and pregnant mothers. For children, the individual measurements done, respectively, determine whether or not each child is normally growing, is stunted, is wasted, or is underweight. For pregnant women, the measurements will determine timely interventions of correcting the malnutrition and even the mode of delivery (normal or assisted vaginal delivery or by Cesarean section). The measurement will therefore also determine the place and cost of delivery if specialists may be required during and after delivery. The type of nutritional follow up will also be determined by the serial quantitative anthropometric measurements. In more sophisticated healthcare set-ups such as in developed countries [17–19], anthropometry is not only vital for timely and appropriate diagnosis of abnormalities such as microcephaly, macrocephaly, anencephaly, diabetes mellitus, hypertension, and other lifestyle-related illnesses, but it also enables early diagnosis of metabolic syndrome and dyslipidemia, among others. Furthermore, the measurements are helpful in initial assessment and progress of physical fitness of athletes and even the general population [18, 19] and for monitoring of nutritional status of children and pregnant mothers [20, 21] by the use of newer scientific methods in comparison to conventional ones.

**8.2 Pathophysiology of malnutrition**

*DOI: http://dx.doi.org/10.5772/intechopen.92007*

*Malnutrition: Current Challenges and Future Perspectives*

retardation [22].

**47**

**8.3 Clinical presentation of malnutrition**

Malnutrition and its complications may affect virtually part of the human body

Among the adjustments are reduced thyroxine and insulin productions to mini-

mize metabolic rate and increase glucose availability for generation of energy, respectively. Consequently, protein deficiency leads to impaired/arrested or failed

suppressed due to relatively reduced antibody production occasioned by protein deficiency. Other immune response changes include decreased complement system and certain cytokine functioning, impaired phagocytosis due to decreased Tlymphocyte levels, loss of delayed hypersensitivity, and decreased secretion of immunoglobulin A (IgA). These are subsequently associated with increased susceptibility to a wide variety of infections. Diarrhea from the infections may further aggravate the situation by causing anorexia, decreased nutrient absorption (also due to villous atrophy that occurs especially in kwashiorkor), and direct nutrient losses, among other changes requiring increased metabolic needs of the body. In order for the body to meet its energy demands, the body resorts to breaking down stored fat and muscles, resulting in body wasting seen especially in marasmus. Other pathological changes within the brain that have been confirmed in various studies, include reduced myelination, brain neurons, weight and growth rate, thinning of the cerebral cortex, and changes in the dendritic spines in severely malnourished infants. Fatty degeneration of the liver and the heart coupled by small bowel atrophy and decreased intravascular volume may result in secondary hyperaldosteronism in some. A differential diagnosis of these changes is severe mental

Protein energy malnutrition (PEM), sometimes synonymously described as undernutrition, commonly presents with a myriad of clinical symptoms and signs [6]. The complaints elicited during history taking typically include poor weight gain, slowing of linear growth, behavioral changes such as apathy (lack of interest in surroundings), irritability, anxiety, impaired social responsiveness, and some deficits in attention. Oedema, apathy, hair and skin changes, and reduction of subcutaneous tissue are frequently observable in patients with PEM [23], and the most affected are the face, arms, legs, and buttocks. It is not unusual to find coexistence of PEM with deficiency of micronutrients, especially in developing countries. The micronutrient-deficient individuals may actually present with features resembling those of PEM. Kwashiorkor and marasmus are two forms of PEM that commonly coexist (hence known as marasmic-kwashiorkor) or may be distinct as separate clinical entities [24]. PEM may cause cognitive impairment, especially if the nutritional deficiency occurs between the third trimester of pregnancy and the first 2 years of life [25]. Iron deficiency anemia in children aged 2 years and below is likely to affect brain function as an acute and probably also as a chronic occurrence.

basically because the energy provided by various biomolecules, vitamins, and micronutrients is essential for all physiological and biochemical functions in the body [6, 22]. Dietary deficiency of these nutrients therefore adversely affects the functioning of the body. Digestion of protein to produce amino acids is required for

metabolism, enzymatic functions, and antibody production, among others. Micronutrients are required as cofactors for various metabolic functions essential for the body. When nutritional deficiency occurs, the body is forced to readjust its hormonal secretion and metabolic functions (a process known as reductive adapta-

tion) in order to economize on the available nutrients for survival.

physical growth and/or cognitive development. Immunity may also be

However, there are situations whereby such measurements are discouraged. These include individuals who have undergone limb amputation or those with Plaster of Paris. Anthropometric measurements may be erroneous for those with gross abdominal obesity because of difficulties of locating important reference bony landmarks. Inexperienced personnel taking the measurements may also increase the chances of erroneous measurements.

The body mass index (BMI, which is the weight in kilograms divided by the square of the height in meters—kg/m<sup>2</sup> ) is helpful in determining the classification of obesity, overweight, or underweight in both children and adults. The range of measurements calculated in this manner, in relation to given limits for the normal and abnormal values, will determine whether or not an individual is healthy in terms of BMI. Normal weight BMI range is generally between 18.5 and 24.9. Moderate to severe thinness in adults is indicated by BMI < 17.0, whereas a BMI < 18.5 is an indication of underweight. Individuals considered overweight are those with BMI ≥ 25.0, while those considered obese have BMI ≥ 30.0. The health implications of underweight, obesity, and overweight have already been discussed in the previous section. Generally, overweight and obesity predispose to a wide range of noncommunicable diseases. Among these are malignancies of various types, musculoskeletal and respiratory disorders, gallbladder diseases, ischemic (coronary) heart disease, and associated complications such as heart attack and stroke, among others. Some of these drastically reduce the lifespan and/or quality of life of affected individuals. The significance and implications of BMI are therefore of paramount importance in public health, which cannot be anymore overemphasized.

#### **8.2 Pathophysiology of malnutrition**

**8.1 Anthropometric measurements**

*Malnutrition*

The major mode of assessment of nutritional status of gravid women and children is by the use of anthropometry (the process by which anthropometric measurements are serially taken). The measurements have been developed and improved over time. These measurements taken quantitatively and involve measurements of muscle girth, bulk, and sometimes muscle power and tone if other inherent nervous system problems are suspected. Bone length and density as well as quantity of adipose tissue may also be measured. However, the main anthropometric measurements are those of weight and height, and from these two, the body mass index (BMI) may be calculated. Also important are the measurements of head circumference, waist, hip, and limb circumferences as well as the thickness of skin folds. As already discussed in the previous section, such measurements are important in assessing the nutritional status of children and pregnant mothers. For children, the individual measurements done, respectively, determine whether or not each child is normally growing, is stunted, is wasted, or is underweight. For pregnant women, the measurements will determine timely interventions of correcting the malnutrition and even the mode of delivery (normal or assisted vaginal delivery or by Cesarean section). The measurement will therefore also determine the place and cost of delivery if specialists may be required during and after delivery. The type of nutritional follow up will also be determined by the serial quantitative anthropometric measurements. In more sophisticated healthcare set-ups such as in developed countries [17–19], anthropometry is not only vital for timely and appropriate diagnosis of abnormalities such as microcephaly, macrocephaly, anencephaly, diabetes mellitus, hypertension, and other lifestyle-related illnesses, but it also enables early diagnosis of metabolic syndrome and dyslipidemia, among others. Furthermore, the measurements are helpful in initial assessment and progress of physical fitness of athletes and even the general population [18, 19] and for monitoring of nutritional status of children and pregnant mothers [20, 21] by the use of

newer scientific methods in comparison to conventional ones.

chances of erroneous measurements.

square of the height in meters—kg/m<sup>2</sup>

**46**

However, there are situations whereby such measurements are discouraged. These include individuals who have undergone limb amputation or those with Plaster of Paris. Anthropometric measurements may be erroneous for those with gross abdominal obesity because of difficulties of locating important reference bony landmarks. Inexperienced personnel taking the measurements may also increase the

The body mass index (BMI, which is the weight in kilograms divided by the

of obesity, overweight, or underweight in both children and adults. The range of measurements calculated in this manner, in relation to given limits for the normal and abnormal values, will determine whether or not an individual is healthy in terms of BMI. Normal weight BMI range is generally between 18.5 and 24.9. Moderate to severe thinness in adults is indicated by BMI < 17.0, whereas a BMI < 18.5 is an indication of underweight. Individuals considered overweight are those with BMI ≥ 25.0, while those considered obese have BMI ≥ 30.0. The health implications of underweight, obesity, and overweight have already been discussed in the previous section. Generally, overweight and obesity predispose to a wide range of noncommunicable diseases. Among these are malignancies of various types, musculoskeletal and respiratory disorders, gallbladder diseases, ischemic (coronary) heart disease, and associated complications such as heart attack and stroke, among others. Some of these drastically reduce the lifespan and/or quality of life of affected individuals. The significance and implications of BMI are therefore of paramount

importance in public health, which cannot be anymore overemphasized.

