The Impact of Malnutrition on the Body Continues Despite Food Intake

Denise Potvin, a registered nurse stationed in Rafah, a southern Gaza city, has recently noticed an alarming rise in malnutrition among young children. Before the present war between Israel and Hamas, such cases were not typically observed, explains Potvin. However, now they are seeing more and more instances.

As stated by a recent count on May 18, a total of 31 individuals, including a minimum of 28 children, have died from malnutrition. Southern parts of Gaza have noted malnutrition rates as high as 9 percent in children under the age of five, reports the World Health Organization. In northern regions of Gaza, malnutrition fractions are even higher – approximately 25 percent of children are malnourished, with up to 4 percent severely affected, as per an initial agency report. The Integrated Food Security Phase Classification partnership issued a report warning of imminent famine in northern Gaza in March and highlighted the risk to the remaining parts of Gaza as well.

Gaza's children are not the only victims. Other countries including Afghanistan, Sudan, Nigeria, Yemen, Haiti, Pakistan, and the Democratic Republic of Congo are also witnessing child malnutrition as a consequence of issues such as conflict, poverty, natural disasters, trapped with little or no food supplies. These sudden disruptions can result in acute malnutrition, wasting, and in instances where the situation persists, childhood death due to chronic malnutrition and stunting.

In 2021, malnutrition was a global problem, with around 36.4 million children acutely malnourished worldwide, with severe malnutrition affecting 9.8 million of these children, says Food Security Information Network. WHO estimated that in 2022, around 149 million children were stunted and 45 million were wasted, while over 13 million had severe wasting. These figures do not include moderately malnourished children. The WHO asserts that almost half of all under-five deaths, more so in low- and middle-income nations, are due to malnutrition.

Even when managed and treated, malnutrition can have lifelong consequences that include an elevated risk of death in the year succeeding recovery, hindered growth, and hampered intellectual development manifesting even in their adult years.

When an individual becomes malnourished, the body prioritizes energy for vital functions like maintaining the heart and lungs over other areas, explains Indi Trehan, a pediatrician at the University of Washington, Seattle. As a result, growth, brain connection development, wound healing, and body temperature maintenance suffer.

One of the most impactful effects of malnutrition is on the immune system, says Trehan. Dysfunctional immune systems are unable to fight off infections, making individuals susceptible to mortality from illnesses that generally healthy individuals could recover from more easily.

One research study found that children that were moderately underweight for their age were at a doubled risk of succumbing to pneumonia when compared to children of a healthy weight. In similar terms, another study found that malnourished children with HIV were four times more at risk of mortality compared to their malnourished counterparts without HIV.

The extent of malnutrition is determined by measuring the child's height, weight, and mid-upper arm circumference to discern how much they deviate from the mean for their age or height. Children presenting malnutrition symptoms may be either stunted, wasted, or both.

Children are classified as moderately malnourished when they fall two to three standard deviations below the average weight-for-height score, whereas severe malnutrition is diagnosed when a child falls more than three standard deviations below average. Other indications of severe acute malnutrition include nutritional edema also known as kwashiorkor, characterized by swelling in the hands and feet and a state of illness rendering them incapable of eating.

In Rafah, Potvin, affiliated with Doctors Without Borders, is witnessing firsthand the vicious cycle between malnutrition and the immune system. Living conditions such as crowded tent villages and insufficient access to clean water, sanitation, and hygiene greatly increase the likelihood of malnourished children contracting infectious diseases, which in turn, exacerbates their malnutrition. According to Potvin, clinics in Rafah are seeing a steady stream of respiratory infections, diarrheal conditions, and various skin diseases.

Curing malnutrition involves more than just feeding a hungry child. It's estimated by MSF that globally, only 3 percent of severely malnourished children receive the necessary life-saving treatment. Approximately one in five children admitted for severe malnutrition will die before they are discharged, according to public health nutritionist Gerard Bryan Gonzales from Ghent University in Belgium.

Even after being discharged from the hospital, these children often face significant risks of death. A PLOS One review of multiple studies from 2018 suggested that up to 10 percent of seriously malnourished children die within a year of leaving the hospital. On a global scale, this could translate to hundreds of thousands, if not millions, of severely malnourished children dying even after being treated. This figure could potentially be higher, as researchers were unable to track the fate of up to 45% of children who left the study.

In a study of malnourished children in Kenya, Gonzales and colleagues discovered that about 10% of children, or 177 out of 1,704, ended up back in the hospital after being discharged.

James Njunge, a biochemist at the KEMRI-Wellcome Trust Research Programme in Kilifi, Kenya, suggests it's unclear as to why many children die after being treated for malnutrition. But it's known that once a child becomes malnourished, there is a complicated biochemical process at work that may not be reversible.

Njunge and his team are investigating potential causes of deaths resulting from severe malnutrition in children who have been discharged from hospitals in different countries. They hope to identify factors such as particular proteins, hormones, nutrients or gut microbes that may explain the pattern of fatalities.

