what are research questions in malnutrition

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• Published: 15 October 2018

Protein, malnutrition and wasting disorders

The impact of using a malnutrition screening tool in a hospital setting: a mixed methods study

• Doris Eglseer 1 ,
• Daniela Schoberer 1 ,
• Ruud Halfens 2 &
• Christa Lohrmann 1  

European Journal of Clinical Nutrition volume  73 ,  pages 284–292 ( 2019 ) Cite this article

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Background/Objectives

Malnutrition risk screening represents a crucial starting point for the successful management of malnourished patients. This study was conducted to (1) examine the effect of the use of a malnutrition screening tool on process indicators of nutritional care and (2) explore healthcare professionals’ perceptions and opinions regarding this tool.

A mixed methods design was used. A controlled pretest–posttest study was conducted to carry out quantitative analyses, and semi-structured, qualitative interviews were held. Quantitative data were analysed with descriptive statistics, Chi-squared tests, Student’s t -tests and Kruskal–Wallis H tests, using SPSS 23. Qualitative data were analysed by performing a qualitative content analysis using MAXQDA 12. Two comparable hospitals participated in the study, representing one intervention group (IG) and one control group (CG). The Graz Malnutrition Screening Tool (GMS) was implemented and used in the IG for at least 1 month, while the CG received no intervention.

The use of the screening tool positively correlated with significant improvements in the process indicators of nutritional care after 1 month, in terms of the number of nutritional interventions and the frequency of documentation of the diagnosis and the patient’s weight and height. The content of the interviews revealed that nearly all professionals involved perceived the overall screening process positively. Few barriers were identified.

Conclusions

The results of this study show that the use of a screening tool has a positive, short-term impact on the hospital’s process quality of nutritional care. Ongoing efforts are required to sustainably maintain these positive changes. During this process, positive attitudes, nomination of motivated ‘opinion-leaders’ and concerted management support are helpful facilitators.

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Institute of Nursing Science, Medical University of Graz, Graz, Austria

Doris Eglseer, Daniela Schoberer & Christa Lohrmann

Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, The Netherlands

Ruud Halfens

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Ethics approval

Ethical approval was obtained from the responsible ethics committee (29-270 ex 16/17). The hospitals participated on a voluntary basis, and all responsible persons (medical and nursing hospital directors) gave their written informed consent. The persons interviewed agreed orally to participate in the interviews. Following the recommendations of the ethics committee, it was not necessary to obtain the informed consent from the patients because we only collected routine data.

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Eglseer, D., Schoberer, D., Halfens, R. et al. The impact of using a malnutrition screening tool in a hospital setting: a mixed methods study. Eur J Clin Nutr 73 , 284–292 (2019). https://doi.org/10.1038/s41430-018-0339-z

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Received : 17 May 2018

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Accepted : 26 September 2018

Published : 15 October 2018

Issue Date : February 2019

DOI : https://doi.org/10.1038/s41430-018-0339-z

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Barriers and facilitators to screening and treating malnutrition in older adults living in the community: a mixed-methods synthesis

• Philine S. Harris 1 ,
• Liz Payne   ORCID: orcid.org/0000-0002-6594-5668 1 ,
• Leanne Morrison 1 , 2 ,
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• Claire Hallett 4 ,
• Emma L. Parsons 5 ,
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• Michelle Sutcliffe 8 ,
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• Paul S. Little 2 ,
• Michael A. Stroud 10 &
• Lucy Yardley 1 , 11  

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Malnutrition (specifically undernutrition) in older, community-dwelling adults reduces well-being and predisposes to disease. Implementation of screen-and-treat policies could help to systematically detect and treat at-risk and malnourished patients. We aimed to identify barriers and facilitators to implementing malnutrition screen and treat policies in primary/community care, which barriers have been addressed and which facilitators have been successfully incorporated in existing interventions.

A data-base search was conducted using MEDLINE, Embase, PsycINFO, DARE, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews from 2012 to June 2016 to identify relevant qualitative and quantitative literature from primary/community care. Studies were included if participants were older, community-dwelling adults (65+) or healthcare professionals who would screen and treat such patients. Barriers and facilitators were extracted and mapped onto intervention features to determine whether these had addressed barriers.