) is helpful in determining the classification

Malnutrition and its complications may affect virtually part of the human body basically because the energy provided by various biomolecules, vitamins, and micronutrients is essential for all physiological and biochemical functions in the body [6, 22]. Dietary deficiency of these nutrients therefore adversely affects the functioning of the body. Digestion of protein to produce amino acids is required for metabolism, enzymatic functions, and antibody production, among others. Micronutrients are required as cofactors for various metabolic functions essential for the body. When nutritional deficiency occurs, the body is forced to readjust its hormonal secretion and metabolic functions (a process known as reductive adaptation) in order to economize on the available nutrients for survival.

Among the adjustments are reduced thyroxine and insulin productions to minimize metabolic rate and increase glucose availability for generation of energy, respectively. Consequently, protein deficiency leads to impaired/arrested or failed physical growth and/or cognitive development. Immunity may also be suppressed due to relatively reduced antibody production occasioned by protein deficiency. Other immune response changes include decreased complement system and certain cytokine functioning, impaired phagocytosis due to decreased Tlymphocyte levels, loss of delayed hypersensitivity, and decreased secretion of immunoglobulin A (IgA). These are subsequently associated with increased susceptibility to a wide variety of infections. Diarrhea from the infections may further aggravate the situation by causing anorexia, decreased nutrient absorption (also due to villous atrophy that occurs especially in kwashiorkor), and direct nutrient losses, among other changes requiring increased metabolic needs of the body. In order for the body to meet its energy demands, the body resorts to breaking down stored fat and muscles, resulting in body wasting seen especially in marasmus. Other pathological changes within the brain that have been confirmed in various studies, include reduced myelination, brain neurons, weight and growth rate, thinning of the cerebral cortex, and changes in the dendritic spines in severely malnourished infants. Fatty degeneration of the liver and the heart coupled by small bowel atrophy and decreased intravascular volume may result in secondary hyperaldosteronism in some. A differential diagnosis of these changes is severe mental retardation [22].

#### **8.3 Clinical presentation of malnutrition**

Protein energy malnutrition (PEM), sometimes synonymously described as undernutrition, commonly presents with a myriad of clinical symptoms and signs [6]. The complaints elicited during history taking typically include poor weight gain, slowing of linear growth, behavioral changes such as apathy (lack of interest in surroundings), irritability, anxiety, impaired social responsiveness, and some deficits in attention. Oedema, apathy, hair and skin changes, and reduction of subcutaneous tissue are frequently observable in patients with PEM [23], and the most affected are the face, arms, legs, and buttocks. It is not unusual to find coexistence of PEM with deficiency of micronutrients, especially in developing countries. The micronutrient-deficient individuals may actually present with features resembling those of PEM. Kwashiorkor and marasmus are two forms of PEM that commonly coexist (hence known as marasmic-kwashiorkor) or may be distinct as separate clinical entities [24]. PEM may cause cognitive impairment, especially if the nutritional deficiency occurs between the third trimester of pregnancy and the first 2 years of life [25]. Iron deficiency anemia in children aged 2 years and below is likely to affect brain function as an acute and probably also as a chronic occurrence.

Similarly, the deficiency of folic acid has also been associated with defective development of neural tubes.

abnormally low serum albumin levels. Metabolism in such a child is adapted to prolonged survival [24, 27]. In contrast to the situation in kwashiorkor, muscle wasting in marasmus is associated with loss of subcutaneous tissue. Marasmus in some semiliterate societies is sometimes described as 'a child with an appearance of an old man wearing an oversized coat', for lack of better description to make it better understood by those very ignorant of the dangerous situation the child is in and requiring urgent intervention. The child's interest in surroundings and playful nature is therefore deceptive. Marasmus is typically seen in places with severe famine, conflict or war-torn areas with significant food restriction, or more severe cases of anorexia [24]. A child with marasmus may be anemic, but less so than kwashiorkor and hair changes are also fewer than in kwashiorkor. Tuberculosis and other secondary coinfections may occur and should therefore be sought carefully. Complications of malnutrition include infections, hypothermia, hypoglycemia, anemia, dehydration, electrolyte imbalance, growth retardation/failure to thrive, and thrombocytopenia/disseminated intravascular coagulopathy (DIC), among

*Malnutrition: Current Challenges and Future Perspectives*

*DOI: http://dx.doi.org/10.5772/intechopen.92007*

**8.4 Micronutrients (vitamins, minerals, and trace elements) and their toxicities**

deficiencies and toxicities are hereby tabulated (**Table 1**).

**8.5 Useful investigations**

**49**

Micronutrients (vitamins, minerals, and trace elements), in addition to essential fatty acids and amino acids [28, 29], are important for health. Fat-soluble vitamins are A, D, E, and K, while B and C are water-soluble vitamins. Fat-soluble vitamins have a higher potential for toxicity than do water-soluble vitamins, owing to their ability to accumulate in the body. The most toxic are those vitamins that contain iron, especially the following acute ingestions by affected children. In the context of nutrition, a mineral is a chemical element required as an essential nutrient by organisms to perform functions necessary for life [30, 31]. Since minerals are elements, they cannot be synthesized biochemically by living organisms but are obtained by plants from soil [32]. Human beings obtain most of their minerals from eating plants and animals or from drinking water [32]. The five major minerals in the human body are calcium, phosphorus, potassium, sodium, and magnesium [30, 33]. The rest of the elements (at least 20 of them) with specific biochemical body functions are sulfur, iron, chlorine, cobalt, copper, zinc, manganese, molybdenum, iodine, and selenium, which serve as structural and functional roles and electrolytes [30, 34]. The most abundant elements in the body are oxygen, hydrogen, carbon, and nitrogen. Calcium makes up to 99% of bones and teeth and making up about 1.5% of body weight. Phosphorus makes up about two thirds of calcium and about 1% of a person's body weight, while the other major minerals (sodium, potassium, chlorine, sulfur, and magnesium) constitute about 0.85% of the body weight. Overall, the 11 chemical elements (H, C, N, O, Ca, P, K, Na, Cl, S, and Mg) constitute 99.85% of the human body, with the rest forming only 0.15% of the human body [33]. The main sources and clinical presentation of micronutrient

Laboratory studies are done based on information from a complete history and physical examination [6]. The most helpful laboratory studies in assessing malnutrition in a child are hematological studies and laboratory studies evaluating protein status. Hematological studies should include a complete blood count (CBC) with red blood cell (RBC) indices, serum electrolytes, sedimentation rate, urinalysis, culture, and a peripheral smear. The blood tests help to exclude anemia from various nutritional deficiencies, including iron, folic acid, and vitamin B-12

others.

