Malnutrition

• 1. Introduction

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  Malnutrition sits at the center of a paradox that shapes billions of lives. In 2017, nearly one in three people on earth had at least one form of it: wasting, stunting, vitamin deficiency, overweight, obesity, or diet-related disease. Yet at that same moment, the world's farmers were producing enough food to feed around 12 billion people, almost double the actual population. Something had gone profoundly wrong between the harvest and the table.

  The word itself is deceptive. Most people hear "malnutrition" and picture a starving child. But the condition runs in two directions at once. Too little food destroys a body. So does too much of the wrong kind. A 2019 report by The Lancet Commission called for expanding the definition to include "all its forms, including obesity, undernutrition, and other dietary risks." The World Health Organization gave it a name: the double burden of malnutrition, the coexistence of overweight and obesity alongside stunted growth and wasting, sometimes within the same neighborhood.

  This documentary asks how a crisis this large stays so poorly understood, why the solutions that seem obvious keep failing, and what the science of nutrition, built largely between the two World Wars, actually tells us about feeding the human body across a lifetime.

• 2. Two Kinds of Hunger

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  Kwashiorkor takes its name from the Ga language of coastal Ghana. It means "the sickness the baby gets when the next baby is born," because it typically strikes when an older child is weaned and shifted to a diet heavy in carbohydrates, starved of protein. The symptoms are distinctive: edema, liver enlargement, a swollen belly that ironically disguises the child's wasted state, and depigmentation of skin and hair.

  Marasmus, from the Greek for "to waste away," arrives from a different direction. Where kwashiorkor is primarily a protein failure, marasmus results from sustained deficiency in both protein and energy. The body's response is metabolic adaptation: it slows everything down to prolong survival, leaving little subcutaneous fat, severe muscle wasting, and abnormal albumin levels. Both conditions commonly coexist.

  Beyond these acute forms, micronutrient deficiencies operate more quietly. Iodine deficiency is the most common preventable cause of mental impairment worldwide. Even moderate iodine shortfall, particularly in pregnant women and infants, lowers intelligence by 10 to 15 IQ points. Vitamin A deficiency affects one third of children under five globally, causing 670,000 deaths and between 250,000 and 500,000 cases of blindness each year. Iron deficiency drives the most common form of anemia. In 2020, 900 million women and children worldwide had anemia.

  Vitamin B12 deficiency can produce changes in consciousness or thinking, and in some cases irreversible neurological damage. Folate deficiency has been linked to neural tube defects. These are not rare conditions. Two billion people had iodine deficiency in 2017. The harm accumulates invisibly, written into children's brains and bones before anyone thinks to measure it.

• 3. The Weight of Numbers

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  In 2024, 150.2 million children under five years old were stunted, 42.8 million were wasted, and 35.5 million were overweight or obese. In 2021, an estimated 45 percent of all deaths in children were linked to undernutrition.

  The geography of the crisis is uneven in ways that matter for understanding it. Over 90 percent of stunted children under five live in sub-Saharan Africa and South Central Asia. In East Africa, a pooled analysis found chronic undernutrition among children under five at 33.3 percent. In Burundi, that figure reached 53 percent. In Tanzania, stunting among children under five varied from 41 percent in lowland areas to 64.5 percent in highland areas.

  India carries one of the highest burdens of wasting in Asia, with over 20 percent of children affected. In South Sudan, undernutrition measured by stunting, underweight, and wasting among under-five children stood at 23.8 percent, 4.8 percent, and 2.3 percent respectively.

  Among adults, the picture shifts. As of June 2021, 1.9 billion adults were overweight or obese. In 2021, more than 3.1 billion people, 42 percent of the world's population, were unable to afford a healthy diet. In 2022, according to UNICEF, 2.4 billion people were moderately or severely food insecure, 391 million more than in 2019. The COVID-19 pandemic accelerated every one of these trends; experts estimated it could double the number of people at risk of acute hunger, adding around 130 million more undernourished people by the end of 2020 alone.

• 4. Who Bears the Burden

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  In 2022, more than one billion adolescent girls and women suffered from undernutrition, according to UNICEF's report "Undernourished and Overlooked: A Global Nutrition Crisis in Adolescent Girls and Women." The gender gap in food insecurity more than doubled between 2019, when it stood at 49 million, and 2021, when it reached 126 million.

  Globally, 30 percent of women aged 15 to 49 live with anemia. South Asia, West and Central Africa, and Eastern and Southern Africa account for 60 percent of women with anemia and 65 percent of women who are underweight. In India and Pakistan, datasets showed undernutrition rates 1.5 to 2 times higher in women than in men. Samples of 1,000 women in India in 2008 found that malnutrition in women was associated with poverty, lack of development and awareness, and illiteracy.

  In some parts of Kenya in 2006, rates of malnutrition in pregnant women exceeded even the rates in children. During pregnancy and breastfeeding, women require significantly more protein and calories, along with higher levels of iron, iodine, calcium, folic acid, and vitamins A, C, and K. In 2001, the FAO reported that iron deficiency affected 43 percent of women in developing countries and increased the risk of death during childbirth. A 2008 review estimated that universal supplementation with calcium, iron, and folic acid during pregnancy could prevent 105,000 maternal deaths, representing 23.6 percent of all maternal deaths.