Of a total of 2182 studies identified, 21 were included (6 qualitative, 12 quantitative and 3 mixed; 14 studies targeting patients and 7 targeting healthcare professionals). Facilitators addressing a wide range of barriers were identified, yet few interventions addressed psychosocial barriers to screen-and-treat policies for patients, such as loneliness and reluctance to be screened, or healthcare professionals’ reservations about prescribing oral nutritional supplements.

The studies reviewed identified several barriers and facilitators and addressed some of these in intervention design, although a prominent gap appeared to be psychosocial barriers. No single included study addressed all barriers or made use of all facilitators, although this appears to be possible. Interventions aiming to implement screen-and-treat approaches to malnutrition in primary care should consider barriers that both patients and healthcare professionals may face.

Review registrations

PROSPERO: CRD42017071398 . The review protocol was registered retrospectively.

Peer Review reports

Malnutrition (specifically undernutrition) can impair wound healing, reduce muscle strength and weaken the immune response, increasing many health risks including infections and delayed recovery from illness [ 1 ]. Increased prevalence of long-term health conditions makes older adults particularly vulnerable to malnutrition [ 2 , 3 ]. Malnutrition can have medical or physiological causes (e.g. difficulties chewing or swallowing), psychosocial (e.g. poverty or depression [ 2 ]), or a combination of these.

In the UK, more than 3 million people are believed to be malnourished [ 4 ], and the cost associated with malnutrition across health and social care was estimated to be £20 billion in 2015 [ 5 ]. Among community-dwelling older adults in the UK and Ireland, 14% may be at risk of malnutrition [ 6 ], though estimates vary depending on the specific sub-groups and screening tools studied [ 7 ]. The terms malnutrition and undernutrition are commonly used to define the same state, which can arise through inadequate intake of nutrients or an inability of the body to make use of nutrients [ 8 ]. However, risk of malnutrition is sometimes conceptualised as increasing over time for as long as undernutrition continues [ 7 ]. The Global Leadership Initiative on Malnutrition (GLIM) recently agreed diagnostic criteria for malnutrition, which include meeting at least one of the following criteria (non-volitional weight loss, low body mass or low muscle strength) and additionally at least one of the following criteria (reduced food intake or assimilation or disease burden or inflammation) [ 8 ].

Treating malnutrition in older adults may improve their health, quality of life [ 9 , 10 ] and reduce healthcare costs [ 5 ]. In the hospital setting, malnutrition-screen-and-treat policies are recommended [ 11 ], but there is little evidence for their implementation and value in primary care. Systematic screening, using validated tools such as the Malnutrition Universal Screening Tool [ 12 ], improves identification of individuals who may be at risk of malnutrition [ 4 ] allowing treatment which may prevent malnutrition and its consequences [ 13 ]. Treatment includes providing dietary advice [ 14 ], meals [ 15 ] or oral nutritional supplements (ONS [ 16 ]). Treatment may differ depending on the severity of malnutrition risk, and several care pathways, including for the community [ 17 ], have been developed. Care pathways include tools to aid diagnosis of underlying diseases or conditions that make eating or digestion difficult, so that these can be treated [ 18 ]. However, malnutrition remains under-recognised and untreated across all healthcare settings [ 19 ] because healthcare professionals (HCP) often fail to diagnose it [ 20 ] or attach low priority to nutrition in older patients [ 21 ]. Clinical guidelines recommend that screening should be carried out by HCPs who have received appropriate training [ 11 , 22 ], but do not specify how screening should be enacted or the training delivered despite urgent calls to improve HCPs’ nutrition education [ 23 ]. Uncertainty remains about which of various approaches are most practicable and acceptable to HCPs and older adults [ 24 ]. Further, the evidence in support of systematic use of screening tools [ 25 ] and treatment approaches such as giving ONS [ 16 ] has largely emerged from research in secondary care, and comparatively little is known about how this translates to those living at home.