'Kwashiorkor', which is a Ghanaian term that means 'the sickness the older one gets when the next sibling is born', is caused by inadequate consumption of dietary protein [24]. The descriptive definition rightly identifies the fact that the older sibling is deprived of breast feeding and instead is weaned on a diet composed largely of carbohydrates and devoid of proteins [26], thus rendering the older sibling malnourished. The clinical presentation of kwashiorkor mainly includes but exclusive to oedema, apathy, failure to thrive, underweight, and hair changes. Oedema occurs due to hypoalbuminemia following decreased oncotic pressure and consequent fluid extravasation to tissues. Oedema affects the face and the upper and lower extremities and may be slight or gross (anasarca), depending on the degree of protein deficiency. The presence of ascites and pleural effusion suggests the existence of peritoneal infection with tuberculosis (TB peritonitis). Failure to thrive (underweight, usually between 60 and 80% of expected body weight or failed growth) commonly occurs and may be masked by oedema, especially in lower extremities. Unlike in marasmus, kwashiorkor presents with muscle wasting (but with retention of subcutaneous tissue). Wasting of muscles is especially seen on chest, upper arms, and gluteal area. Children with high intake of carbohydrates (hence known as 'sugar babies') but with coexisting kwashiorkor tend to have generalized puffiness and much subcutaneous fat but no skin changes. Those affected also frequently have very low albumin levels. Close observation of an affected child will typically reveal apathy (due to mental changes, making the child apathetic and miserable; hence, the child may sit the whole day without interest in food or surroundings). This is in contrast with marasmus whereby the child is extremely wasted and hungry but may even be playful and interested in surroundings. Hair changes (altered texture, loss of luster, fine, straight, soft, scarce, and easily plucked hair with color changes ranging from brown, and reddish, to gray blond or white) are observable. Skin changes are also common, depicting pigmentation or depigmentation, desquamation (flunky-paint or irregular dermatoses), or ulceration. In severe cases of kwashiorkor, the skin may resemble extensive burns over the child's legs, buttocks, and perineum. Severe cases are prone to potentially fatal hypothermia, due to decreased basal metabolic rate (BMR); hence, the skin cannot respond to a fall in environmental temperature. Hypothermia victims may die especially at night when temperature is very low. Changes in mucous membranes include angular stomatitis, cheilosis, smooth tongue, perianal ulceration, and papillar atrophy. Hepatomegaly may occur due to fatty infiltration of the liver and also may occasion by profound but potentially fatal hypoglycemia. Gastrointestinal changes include anorexia, nausea, and vomiting. Diarrhea is nearly always profused and may result in dehydration and electrolyte imbalance. Dehydration is more chemical than infective in origin. If chemical (malabsorptive) diarrhea occurs, it causes decrease in enzymes, secondarily associated with villous atrophy (the atrophied portions are the tips where lactose is absorbed, hence resulting in lactose intolerance), low proteins, and pancreatic atrophy. Lactose intolerance may also occur and may be due to failure to absorb lactose, resulting in osmotic diarrhea. Lactose in the gut also predisposes to fermentation by normal gut flora, resulting in lactic acid formation, hypoperistalsis that may aggravate diarrhea. Anemia is frequently present and tends to display dimorphic (microcytic/macrocytic hypochromic) picture. If purpura and thrombocytopenia occur, they unfortunately indicate guarded/severe prognosis if no urgent management intervention is instituted.

'Marasmus' (which means 'to waste away') is caused by combined inadequate intake of protein and energy, which causes gaunt expression, severe wasting, leaving little or no edema, minimal subcutaneous fat, severe muscle wasting, and

Similarly, the deficiency of folic acid has also been associated with defective devel-

'Kwashiorkor', which is a Ghanaian term that means 'the sickness the older one gets when the next sibling is born', is caused by inadequate consumption of dietary protein [24]. The descriptive definition rightly identifies the fact that the older sibling is deprived of breast feeding and instead is weaned on a diet composed largely of carbohydrates and devoid of proteins [26], thus rendering the older sibling malnourished. The clinical presentation of kwashiorkor mainly includes but exclusive to oedema, apathy, failure to thrive, underweight, and hair changes. Oedema occurs due to hypoalbuminemia following decreased oncotic pressure and consequent fluid extravasation to tissues. Oedema affects the face and the upper and lower extremities and may be slight or gross (anasarca), depending on the degree of protein deficiency. The presence of ascites and pleural effusion suggests the existence of peritoneal infection with tuberculosis (TB peritonitis). Failure to thrive (underweight, usually between 60 and 80% of expected body weight or failed growth) commonly occurs and may be masked by oedema, especially in lower extremities. Unlike in marasmus, kwashiorkor presents with muscle wasting (but with retention of subcutaneous tissue). Wasting of muscles is especially seen on chest, upper arms, and gluteal area. Children with high intake of carbohydrates (hence known as 'sugar babies') but with coexisting kwashiorkor tend to have generalized puffiness and much subcutaneous fat but no skin changes. Those affected also frequently have very low albumin levels. Close observation of an affected child will typically reveal apathy (due to mental changes, making the child apathetic and miserable; hence, the child may sit the whole day without interest in food or surroundings). This is in contrast with marasmus whereby the child is extremely wasted and hungry but may even be playful and interested in surroundings. Hair changes (altered texture, loss of luster, fine, straight, soft, scarce, and easily plucked hair with color changes ranging from brown, and reddish, to gray blond or white) are observable. Skin changes are also common, depicting pigmentation or depigmentation, desquamation (flunky-paint or irregular dermatoses), or ulceration. In severe cases of kwashiorkor, the skin may resemble extensive burns over the child's legs, buttocks, and perineum. Severe cases are prone to potentially fatal hypothermia, due to decreased basal metabolic rate (BMR); hence, the skin cannot respond to a fall in environmental temperature. Hypothermia victims may die especially at night when temperature is very low. Changes in mucous membranes include angular stomatitis, cheilosis, smooth tongue, perianal ulceration, and papillar atrophy. Hepatomegaly may occur due to fatty infiltration of the liver and also may occasion by profound but potentially fatal hypoglycemia. Gastrointestinal changes include anorexia, nausea, and vomiting. Diarrhea is nearly always profused and may result in dehydration and electrolyte imbalance. Dehydration is more chemical than infective in origin. If chemical (malabsorptive) diarrhea occurs, it causes decrease in enzymes, secondarily associated with villous atrophy (the atrophied portions are the tips where lactose is absorbed, hence resulting in lactose intolerance), low proteins, and pancreatic atrophy. Lactose intolerance may also occur and may be due to failure to absorb lactose, resulting in osmotic diarrhea. Lactose in the gut also predisposes to fermentation by normal gut flora, resulting in lactic acid formation, hypoperistalsis that may aggravate diarrhea. Anemia is frequently present and tends to display dimorphic (microcytic/macrocytic hypochromic) picture. If purpura and thrombocytopenia occur, they unfortunately indicate guarded/severe prognosis if no urgent management intervention is instituted. 'Marasmus' (which means 'to waste away') is caused by combined inadequate intake of protein and energy, which causes gaunt expression, severe wasting, leaving little or no edema, minimal subcutaneous fat, severe muscle wasting, and

opment of neural tubes.

*Malnutrition*

**48**

abnormally low serum albumin levels. Metabolism in such a child is adapted to prolonged survival [24, 27]. In contrast to the situation in kwashiorkor, muscle wasting in marasmus is associated with loss of subcutaneous tissue. Marasmus in some semiliterate societies is sometimes described as 'a child with an appearance of an old man wearing an oversized coat', for lack of better description to make it better understood by those very ignorant of the dangerous situation the child is in and requiring urgent intervention. The child's interest in surroundings and playful nature is therefore deceptive. Marasmus is typically seen in places with severe famine, conflict or war-torn areas with significant food restriction, or more severe cases of anorexia [24]. A child with marasmus may be anemic, but less so than kwashiorkor and hair changes are also fewer than in kwashiorkor. Tuberculosis and other secondary coinfections may occur and should therefore be sought carefully.

Complications of malnutrition include infections, hypothermia, hypoglycemia, anemia, dehydration, electrolyte imbalance, growth retardation/failure to thrive, and thrombocytopenia/disseminated intravascular coagulopathy (DIC), among others.