  At the other end of life, elderly people face a different set of pressures. Chewing and swallowing problems, sensory decline, depression, imbalanced gut microbiome, poverty, and loneliness are major contributors. In developed countries, undernutrition is an increasing problem among nursing home residents and patients in acute care hospitals, even when food is nominally available.

• 5. The Roots of Scarcity

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  Eighty percent of malnourished children live in countries that produce food surpluses, according to estimates from the Food and Agriculture Organization. The economist Amartya Sen observed that in recent decades, famine has always been a problem of food distribution, purchasing power, and poverty, not a simple shortage of supply.

  High food prices are among the most direct barriers. In Bangladesh, low socioeconomic status was associated with chronic malnutrition because it prevented purchase of nutritious foods like milk, meat, poultry, and fruit. In 2007 and 2008, commodity speculation and the diversion of crops to biofuels contributed to a global food price crisis. The United Nations special rapporteur on the right to food, Jean Ziegler, proposed that agricultural waste, such as corn cobs and banana leaves, should be used as biofuel instead of food crops.

  Agricultural productivity compounds the problem in places where it is lowest. Without fertilizers, pesticides, irrigation, machinery, and storage facilities, modern yields are impossible. The World Bank and wealthy donor countries pushed developing nations to use free market policies even as the United States and Europe extensively subsidized their own farmers. Without subsidies, few farmers in developing countries can afford fertilizer at market prices.

  Malawi illustrates what changes when policy shifts. Almost five million of the country's 13 million people once needed emergency food aid. In the early 2000s, the Malawian government introduced subsidies for fertilizer and seed, against World Bank preferences. By 2007, farmers were producing record corn harvests. Corn production leaped to 3.4 million tons compared to 1.2 million tons in 2005, and Malawi became a food exporter. Food prices fell, and farmworker wages rose.

• 6. What Science and Policy Have Built

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  According to historian Michael Worboys, malnutrition was essentially discovered as a scientific subject, and the science of nutrition established, between World War I and World War II. Advances built on Casimir Funk's 1912 formulation of the concept of vitamins. One of the first global documents addressing food security was the 1948 Universal Declaration of Human Rights, which asserted that access to food was part of an adequate standard of living.

  The Right to Food was later anchored in the International Covenant on Economic, Social and Cultural Rights, adopted by the United Nations General Assembly on the 16th of December 1966 and signed by 166 countries as of 2018. The 1974 World Food Conference, held in Rome, Italy, produced a non-binding resolution adopted by all 135 attending countries. The 1996 Rome Declaration on World Food Security set a target of halving the number of undernourished people by 2015.

  On the practical side, reducing malnutrition is a central goal of the United Nations' Sustainable Development Goal 2, Zero Hunger. In April 2012, countries signed the Food Assistance Convention, the world's first legally binding international agreement on food aid. In June 2015, the European Union and the Bill and Melinda Gates Foundation launched a partnership targeting undernutrition in Bangladesh, Burundi, Ethiopia, Kenya, Laos, and Niger.

  The Copenhagen Consensus, a group of economists, ranked micronutrient supplementation as the single most effective development intervention, ahead of interventions against malaria and AIDS. According to the World Bank, fortifying foods with micronutrients improves lives more quickly and at lower cost than other forms of aid. In 2008, the UN World Food Programme, the largest non-governmental food distributor, announced it would begin distributing cash and vouchers in some areas rather than food, describing the shift as a fundamental change in the approach to food aid.

• 7. Treating the Body in Crisis

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  Ready-to-use therapeutic food allows severe malnutrition to be managed outside hospitals in many cases. For those whose malnutrition is complicated by other health problems, in-hospital treatment involves managing low blood sugar, maintaining body temperature, addressing dehydration, and gradual feeding. Routine antibiotics are recommended because malnutrition weakens the immune system severely enough to make infection a constant risk.

  Refeeding carries its own danger. Severely malnourished individuals can develop refeeding syndrome if fed too quickly, regardless of whether food is given orally, by nasogastric tube, or intravenously. The syndrome can present several days after eating begins, with potentially fatal heart failure, abnormal heart rhythms, and confusion.

  For diarrhea, which is both a cause and a consequence of malnutrition, oral rehydration therapy is the preferred treatment. In 2003, the WHO and UNICEF introduced reduced-osmolarity oral rehydration solution, which contains lower concentrations of sodium and glucose than earlier preparations and reduces stool volume and vomiting while preventing dehydration. Each packet is mixed with a liter of water for general use; for malnourished children, experts recommend adding a packet to two liters of water along with extra sucrose and potassium solution.

  In 2016, estimates suggested that more widespread breastfeeding could prevent about 823,000 deaths annually of children under age five. The medical community recommends exclusively breastfeeding infants for six months, with continued breastfeeding up to two years or older. Global exclusive breastfeeding rates rose from 33 percent to 39 percent between 1995 and 2010, according to surveys conducted over that period.