More research on the barriers to nutritional screening and treatment in older, community-dwelling adults [ 24 , 26 ] has been called for. Previous reviews have focused on patient [ 27 ] or HCP barriers [ 13 , 28 ] in isolation, or on the effectiveness of randomised controlled trials (RCTs) [ 24 ]. Given the limited evidence available [ 26 ], the current synthesis seeks to extend the literature by reviewing findings about older patients and HCPs, from both qualitative and quantitative studies, including non-RCT studies, which can, if well designed, be considered strong evidence [ 26 ] and can inform us of the acceptability and feasibility of intervention features. The core analysis, and novel contribution to the literature, is a mapping [ 29 ] of barriers, facilitators and intervention features to identify how the content and design of interventions can be optimised and to identify gaps in recent intervention research.

The aims of this synthesis are to: 1) identify barriers and facilitators to implementing malnutrition screen and treat policies in primary/community care; 2) map barriers and facilitators to features in existing interventions; and 3) make recommendations for the design of interventions targeting malnutrition in older adults and nutrition education for HCPs.

Barriers and facilitators to screen-and-treat approaches were extracted [ 30 ] and mapped onto intervention features [ 29 ] to determine whether barriers had been addressed and what solutions were available and feasible. A meta-analytic, causal approach to the quantitative studies was considered, but deemed unsuitable because of the heterogeneity of the interventions. Instead, we used thematic synthesis and aspects of Intervention Component Analysis [ 30 , 31 ] to describe and critically interpret the findings (see [ 30 ]. The protocol can be found here: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017071398 (PROSPERO registration number CRD42017071398).

Literature search

Seven databases (MEDLINE, Embase, PsycINFO, DARE, CINAHL, Cochrane Central and Cochrane Reviews) were searched in June 2016. Search terms are shown in Additional file  1 . The search was restricted to references from 2012 onwards, to focus on publications since Cochrane reviews on malnutrition screening [ 32 ] and interventions for malnutrition [ 33 ]. LP, DG and JS screened titles and abstracts and excluded irrelevant references. LP and PH screened full text publications for eligibility. Qualitative and quantitative intervention studies and studies exploring older people’s eating patterns or appetite or health professionals’ experiences in relation to undernutrition were included if participants were either adults 65+ living at home or healthcare professionals who would care for these participants. Studies were excluded if participants were care home residents or hospital inpatients, or if participants presented with a terminal disease, cancer, dementia or diabetes, who may have specific nutritional requirements due to their conditions. Studies were also excluded if they were not in English. Inclusion/exclusion criteria are shown in Additional file  2 .

Data coding, extraction and synthesis

Key study characteristics were extracted and tabulated (Additional file  4 : Tables S4-S5). Figure  1 is a flow chart outlining eligible studies containing qualitative and quantitative data; those presenting primarily quantitative data will be referred to as “interventions” and included RCTs ( n  = 6), RCT feasibility ( n  = 3) and pre-post designs ( n  = 4).

Flow chart of studies included in the synthesis

Papers reporting on the studies (all sections bar the introduction, following Corbett and colleagues [ 30 ]) were coded line-by-line and codes organised into descriptive themes, in line with thematic synthesis [ 34 ]: PH and LP established an initial coding manual with the aim of capturing barriers and facilitators to malnutrition-screen-and-treat approaches and intervention features designed to address barriers and incorporate facilitators. PH and LP double-coded a subset of studies (8 of 21) using this coding manual. Discrepancies were discussed and the coding manual was refined accordingly. PH coded the remaining studies. LP read all remaining studies and resulting codes, and the findings and additional codes were discussed with all authors. The emerging codes were organised into barriers and facilitators, for patients and HCPs, to screening, nutritional self-care and ONS use.

Following Shepherd and colleagues [ 29 ], the resulting data were first analysed and synthesised narratively to provide an overview of included studies. Syntheses are not reported here; findings are similar to previous reviews, e.g. [ 24 , 28 ] Then, novel to malnutrition screening literature and reported here, intervention and qualitative studies were synthesised to map barriers and facilitators onto intervention features in a matrix, identifying which interventions (if any) had addressed barriers or incorporated facilitators. Of note, in some instances no facilitator was explicitly named in the reviewed studies, but a possible solution to addressing the barrier was found in intervention features. All authors read and commented on the draft synthesis and provided clinical and / or nutritional expertise during search strategy development and analysis of findings.