#### **8.4 Micronutrients (vitamins, minerals, and trace elements) and their toxicities**

Micronutrients (vitamins, minerals, and trace elements), in addition to essential fatty acids and amino acids [28, 29], are important for health. Fat-soluble vitamins are A, D, E, and K, while B and C are water-soluble vitamins. Fat-soluble vitamins have a higher potential for toxicity than do water-soluble vitamins, owing to their ability to accumulate in the body. The most toxic are those vitamins that contain iron, especially the following acute ingestions by affected children. In the context of nutrition, a mineral is a chemical element required as an essential nutrient by organisms to perform functions necessary for life [30, 31]. Since minerals are elements, they cannot be synthesized biochemically by living organisms but are obtained by plants from soil [32]. Human beings obtain most of their minerals from eating plants and animals or from drinking water [32]. The five major minerals in the human body are calcium, phosphorus, potassium, sodium, and magnesium [30, 33]. The rest of the elements (at least 20 of them) with specific biochemical body functions are sulfur, iron, chlorine, cobalt, copper, zinc, manganese, molybdenum, iodine, and selenium, which serve as structural and functional roles and electrolytes [30, 34]. The most abundant elements in the body are oxygen, hydrogen, carbon, and nitrogen. Calcium makes up to 99% of bones and teeth and making up about 1.5% of body weight. Phosphorus makes up about two thirds of calcium and about 1% of a person's body weight, while the other major minerals (sodium, potassium, chlorine, sulfur, and magnesium) constitute about 0.85% of the body weight. Overall, the 11 chemical elements (H, C, N, O, Ca, P, K, Na, Cl, S, and Mg) constitute 99.85% of the human body, with the rest forming only 0.15% of the human body [33]. The main sources and clinical presentation of micronutrient deficiencies and toxicities are hereby tabulated (**Table 1**).

#### **8.5 Useful investigations**

Laboratory studies are done based on information from a complete history and physical examination [6]. The most helpful laboratory studies in assessing malnutrition in a child are hematological studies and laboratory studies evaluating protein status. Hematological studies should include a complete blood count (CBC) with red blood cell (RBC) indices, serum electrolytes, sedimentation rate, urinalysis, culture, and a peripheral smear. The blood tests help to exclude anemia from various nutritional deficiencies, including iron, folic acid, and vitamin B-12


Vitamin K-1 supplements are usually 2.5– 10 mg. Phytonadione promotes liver synthesis of factors II, VII, IX, and X

**Vitamin B Vitamin B-1** (thiamin): found in organ

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**Vitamin C** (ascorbic acid)

**51**

meats, yeast, eggs, and green, leafy vegetables. Vitamin B-1 supplements usually contain 50–500 mg of vitamin B-1 per tablet. This vitamin is a cofactor for pyruvate dehydrogenase in the Krebs cycle. The RDA is 1.5 mg (0.7 mg for children aged 1–4 years). **Vitamin B-2:** The RDA for vitamin B-2 (riboflavin) is 1.7 mg (0.8 mg for children aged 1–4 years). Supplements usually are 25–100 mg. **Vitamin B-3** (niacin) is found in green vegetables, yeast (pumpernickel bagels may contain 190 mg of niacin), animal proteins, fish, liver, and legumes. Supplements are usually 20– 500 mg per tablet. Vitamin B-3 synthesis requires tryptophan. Niacin is converted to nicotinamide adenine dinucleotide (NAD) or nicotinamide adenine dinucleotide phosphate (NADP). NAD and NADP are coenzymes for dehydrogenase-type reactions. **Vitamin B-6** functions in protein and amino acid metabolism. Pyridoxine is the treatment of choice for isoniazid overdose. It is also used by bodybuilders, as well as for the treatment, with varying results, of the following [40]: premenstrual syndrome (PMS), Carpal tunnel syndrome, Schizophrenia, Childhood autism, Attention deficit hyperactivity disorder (ADHD). **Vitamin B-12** (cyanocobalamin), which requires an intrinsic factor for absorption, is found in milk products, eggs, fish, poultry, and meat. Supplements usually contain 25–250 mcg of the vitamin per tablet. Vitamin B-12 is a treatment of pernicious anemia and cyanide poisoning

**Functions:** An antioxidant and reducing agent, its controversial uses include treatment of upper respiratory tract infections and cancer [41]. Supplements are usually 100–2000 mg per capsule. **Sources**: Vitamin C is found in citrus fruits

tube defects and may reduce serum homocysteine levels (which are a coronary artery disease risk factor). It may also have a therapeutic role as an adjuvant therapy for the treatment of methanol toxicity, since it enhances the elimination of formate. **Sources**: Folate is found in oranges and green, leafy vegetables

and vegetables

**Folate** (folic acid) **Functions**: Decreases the risk of neural

**toxicity**

[38, 39]

tablet

administration of vitamin K corrects this. High doses of vitamin E increase the vitamin K requirement; coagulopathy can occur in patients who are deficient in vitamin K [38, 39] (concomitant use of vitamin E and anticoagulants can also increase the risk of bleeding complications)

In large doses, niacin decreases synthesis of LDL cholesterol level. The RDA is 20 mg (9 mg for children aged 1–4 years). Vitamin B-6 (i.e., pyridoxine) is found in poultry, fish, pork, grains, and legumes. Supplements usually are 5–500 mg per

Rebound scurvy (in infants born to women

Glossitis, anemia (megaloblastic), and neural tube defects (in fetuses of women without folate supplementation)

taking high doses), renal colic (nephrolithiasis), diarrhea nausea, hemolysis (if glucose-6-phosphate dehydrogenase (G6PD) deficiency is present), dental decalcification, increased estrogen levels, occult rectal bleeding

Pro-vitamin A plant carotenoids (mainly carrots), animal products (liver, milk, kidney, fish oil), fortified foods, and drug supplements. Aids in night vision, growth. Isotretinoin (Accutane) used for the treatment of severe forms of acne, is closely related to the chemical structure of vitamin A (hence similar pharmacology and

Dairy products, egg yolks, liver, and fish. It facilitates calcium absorption and mobilizes

Vegetable oil, nuts, sunflower, wheat, green leafy vegetables, fish. It is an antioxidant and free-radical scavenger in lipophilic environments. Storage of the vitamin occurs in adipose tissue, the liver, and muscle. Vitamin E may block absorption of vitamins A and K. It also decreases low-density lipoprotein (LDL) cholesterol level at doses more than

Produced by intestinal bacteria (vitamin K-2) and is found in green, leafy vegetables; cow's milk; and soy oil (vitamin K-1).

calcium from bone

400 IU/day

toxicity)

**Vitamin A** (Retinol)

*Malnutrition*

**Vitamin D** (Cholecalciferol)

**Vitamin E** (tocopherol and tocotrienol)

**Vitamin K** (phytonadione)

**50**

**toxicity**

**Vitamin A deficiency** presents with night blindness, xerophthalmia, poor growth, and hair changes. Birth defects (when taken during pregnancy), intracranial hypertension, depression, and suicidal ideation have been reported with isotretinoin. **In acute vitamin A toxicity**, some or all of the following may be present: nausea, vomiting, anorexia, irritability, drowsiness, altered mental status, abdominal pain, blurred vision, headache, muscle pain with weakness, seizures. **In chronic vitamin A toxicity,** some or all of the following may be present: anorexia, hair loss, dryness of mucus membranes, fissures of the lips, pruritus, fever, headache, insomnia, fatigue, irritability, weight loss, bone fracture [35], hyperlipidemia, hypercalcemia [36]. Anemia, bone and joint pains, diarrhea, menstrual abnormalities, epistaxis. Vitamin A may cause increased bone resorption and promote the development of osteoporosis. **Carotenemia** (excess vitamin A intake) has no adverse consequences because the conversion of carotenes to retinol is not sufficient to cause toxicity. Carotenemia is manifested by a yellow-orange coloring of the skin, primarily the palms of the hands and the soles of the feet. It differs from jaundice in that the sclerae remain white

**Vitamin D deficiency**: Poor growth, rickets, and hypercalcemia. Place patients with vitamin D toxicity on a low-calcium diet. Consider oral calcium disodium edetate to increase fecal excretion of calcium. In cases of severe hypercalcemia, patients may require hydration, diuretics,

Since vitamin E may block absorption of vitamin K, a nutritional assessment for vitamin K deficiency is useful in patients who present with bleeding and a prolonged prothrombin time (PT). The effects of **acute vitamin E toxicity** include nausea, gastric distress, abdominal cramps, diarrhea, headache, fatigue, easy bruising, and bleeding—prolonged PT and activated partial thromboplastin time (aPTT), inhibition of platelet aggregation, diplopia —at dosages as low as 300 IU, muscle weakness, creatinuria. **Chronic Vitamin E toxicity** effects include all of the above, as well as suppression of other antioxidants and increased risk of hemorrhagic stroke. Vitamin E supplementation was shown to increase the risk of prostate cancer in healthy men, in the Selenium and Vitamin E Cancer Prevention Trial (SELECT) [37]

