Malnutrition can manifest itself in different ways and for different causes.
Being undernourished and being overweight have historically been considered separate problems and present in populations with different risk factors. Undernourishment has always been associated with poverty, food insecurity, and infections, while obesity has been associated with greater affluence and a sedentary lifestyle: today, both forms of malnutrition can be present within the same community.
Until a few decades ago, the term malnutrition was associated with the image of skinny children, with protruding bellies due to the lack of protein, short or stunted growth, that is to say suffering from what is called malnutrition by default (stunting or wasting): a deficit in calories, a deficit in macronutrients (carbohydrates, proteins, fats) and micronutrients (minerals: for example iodine deficiency and thyroid problems; and vitamins: vitamin D deficiency was until the 1950s a major health problem because of its influence on the skeleton).
In recent years, malnutrition has risen sharply, and cases of malnutrition in industrialized countries have begun to increase: being overweight and obesity has become increasingly frequent, even among children and adolescents, with significant respiratory, cardiovascular, and psychological consequences.
The triple burden of malnutrition (undernutrition, micronutrient deficiency, and being overweight) has different origins: inadequate maternal nutrition, a diet low in micronutrients during childhood, and changes in the food system, that put people at greater risk of consuming foods that are high in simple sugars and salt, but low in essential nutrients. Another factor that has played a role is the COVID-19 pandemic infection, which has led to increased food insecurity and affected the psychological well-being of many adults and, in particular, children and adolescents.
Our inactive lifestyles, the excessive availability of high-calorie and cheap foods, and increasingly virtual social interactions have contributed to this reversal, and rates of overweight people and obesity have increased dramatically. Diseases that were thought to be left in the past are reappearing: whereas in the last century, the causes could be the lack of knowledge and difficult access to food and care, today, the causal factors are psychological, and sometimes psychiatric.
Medical conditions such as psychiatric disorders, anorexia nervosa, celiac disease, Crohn’s disease, hemodialysis, and major food allergies can increase the risk of micronutrient deficiency.
Food selectivity, increasingly common in children for more or less serious psychological reasons, can strongly affect the development of growing subjects. One of the examples of which the literature reports several new cases is scurvy. According to a recent literature review, although considered a rare disease in high-income countries, scurvy, caused by vitamin C deficiency, the complications of which can be fatal, has recently been increasingly reported in children, especially those with restrictive eating habits or mental or physical disabilities. Due to the broad clinical spectrum (musculoskeletal disorders and/or mucocutaneous lesions or systemic symptoms), scurvy can mimic several conditions, including autoimmune diseases, infections and neoplasia. According to the study in question, scurvy should be considered in patients with musculoskeletal disorders, not only in those with risk factors but also in healthy children.
I myself recently witnessed a case of scurvy in the paediatric hospital where I work in Genoa, Italy. Vitamin C deficiency leads to vascular fragility and impaired bone formation in the patient who presents with gingival bleeding, petechiae, bone and joint pain. In addition, children may show irritability, anorexia, and stunted growth. One reason for these cases is that the traditional Mediterranean diet in Italy is giving way to so-called “Western” diets, where the consumption of ready-to-use foods, low in fiber and rich in flavour enhancers predominates. In addition, in some families, fruit consumption is almost non-existent. It is therefore difficult to help a child if the whole family does not decide to change their lifestyles.
In past centuries, the world has experienced unprecedented economic growth, accompanied by extraordinary scientific progress and technological development. However, the benefits have not been shared equitably and malnutrition persists. The policy interventions that will certainly be needed will have to take into account the effect on environmental and human health in order to respond to this health emergency, which will otherwise persist and worsen.
The indications and exhortations are always the same: do not forget to eat real foods (composed from staple foods and not ready-made meals), especially those of plant origin, in the quantities that your body, and not your mind, needs, and use this incredible machine that is your body, while listening carefully to the signals of hunger and satiety.
(1) Wells et coll (2020) The double burden of malnutrition: Aetiological pathways and consequences for health. Lancet; 395 (10217): 75-88.
(2) Blankenship, Rudert et Aguayo (2020) Triple trouble: Understanding the burden of child undernutrition, micronutrient deficiencies, and overweight in East Asia and the Pacific. Matern Child Nutr; 16(Suppl 2): e12950.
(3) Popkin, Corvalan et Grummer-Strawn (2019). Dynamics of the double burden of malnutrition and the changing nutrition reality. The Lancet; 395(10217): 65-74.
(4) Brambilla et coll (2018) Pediatric Scurvy: when contemporary eating habits bring back the past. Front Pediatr; 1;6:126
(5) Trapani et coll (2022) A Narrative Review on Pediatric Scurvy: The Last Twenty Years. Nutrients; 14:684.
(6) Gallizzi et coll (2020) Scurvy may occur even in children with no underlying risk factors: a case report. J Med Case Rep;14(1):18.
(7) Wells et coll (2021) The future of human malnutrition: rebalancing agency for better nutritional health. Global health; 17:119.
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