Practical barriers to screen-and-treat approaches to malnutrition

Physiological barriers to screen-and-treat approaches to malnutrition

Critical appraisal

Studies were assessed using the Mixed-Methods Appraisal Tool (MMAT [ 35 ]). The MMAT differentiates studies based on how many quality criteria they meet: High quality studies meet at least 2 of 4 quality criteria, whereas low quality studies meet fewer than 2 criteria. LP and PH first trialled the MMAT on a small selection of papers. Overall, agreement was acceptable (76%), but some criteria were identified as ambiguous (criteria 1.3, 1.4, 2.3, 3.4 and 4.4). The raters agreed on a mutual understanding of these before each independently assessing all remaining studies.

Of the 21 included studies (Fig. 1 ), seven focused on HCPs and 14 on older people, who are referred to as ‘patients’, though some were not recruited or treated by HCPs; see Additional file 4 : Tables S4-S5 for details of HCPs and patients. Around half of all studies (seven interventions and three qualitative) met MMAT criteria for high quality [ 35 ], however no low quality studies are excluded from the results presented below [ 36 ]. Results drawn from interventions deemed to be of higher or lower quality are summarised separately in Additional file 3 : Tables S1-S3, to show which results are likely to be more reliable.

All extracted barriers and facilitators can be found in Additional file 3 : Tables S1-S3 and all study characteristics can be found in Additional file 4 : Tables S4-S5. Of note, the ten interventions targeting patients varied considerably in content. As detailed in Additional file 4 : Table S4, seven [ 37 , 38 , 39 , 40 , 41 , 42 , 43 ] provided individual nutritional counselling from dietitians or nutritionists. In three of these [ 38 , 39 , 40 ], this was complemented with support from physicians, nurses, physiotherapists or occupational therapists, in a multi-disciplinary approach. In three other interventions [ 44 , 45 , 46 ], participants received nutrition: one intervention provided participants with ONS, one with food and one with snacks. The reported effectiveness of all interventions was varied and inconclusive, echoing previous reviews [ 24 , 47 ]. For example, some of the nutritional counselling interventions showed some promising effects on body weight [ 37 , 43 ] and physical functioning [ 37 ], whilst others did not [ 41 , 42 ].

Figures 2 , 3 and 4 show whether interventions have incorporated the barriers and facilitators that emerged from qualitative studies. In the figures, these are separated by barriers and facilitators that patients and healthcare professionals may experience. In the following text, they are described together to emphasise areas where barriers and facilitators overlapped or differed.

Barriers and facilitators to screening

Barriers to screening were common to both patients and HCPs: time taken to screen and reservations toward screening. Duration of screening was mostly addressed through shorter screening tools. The burden on HCPs’ time was additionally alleviated by patients filling in parts of the screener themselves, which seemed acceptable to patients and HCPs and mostly accurate (see Additional file 3 : Table S1). Screening was not currently part of practice routine (see [ 28 ], but possible solutions included screening during routine appointments.

Patients were reluctant to describe their diet, for example because they were uncomfortable disclosing a poor diet [ 48 ], whereas HCPs had doubts over the need for and benefits of screening. Interventions educated HCPs on the purpose and importance of screening, but no intervention reported doing the same for patients. No intervention measured whether HCPs’ scepticism had been alleviated through training and only one intervention reported the number of patients who turned down screening (20% [ 46 ]).

Barriers and facilitators to treating malnutrition

Patients perceived physiological and practical barriers to nutritional self-care (e.g. difficulties chewing, swallowing, shopping or preparing food). Multidisciplinary approaches addressed these by referring to the relevant specialist (e.g. dentist, physiotherapist or occupational therapist). Conversely, interventions that provided nutritional or dietitian counselling addressed physiological barriers, such as being unable to eat big portions, through self-help advice. Changes to eating behaviour, e.g. eating smaller portions or adding energy-rich food, was often central to these and appeared feasible and acceptable [ 37 , 41 , 42 , 43 ].