Vitamin E can prolong the prothrombin time (PT) by inhibiting vitamin K– dependent carboxylase, although

steroids



use; protein, carbohydrate, and fat metabolism; maintenance of normal cell membrane function; and the regulation of parathyroid hormone (PTH) secretion. Systemically, lowers blood pressure and alters peripheral vascular resistance. **Sources**: Spinach, legumes, nuts, seeds, whole grains, peanut butter, avocado

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**Phosphorus Functions**: A component of bones, cells, in

**Potassium** [43] **Function**: A systemic electrolyte and is

**Sodium** [44, 45] **Function:** A systemic electrolyte and is

milk, and spinach

**Chlorine** [46, 47] **Function:** Needed for production of

**Calcium** [48, 49] **Function:** Needed for muscle, heart and

**53**

essential in co-regulating ATP with potassium. **Sources:** Table salt (sodium chloride, the main source), sea vegetables,

hydrochloric acid in the stomach and in cellular pump functions. **Sources:** (with sodium): beans, lentils, dairy products, seafood, banana, prune, carrot, orange

digestive system health, builds bone, supports synthesis and function of blood cells. **Sources:** Dairy products, eggs,

potato, tomato, Irish potato

energy processing, in DNA and ATP (as phosphate) and many other functions. **Sources**: Red meat, dairy foods, fish, poultry, bread, rice, oats. In biological contexts, usually seen as phosphate

essential in co-regulating ATP**. Sources:** fruits, vegetables, beans and nuts, sweet **toxicity**

symptoms)

disturbances)

vomiting, paresthesias)

oliguria, weakness)

and convulsions)

**Deficiency:** Hypophosphatemia (most asymptomatic; severe/chronic forms have weakness, bone pain, rhabdomyolysis, and altered mental status)**. Toxicity/excess:** Hyperphosphatemia (asymptomatic; may have hypocalcemia—muscle cramps, tetany, and perioral numbness or tingling; uremia—fatigue, shortness of breath, anorexia, nausea, vomiting; sleep

**Deficiency:** Hypokalemia (features of underlying cause; weakness and fatigue; muscle cramps and pain (severe); worsening diabetes control or polyuria; palpitations; psychological symptoms (e.g., psychosis, delirium, hallucinations, depression); cardiac arrhythmias; respiratory failure). **Toxicity/excess:** Hyperkalemia: (asymptomatic; nonspecific; frank muscle paralysis, dyspnea, palpitations, chest pain, nausea or

**Deficiency:** Hyponatremia: (nausea and malaise, mild reduction in the serum sodium, lethargy, decreased level of consciousness, headache, and (if severe) seizures and coma). **Toxicity/excess**: Hypernatremia (elderly, diabetic, inadequate care; lethargy, confusion, abnormal speech, irritability, seizures, nystagmus, myoclonic jerks, tachycardia,

**Deficiency:** Hypochloremia [fluid loss, dehydration, weakness/fatigue, dyspnea, diarrhea or vomiting (fluid loss)]. **Excess:** Hyperchloremia (fluid retention, hypertension, muscle weakness, spasms, or twitches, irregular heart rate, confusion, difficulty concentrating, and personality changes, numbness or tingling, seizures

**Deficiency:** Hypocalcaemia (acute symptoms: multiple CVS effects causing syncope, chronic heart failure, and angina; neuromuscular symptoms: numbness,

disturbances, common being hyperexcitability, neuromuscular irritability, including tremor, fasciculations, tetany, Chvostek and Trousseau signs, and convulsions, apathy, muscle cramps, hyperreflexia, acute organic brain syndromes, depression, general weakness, anorexia, vomiting; osteoporosis, nephrolithiasis**—**urinary stones; diabetes mellitus often associated). **Toxicity**/**excess**: Hypermagnesemia (neuromuscular symptoms—deep tendon reflex attenuation, facial paresthesias, muscle weakness—especially respiratory, causing apnea; conduction system

**Iron Function**: Required for many proteins and

*Malnutrition*

beans, dark chocolate

**Iodine Functions**: Required for synthesis of

**Zinc Functions**: Zinc is necessary for growth,

**Copper Functions**: It helps maintain a healthy

grains, legumes

**Magnesium Function**: Required for processing ATP and

**52**

for bones, energy transfer, storage, and

metabolism, promotes strong and healthy bones and ensures the nervous system works properly. Required component of many redox enzymes, including cytochrome c oxidase. **Sources**: Liver, seafood, oysters, nuts, seeds; some: whole

DNA synthesis and normal taste perception. It also supports wound healing, immune function and reproductive health and testosterone production. **Sources**: Oysters, Red meat, poultry, seafood, whole grains, nuts and fortified cereals

enzymes, notably hemoglobin to prevent anemia. **Sources**: Meat, seafood, nuts,

thyroid hormones, thyroxine, and triiodothyronine and to prevent goiter. **Sources**: Seaweed (kelp or kombu), grains, eggs, iodized salt, saltwater fish

**toxicity**

**Deficiency**: Iron deficiency anemia features: Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes (koilonychia). **Toxicity**: Iron overload disorder (hemochromatosis) [42]

**Iodine deficiency**: Severe iodine deficiency results in goiter. Population effects of severe iodine deficiency, termed iodine deficiency disorders (IDDs), include endemic goiter, hypothyroidism, and cretinism, decreased fertility rate, increased infant mortality, and mental retardation**. Iodine excess**: Iodism, Hyperthyroidism. **Iodine toxicity**: Excessive iodine may cause

hypothyroidism by feedback inhibition of thyroid hormone production and conversion of triiodothyronine (T3) to less

active thyroxine (T4).

immunity suppression

gray hair (due to melanin

underproduction), vision loss. **Copper toxicity [33]**: nausea, vomiting (food or blood), diarrhea, stomach pain, black, "tarry" stools, headaches, dyspnea, cardiac arrhythmias, low blood pressure, coma, jaundice, kidney damage, liver damage

**Deficiency:** Hypomagnesemia (earliest: neuromuscular and neuropsychiatric

**Copper deficiency**: fatigue and weakness (due to iron deficiency anemia; also copper is required to generate ATP), frequent sickness (due to neutropenia), weak and brittle bones (osteoporosis), learning and memory difficulties (e.g., Alzheimer's disease), walking difficulties, increased sensitivity to cold, pallor and premature

**Deficiency**: Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, diminished immune response, poor wound healing. Symptoms/ signs: acne, eczema, xerosis, seborrheic dermatitis, or alopecia, oral ulceration, stomatitis, or white tongue coating. Rarely, angular cheilitis disturbed sense of smell and taste, night blindness, impaired immunity, diarrhea, anorexia; psychological disturbances: behavioral abnormalities, such as irritability, lethargy, and depression (due to impaired cognitive functions), delayed growth, teratogenic effects, hypogonadism, delayed puberty, and sexual maturity. **Toxicity**: nausea, vomiting, abdominal pain, diarrhea, flulike malaise, lowering of good HDL cholesterol (increased risk of heart disease). Decreased taste function (hypogeusia), copper deficiency (associated with sideroblastic and iron deficiency anemia and neutropenia),



Symptoms persisting 90 days or longer

deficiencies, which are measured by assessing serum albumin, retinol-binding protein, prealbumin, transferrin, creatinine, and BUN levels. Others include retinolbinding protein, prealbumin, and transferrin determinations that are much better short-term indicators of protein status than albumin. A better parameter to use in the field is serum albumin, since it has a longer half-life. In children who have a history of adequate food intake and signs/symptoms of malnutrition, focus is made toward identifying the cause of malnutrition. Stool specimens should be obtained if the child has a history suggestive of presence of worms or other parasites or circumstances that predispose to malnutrition. Other useful tests include thyroid functions or sweat chloride tests, liver function and triglyceride tests (for suspected liver disease), zinc levels (especially if chronic diarrhea is present), blood and urine sugar levels (to rule out diabetes mellitus), and coeliac serology tests, among other tests, depending on suspected cause(s). Nutritional assessment parameters such as height and weight (for BMI), MUAC, head circumference in children aged three and below, and others that are recognized according to the WHO standards are also