In 2022, Njunge and his colleagues reported in Science Advances that both inflammation and damaged metabolism were associated with death in severely malnourished children in Kenya and Malawi. Additionally, there's the factor of families that prematurely take their children home against medical advice because they need to return to work or care for other children.

Even after recovery and gaining adequate weight, malnourished children may suffer from lingering internal damage. Some severely malnourished children exhibit high levels of inflammation which leads to further complications. This inflammation hampers the body's ability to absorb and utilize nutrients and could potentially cause organ damage, resulting in mortality.

Research published in Science Translational Medicine shows that severely malnourished children in Zimbabwe and Zambia continued to display high levels of inflammation a year after hospital discharge, compared to well-nourished children in their communities. Gut inflammation was also numerous in these children, damaging the finger-like structures or villi in their intestinal walls that help absorb nutrients.

This damage to the villi could potentially set up malnourished children for a lifetime of health problems as they may struggle to absorb necessities for growth and development, even after malnutrition has been treated.

Studying malnourished children shows the villi (upper left) which aid nutrient absorption in the intestines becoming almost non-existent (upper right), even after conventional treatment (lower left). But the addition of teduglutide to therapeutic food may help restore the growth of these structures (bottom right).

Research by Sturgeon and colleagues have been investigating drugs that may restore the gut lining in malnourished children. They found that a molecule named teduglutide decreased inflammation markers in children being treated for severe malnutrition in Zambia and Zimbabwe. This compound, which is typically used to treat short bowel syndrome, also stimulated the growth of villi as was reported in Nature Communications on April 17.

Other researchers are also developing new treatments to help children with the lasting consequences of malnutrition.

For example, children with malnutrition often have underdeveloped gut microbiomes, says Jeffrey Gordon, a microbiome researcher at Washington University School of Medicine in St. Louis (SN: 2/18/16). In most children, the rise and fall of certain types of gut bacteria follows a predictable pattern. But that pattern is disturbed in kids with malnutrition. In those kids, “there are features of the microbial community that appear younger or more immature than you would expect based on the chronological age,” Gordon says.

Those disturbances can affect development of children’s guts and immune systems, perhaps causing kids to have lasting digestive issues and immune system problems, he says.

Gordon and his colleagues developed a therapeutic food that fosters gut microbe growth (SN: 6/7/21). It is a mix of chickpea and soybean flours, peanut paste and mashed green banana. The researchers tested the microbe-fostering food against a standard therapeutic food composed of rice, lentil and milk powder, and found that it helped children gain weight faster even though the experimental food has fewer calories, Gordon’s team reported in the New England Journal of Medicine in 2021.

The reason why the babies gained weight is because of two strains of Prevotella copri bacteria, which broke down molecules in the microbe-nourishing food, the researchers reported March 19 in Nature Microbiology. Knowing how microbes and specific molecules within the foods work together may help the researchers design even better therapeutic foods to treat or even prevent malnutrition in the future, Gordon says.

Because so many children die from malnutrition, few studies have been able to determine the longer-term consequences of childhood starvation on adults. What researchers do know is that severe malnutrition or exposure to famine in childhood is associated with an increased risk of high blood pressure, cardiovascular disease, and metabolic problems such as diabetes, Ghent University’s Gonzales and his colleagues reported in BMJ Global Health in 2021. 

Part of the problem may be the high fat content of the diets that are traditionally used to treat malnutrition, Gonzales says. “It might stress the system too much [so] that the body has this long-term persistent dysregulation,” he says. Right now, treatment strategies are focused on keeping children from dying in the next year. “We’re trying ways now to really study whether we are giving children what they really need,” Gonzales says. “Are we treating them in a way that they don’t only survive, but they are also thriving?”

It’s a time-sensitive question, Trehan says. If young children don’t get proper nutrition while their brains are developing, “you’re not going to catch up no matter how good your schools and your rehab and things like that are after the fact.”

People who survive severe malnutrition in childhood may be a bit shorter than if they’d gotten enough food to grow to their genetic potential, Trehan says. That’s probably not a big deal. “We’re not trying to grow an army of basketball players,” he says. But stunting can also be an indicator of missed intellectual development (SN: 3/21/13). “We want an army of smart kids who can then do good in school and then get good jobs and then help their societies develop.” With malnutrition, “you’re really hitting a population for the long-term.”

People who had been severely malnourished as children in Congo were less likely as adults to report doing well in school, had less education and lower self-esteem than peers in their communities who were never malnourished, researchers reported in 2020 in PLOS One.

And it’s not just the people who suffered food shortages that pay the price, Gonzales says. When chronic adult health problems arise in formerly malnourished people, health systems around the world are stressed. Many people who survived malnutrition in low- or middle-income countries have since moved to wealthier nations where they may add to the disease burden, he says. “It is a global problem that requires global solutions.”