*Deficiencies and toxicities of micronutrients, including vitamins, minerals, and trace elements.*

**Micronutrient Functions/sources Clinical presentation of deficiency/**

**Functions:** Its part of vitamin B-12 (required in the synthesis of vitamin B-12; hence needed for erythropoiesis; also essential for maintaining the nervous system. Cobalt is also part of the biotindependent Krebs-cycle, for glucose/energy production. **Sources**: Animal products containing vitamin B-12 (milk products, eggs, fish, poultry, and meat)

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**Functions**: It is a cofactor for several enzymes that breakdown xanthine, hypoxanthine, and sulfite. They also break down and detoxify many harmful compounds. It is affected by the amount of copper and sulfate in the diet. **Sources:** Legumes, whole grains (cereals), nuts, and

leafy vegetables

**toxicity**

fatigue and hair loss]

can result in blindness

**Deficiency:** Very rare. **Excess:**

characterized by high levels of molybdenum, uric acid, and xanthine oxidase in blood). Molybdenum is contraindicated in patients with gallstones or kidney disease. Molybdenum supplements can cause a copper deficiency, by displacing copper from body tissues

Molybdenum toxicity (gout-like syndrome,

include fingernail discoloration and loss

**Deficiency:** Pernicious anemia (B-12 deficiency): numbness, Fatigue, and tingling sensation, later, decreased nerve function. **Excess:** Cobalt poisoning (characterized by toxic cardiomyopathy, polycythemia, leading to congestive cardiac failure). Poisoning can follow excessive inhalation, ingestion or direct body contact. It can also cause goiter or inactivity of thyroid and hyperglycemia. Cobalt poisoning has been reported after hip-replacement surgery if cobalt/ chromium was used during the surgery, as a metal-to-metal hip implant). Cobalt is contraindicated in people with Leber's syndrome, a rare eye condition, should not take it without medical advice; otherwise, it

**8.6 Treatment and management principles and prevention of malnutrition**

The principles laid down for the management of malnutrition are generally applied [6]. These include the need for multi-disciplinary professional approach for

done.

**55**

**Cobalt** (cyanocobalamin) [58, 59]

**Molybdenum** [58]

**Table 1.**


#### **Table 1.**

**Micronutrient Functions/sources Clinical presentation of deficiency/**

canned fish with bones (salmon, sardines), green leafy vegetables, nuts, seeds, tofu,

**Functions:** A cofactor in enzyme functions; antioxidant properties in mitochondria; has role in metabolism of carbohydrates, amino acids, cholesterol & gluconeogenesis; formation of health cartilage & bone; increases collagen production (improved wound healing). **Sources:** Whole grains (cereals, brown rice), legumes, seeds, nuts, leafy vegetables, tea, coffee, pineapples, sweet

**Function:** Chromium can improve insulin sensitivity and enhance protein, carbohydrate, and lipid metabolism, although its mechanisms of action and quantity needed not well-defined. **Sources**: Broccoli, grape juice (especially red), meat, whole grain products, processed meats, high-bran breakfast cereals, coffee, nuts, green beans, broccoli, spices, and some

brands of wine and beer

**Function**: Essential to activity of antioxidant enzymes like glutathione peroxidase. Also plays role in thyroid hormone metabolism, DNA synthesis, reproduction and protection from infection. **Sources**: Brazil nuts, Sea foods (especially fish—yellow-fin tuna fish, cod, red snapper, and herring), organ meats/ beef & poultry, grains, dairy products, eggs, rice, beans, whole-wheat bread

thyme

potatoes

**Manganese** [50–52]

*Malnutrition*

**Chromium** [53–55]

**Selenium** [35, 40, 56, 57]

**54**

**toxicity**

tingling, tetany, bronchospasms, dysphagia, voice changes (laryngospasms)). **Excess/toxicity:** Hypercalcemia (nausea, vomiting, alterations of mental status, abdominal or flank pain, constipation, lethargy, depression, weakness and vague muscle/ joint aches, polyuria, polydipsia, nocturia,

**Deficiency:** Manganese deficiency (characterized, more so in animals than humans, by impaired growth, impaired reproductive function, skeletal abnormalities, impaired glucose tolerance, and altered carbohydrate and lipid metabolism; humans develop bone demineralization, decreased serum cholesterol, rashes). **Toxicity/excess:** Manganism (psychiatric and motor disturbances from chronic exposure; neurological symptoms including: reduced response speed, irritability, mood changes, and compulsive behaviors; more protracted

exposure produces idiopathic Parkinsonism-like disorder, Lou Gehrig's disease and multiple sclerosis)

toxicities (Rom, 2007)]

**Deficiency:** Selenium deficiency [characterized by male/female infertility, muscle weakness, fatigue, mental fog, alopecia, and weakened immunity). People at risk of deficiency: thyroid (goiter), dialysis, HIV, malignancy, Crohn's and Grave's disease patients, pregnancy]. **Excess:** Selenosis [characterized by diarrhea, fatigue, hair loss, joint pain, nail discoloration or brittleness and nausea. Symptoms persisting 90 days or longer

**Deficiency:** Chromium deficiency (due to total parenteral intake/I-V fluids: symptoms and signs include severely impaired glucose tolerance, weight loss, peripheral neuropathy, and confusion)**. Excess:** Chromium toxicity [**Acute exposure**: Intense G.I.T irritation/ ulceration and corrosion, epigastric pain, nausea, vomiting, diarrhea, vertigo, fever, muscle cramps, hemorrhagic diathesis, toxic nephritis, renal failure, intravascular hemolysis, circulatory collapse, liver damage, acute multisystem organ failure, and coma/death, depending on the dose (Hay, Derazon et al., 2000; Lewis, 2004; Meditext, 2005). **Chronic esxposure**: Repeated skin contact causes incapacitating eczematous dermatitis with edema; conjunctiva and mucous membrane irritation, nasal ulcers and perforations, keratitis, gingivitis, periodontitis and lung cancer (Cohen and Costa, 1998; Lewis, 2004; Meditext, 2005); bronchitis, sinusitis, nasal polyps; liver and kidney

headache, confusion)

*Deficiencies and toxicities of micronutrients, including vitamins, minerals, and trace elements.*

deficiencies, which are measured by assessing serum albumin, retinol-binding protein, prealbumin, transferrin, creatinine, and BUN levels. Others include retinolbinding protein, prealbumin, and transferrin determinations that are much better short-term indicators of protein status than albumin. A better parameter to use in the field is serum albumin, since it has a longer half-life. In children who have a history of adequate food intake and signs/symptoms of malnutrition, focus is made toward identifying the cause of malnutrition. Stool specimens should be obtained if the child has a history suggestive of presence of worms or other parasites or circumstances that predispose to malnutrition. Other useful tests include thyroid functions or sweat chloride tests, liver function and triglyceride tests (for suspected liver disease), zinc levels (especially if chronic diarrhea is present), blood and urine sugar levels (to rule out diabetes mellitus), and coeliac serology tests, among other tests, depending on suspected cause(s). Nutritional assessment parameters such as height and weight (for BMI), MUAC, head circumference in children aged three and below, and others that are recognized according to the WHO standards are also done.

#### **8.6 Treatment and management principles and prevention of malnutrition**

The principles laid down for the management of malnutrition are generally applied [6]. These include the need for multi-disciplinary professional approach for specific, supportive, and preventive management. Specific and supportive treatments will largely depend on the classification of malnutrition encountered, while preventive measures will also depend on avoiding the prevalent cause and the predisposing factors encountered by those affected. Specific treatments will focus on the actual cause(s) of the malnutrition diagnosed after thorough evaluation of history, physical examination, and various investigations. These include provision of specific dietary food measured out depending on their preparation or manufacture, in addition to appropriate food supplements that may be fortified or not, depending on the prevailing cultural and socioeconomic practices encountered. Supportive management entails the need to initially manage life-threatening anemia, hypoglycemia, and/or hypothermia if these are found. Zinc [60, 61], folic acid, iodine, and vitamins A and D, among other supplements may also be given if indicated. Any other micronutrient deficiencies must be corrected, especially for children who still require to growth and development. Prevention measures largely address the need to avoid the predisposing factors of malnutrition from recurring in future, through appropriate health education and follow-up assessment schedules and programs. Promotion of breastfeeding, appropriate weaning practices, and ageappropriate nutritional counseling are strongly recommended in developing countries where there are major challenges in getting safe alternatives for human milk. The need to address emerging trends of food fortification, Ready-to-Use Therapeutic Foods (RUFT) [62], and other related issues is also important. Supplementations that are beneficial for pregnant mothers worldwide need special appropriate attention [63, 64]. Nutritional researches, with a view to addressing emerging and/or reemerging nutritional challenges, such as those associated with antiretroviral and pellagra (IPT) [65] should also be encouraged.

Organization among others that adhere to evidence-based data for such important

Although nixtamalization (the process for the preparation of maize/corn or other grain, by soaking and cooking them in an alkaline solution—usually lime water or wood ash lye then washed and hulled to soften them) is an ancient practice of improving the nutritional value of maize and other grains such as sorghum, some of its benefits (e.g., the ability to remove between 97 and 100% of aflatoxin from contaminated maize) [66] may continue to encourage the practice in places where maize is the staple food. The fact that pellagra was in the past found to be endemic in poor populations that used maize in southern parts of the United States during the early period of the twentieth century [68] does not rule out the possibility of the same happening in contemporary times within the developing world. It is encouraging to note that pellagra was nearly eliminated in the developed world after fortification of wheat flour was achieved [69]. However, it might remain a challenge in places where such fortification has not been fully achieved, a likely scenario in many developing countries. The fact is that case studies such as the one described in Kenya recently (although this was a patient on antiretroviral therapy and prone to drug induced pellagra on treatment for tuberculosis) [65] may suggest the need to explore the possibility of existing pellagra due to niacin deficiency and in the absence of nixtamalization—a process that is rarely practiced in some societies, despite the need for it in some. In this regard perhaps, nixtamalization may still have a place in modern societies, especially in the developing world, and may need to be explored and improved. This has in the past been done with some benefits of reducing pellagra, improving availability of dietary calcium, copper, and zinc and removal of mycotoxins (aflatoxin) that is produced by *Fusarium proliferatum* and *Fusarium verticillioides* in certain places [70]. However, other unexplored effects (beneficial and adverse) may need to be investigated through further research.

**8.8 Innovative lipid-based nutrient supplements and ready-to-use therapeutic**

In addition to food fortification already described, innovative lipid-based nutrient supplements have also been introduced to alleviate undernutrition in vulnerable populations (notably infants, lactating mothers, and pregnant women). The project has already been piloted in several countries, including Burkina Faso, Ghana, and Malawi, among others. Some of their products had already been fortified by 2011 [71], namely, micronutrient powder (MNP) and lipid-based nutrient supplements (LNS); these are effective in reducing anemia and iron deficiency. Both are

designed to be easily consumable by infants (thus advantageous over the pill forms commonly prepared as micronutrient pill supplements). However, an evaluation study [72] suggested that the micronutrients constituted in it may alone be insufficient to stimulate linear growth. Many studies (especially on LNS) applicable to different cultural settings are ongoing, despite challenges associated with adding

Also introduced for better management of malnutrition are Ready-to-Use Therapeutic Foods (RUTF), which are high-energy lipid-based spreads that are designed to be used for the treatment of severe acute malnutrition (SAM) and in any cultural setting [62, 73]. F-75 and F-100 are two commonly available formulations from the World Health Organization (WHO) [74], which are used for the management of severe acute malnutrition. Their preparation process is elaborate [62], and the products are highly successful in terms of affordability and availability, in the management of malnutrition in various healthcare settings [73]. They are

recommended by the World Health Organization and should gradually introduce

decisions, should lead the way.

*Malnutrition: Current Challenges and Future Perspectives*

*DOI: http://dx.doi.org/10.5772/intechopen.92007*

**foods (RUTF)**

micronutrients into the product.

**57**

#### **8.7 Food fortification and nixtamalization**

Food fortification [66], described as the supplementation of one or more components to improve the benefits from the natural or artificial food products [67], has received much professional and cosmopolitan attention. Food fortification is either voluntary or mandatory. Voluntary fortification gives food manufacturers the option to add minerals, vitamins, or both, to the food to be fortified, provided there is compliance with the laid down rules and regulations by Food and Drug Administration (FDA). On the other hand, mandatory fortification provides no option to do the same, in order to ensure that the significant public health need(s) is/are addressed adequately. Some of the mandatory fortifications achieved in the past include that of global iodized salt, vitamins A and D, zinc, folic acid, and iron and fortification of several B vitamins (thiamin, riboflavin, and niacin) to baking flour in certain countries, such as the United States during the 1940s onward, among many others. Such approaches by the FDA have successfully seen the reduction of neural tube defects (by 1998) among other problems. Food fortification as the major approach to the treatment of malnutrition is considered more cost effective and enables improvement of health achievable over a relatively shorter time than other forms of food aid. Many countries continue to identify their own fortification requirements and the approaches to address them; hence, fortification programs should be developed in this manner to address other common nutritional deficiencies. Iron deficiency, among many others, still needs to be addressed locally and globally. Despite the progress in food fortification, there are still major challenges to be overcome to ensure that malnutrition is well managed. However, precautions need to be taken to avoid over-fortification, by ensuring that minimum and maximum daily dietary requirements for fortification are met for each type of fortification. To achieve these, global authorities, including the World Health

#### *Malnutrition: Current Challenges and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.92007*

specific, supportive, and preventive management. Specific and supportive treatments will largely depend on the classification of malnutrition encountered, while preventive measures will also depend on avoiding the prevalent cause and the predisposing factors encountered by those affected. Specific treatments will focus on the actual cause(s) of the malnutrition diagnosed after thorough evaluation of history, physical examination, and various investigations. These include provision of specific dietary food measured out depending on their preparation or manufacture, in addition to appropriate food supplements that may be fortified or not, depending on the prevailing cultural and socioeconomic practices encountered. Supportive management entails the need to initially manage life-threatening anemia, hypoglycemia, and/or hypothermia if these are found. Zinc [60, 61], folic acid, iodine, and vitamins A and D, among other supplements may also be given if indicated. Any other micronutrient deficiencies must be corrected, especially for children who still require to growth and development. Prevention measures largely address the need to avoid the predisposing factors of malnutrition from recurring in future, through appropriate health education and follow-up assessment schedules and programs. Promotion of breastfeeding, appropriate weaning practices, and ageappropriate nutritional counseling are strongly recommended in developing countries where there are major challenges in getting safe alternatives for human milk. The need to address emerging trends of food fortification, Ready-to-Use Therapeutic Foods (RUFT) [62], and other related issues is also important. Supplementations that are beneficial for pregnant mothers worldwide need special appropriate attention [63, 64]. Nutritional researches, with a view to addressing emerging and/or reemerging nutritional challenges, such as those associated with antiretroviral and

Food fortification [66], described as the supplementation of one or more components to improve the benefits from the natural or artificial food products [67], has received much professional and cosmopolitan attention. Food fortification is either voluntary or mandatory. Voluntary fortification gives food manufacturers the option to add minerals, vitamins, or both, to the food to be fortified, provided there is compliance with the laid down rules and regulations by Food and Drug Administration (FDA). On the other hand, mandatory fortification provides no option to do the same, in order to ensure that the significant public health need(s) is/are addressed adequately. Some of the mandatory fortifications achieved in the past include that of global iodized salt, vitamins A and D, zinc, folic acid, and iron and fortification of several B vitamins (thiamin, riboflavin, and niacin) to baking flour in certain countries, such as the United States during the 1940s onward, among many others. Such approaches by the FDA have successfully seen the reduction of neural tube defects (by 1998) among other problems. Food fortification as the major approach to the treatment of malnutrition is considered more cost effective and enables improvement of health achievable over a relatively shorter time than other forms of food aid. Many countries continue to identify their own fortification requirements and the approaches to address them; hence, fortification programs should be developed in this manner to address other common nutritional deficiencies. Iron deficiency, among many others, still needs to be addressed locally and globally. Despite the progress in food fortification, there are still major challenges to be overcome to ensure that malnutrition is well managed. However, precautions need to be taken to avoid over-fortification, by ensuring that minimum and maximum daily dietary requirements for fortification are met for each type of fortification. To achieve these, global authorities, including the World Health

pellagra (IPT) [65] should also be encouraged.

*Malnutrition*

**8.7 Food fortification and nixtamalization**

**56**

Organization among others that adhere to evidence-based data for such important decisions, should lead the way.

Although nixtamalization (the process for the preparation of maize/corn or other grain, by soaking and cooking them in an alkaline solution—usually lime water or wood ash lye then washed and hulled to soften them) is an ancient practice of improving the nutritional value of maize and other grains such as sorghum, some of its benefits (e.g., the ability to remove between 97 and 100% of aflatoxin from contaminated maize) [66] may continue to encourage the practice in places where maize is the staple food. The fact that pellagra was in the past found to be endemic in poor populations that used maize in southern parts of the United States during the early period of the twentieth century [68] does not rule out the possibility of the same happening in contemporary times within the developing world. It is encouraging to note that pellagra was nearly eliminated in the developed world after fortification of wheat flour was achieved [69]. However, it might remain a challenge in places where such fortification has not been fully achieved, a likely scenario in many developing countries. The fact is that case studies such as the one described in Kenya recently (although this was a patient on antiretroviral therapy and prone to drug induced pellagra on treatment for tuberculosis) [65] may suggest the need to explore the possibility of existing pellagra due to niacin deficiency and in the absence of nixtamalization—a process that is rarely practiced in some societies, despite the need for it in some. In this regard perhaps, nixtamalization may still have a place in modern societies, especially in the developing world, and may need to be explored and improved. This has in the past been done with some benefits of reducing pellagra, improving availability of dietary calcium, copper, and zinc and removal of mycotoxins (aflatoxin) that is produced by *Fusarium proliferatum* and *Fusarium verticillioides* in certain places [70]. However, other unexplored effects (beneficial and adverse) may need to be investigated through further research.

#### **8.8 Innovative lipid-based nutrient supplements and ready-to-use therapeutic foods (RUTF)**

In addition to food fortification already described, innovative lipid-based nutrient supplements have also been introduced to alleviate undernutrition in vulnerable populations (notably infants, lactating mothers, and pregnant women). The project has already been piloted in several countries, including Burkina Faso, Ghana, and Malawi, among others. Some of their products had already been fortified by 2011 [71], namely, micronutrient powder (MNP) and lipid-based nutrient supplements (LNS); these are effective in reducing anemia and iron deficiency. Both are designed to be easily consumable by infants (thus advantageous over the pill forms commonly prepared as micronutrient pill supplements). However, an evaluation study [72] suggested that the micronutrients constituted in it may alone be insufficient to stimulate linear growth. Many studies (especially on LNS) applicable to different cultural settings are ongoing, despite challenges associated with adding micronutrients into the product.

Also introduced for better management of malnutrition are Ready-to-Use Therapeutic Foods (RUTF), which are high-energy lipid-based spreads that are designed to be used for the treatment of severe acute malnutrition (SAM) and in any cultural setting [62, 73]. F-75 and F-100 are two commonly available formulations from the World Health Organization (WHO) [74], which are used for the management of severe acute malnutrition. Their preparation process is elaborate [62], and the products are highly successful in terms of affordability and availability, in the management of malnutrition in various healthcare settings [73]. They are recommended by the World Health Organization and should gradually introduce

until the child attains normal growth [75, 76]. Some have been successfully used in African countries, especially among children aged 5 years and below [67]. Like all other new formulations, the current and future challenges that RUTF may have should to be considered especially those concerning their safety, reliability, and affordability with short- and/or long-term use.

**References**

home-page/

2019 edition.

feeding/

2016

**59**

[1] Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, et al. Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions. Journal of Parenteral and Enteral Nutrition. 2013;**37**(4):460-481

*DOI: http://dx.doi.org/10.5772/intechopen.92007*

*Malnutrition: Current Challenges and Future Perspectives*

[10] IAP Textbook of Pediatrics. 4th ed. Vol. 1. New Delhi: Jaypee Publishers. pp.

thresholds for wasting, overweight and stunting in children under 5 years. Public Health Nutrition. 2018;**22**(1):1-5

[11] de Onis M et al. Prevalence

[12] World Health Organization. Nutrition Landscape Information System (NLIS) Country Profile

[13] Stevenson RD, Conaway MR. Weight and mortality rates: "Gomez Classification" for children with cerebral palsy? Pediatrics. August 2011; **128**(2):e436-e437. DOI: 10.1542/

[14] Gueri M, Gurney JM, Jutsum P. The

Gomez classification. Time for a change? Bulletin of the World Health Organization. 1980;**58**(5):773-777

[15] Waterlow JC. Classification and

malnutrition. British Medical Journal. 1972;**3**(5826):566-569. DOI: 10.1136/

[16] Watts G. John Conrad Waterlow. The Lancet. 2010;**376**(9757):1982. DOI: 10.1016/S0140-6736(10)62252-0

[17] Smits MM, Boyko EJ, Utzschneider KM, Leonetti DL, McNeely MJ, Suvag S, et al. Arm length is associated with type

2 diabetes mellitus in Japanese-Americans. Diabetologia. 2012;**55**(6):

[18] Vasconcelos AP, Cardozo DC, Lucchetti AL, Lucchetti G. Comparison of the effect of different modalities of physical exercise on functionality and anthropometric measurements in community-dwelling older women. Journal of Bodywork and Movement Therapies. 2016;**20**(4):851-856

definition of protein-calorie

143-144

Indicators. 2010

peds.2011-1472

bmj.3.5826.566

1679-1684

[2] WHO. Malnutrition—The Global Picture. World Health Organization. Available from: http://www.who.int/

[3] UNICEF/WHO/World Bank Joint Child Malnutrition Estimates. March

[4] United Nations Children's Fund. Data. Infant and young child feeding. Available from: https://data.unicef.org/ topic/nutrition/infant-and-young-child-

[5] Bwibo N, Stanfield P, et al. Child health. In: A Manual for Medical and Health Workers in Health Centres and Rural Hospitals. Nairobi: AMREF; 2005

[6] Shashidhar HR, Bhatia J, et al. Malnutrition. Medscape website. 2017

[7] Black RE, Laxminarayan R, Temmerman M, et al., editors.

[8] Alcoba G, Kerac M, Breysse S, Galetto-Lacour C, Salpeteur A, et al. Do children with uncomplicated severe acute malnutrition need antibiotics? A systematic review and meta-analysis.

PLoS One. 2013;**8**(1):E53184

10.1016/j.pcl.2009.07.001

[9] Grover Z, Ee LC. Protein energy malnutrition. Pediatric Clinics of North America. 2009;**56**(5):1055-1068. DOI:

Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities. 3rd ed. Vol. 2. Washington, DC: The International Bank for Reconstruction and Development/The World Bank;

### **Author details**

Joseph Kiprop Choge Department of Clinical Medicine, University of Kabianga, Kenya

\*Address all correspondence to: jchoge@kabianga.ac.ke

© 2020 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.

*Malnutrition: Current Challenges and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.92007*

#### **References**

until the child attains normal growth [75, 76]. Some have been successfully used in African countries, especially among children aged 5 years and below [67]. Like all other new formulations, the current and future challenges that RUTF may have should to be considered especially those concerning their safety, reliability, and

affordability with short- and/or long-term use.

*Malnutrition*

**Author details**

**58**

Joseph Kiprop Choge

Department of Clinical Medicine, University of Kabianga, Kenya

© 2020 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,

\*Address all correspondence to: jchoge@kabianga.ac.ke

provided the original work is properly cited.

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[18] Vasconcelos AP, Cardozo DC, Lucchetti AL, Lucchetti G. Comparison of the effect of different modalities of physical exercise on functionality and anthropometric measurements in community-dwelling older women. Journal of Bodywork and Movement Therapies. 2016;**20**(4):851-856

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the History of Medicine and Health.

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**65**

Section 2

Malnutrition and Global

Determinats

Section 2