Psychosocial barriers were the most frequent to not be addressed by interventions. More specifically, older adults may not consider nutrition as important, or fail to recognise the problem [ 48 , 49 , 50 , 51 ] because they perceive themselves as healthy, and consequently avoid ‘unhealthy’, energy-dense food [ 45 , 50 , 51 ] . No facilitators to these barriers emerged from the qualitative studies.

No intervention addressed the barrier of loneliness. Qualitative studies showed older adults may struggle with cooking [ 46 , 49 , 50 ] and eating alone [ 51 ]. A possible solution may be to offer ideas to help patients connect with others, but none of the interventions offered such self-help advice.

A further gap was how the intervention is presented to patients. Patients may be dissuaded from engaging if told that the aim is for them to gain weight, which may be perceived as aversive [ 52 ]. No intervention explicitly stated how the intervention was presented to patients.

Key barriers faced by HCPs were lack of time and low self-efficacy in malnutrition treatment pathways. Provision of written resources to alleviate burden placed on HCPs was a common feature of interventions and well-received by HCPs. Training to raise self-efficacy and build motivation for the importance of nutritional care was provided by only one high quality intervention [ 41 ]. No other solutions were identified in qualitative studies or tested in interventions.

Barriers or facilitators to ONS uptake

Giving patients ONS is one treatment approach in the reviewed studies. No interventions recorded (by measuring compliance) whether patients were persuaded to consume ONS. Of note, in the intervention where ONS uptake resulted in improved weight and physical function [ 45 ], participants received clear instructions on how to take ONS, which no others reported. A notable psychosocial barrier was that patients may be reluctant to consume it publicly due to unwanted attention. A possible facilitator mentioned was to normalise consumption [ 53 ], by treating ONS as food not medicine, but interventions did not address this.

HCPs had reservations about prescribing ONS. These reservations were only addressed in one intervention [ 54 ] (deemed low quality), despite ONS frequently being a component of interventions. It is not yet clear what an effective training programme for HCPs needs to incorporate, but simple solutions have been proposed such as explaining that appropriate prescribing can save money (Fig. 2 ).

Psychosocial barriers to screen-and-treat approaches to malnutrition

This synthesis identified, from recent literature, barriers and facilitators to screening and treating malnutrition in community-dwelling older adults in primary care, and demonstrated whether and how interventions have incorporated these. The studies document numerous physiological, practical and psychosocial barriers to patients’ and HCPs’ engagement with screening and treating malnutrition, but our novel approach to mapping these onto intervention features revealed the following gaps: interventions did not address patients’ scepticism about malnutrition screening, endeavour to increase readiness to be screened (e.g. through education) or measure reactions to screening. We currently have little data on how older adults perceive screening or why they are reluctant to be screened [ 48 , 49 ]. Notably, findings relating to patients’ barriers to screening emerged largely from HCPs’ experiences [ 48 , 49 , 55 ]. Moreover, we noted some conflicting findings, such as that some patients are willing to be screened when the purpose of screening is explained to them [ 55 ], whilst others seem to prefer not to know [ 55 ]. Similarly, some patients in a qualitative study were surprised or offended to be told they were ‘at risk’ after screening, while others were unconcerned [ 56 ]. Such differences may be due to preferences of individual patients, their experience of the patient-practitioner relationship or the way that risk information is conveyed. Further studies exploring older patients’ experience of being screened in primary care are needed to promote and support their self-management and identify effective ways to convince patients of the value of screening.

Practical and physiological barriers and facilitators to nutritional self-care were incorporated in the interventions reviewed, and steps taken to overcome these barriers are in line with those suggested by care pathways for the management of disease-related malnutrition [ 17 ]. However, a prominent gap was in considering psychosocial barriers, which may link to psychosocial causes of malnutrition [ 2 ]. These included loneliness, and patients perceiving themselves as healthy and avoiding ‘unhealthy’ food, highlighting the potential benefit of screening regardless of whether patients report any health issues. A recent randomised controlled intervention study identified additional beliefs that interfered with patients’ adoption of self-care components, including not believing that the recommended action would solve the problem [ 57 ].

A psychosocial barrier to engaging in nutritional interventions may be how an intervention is presented to patients (e.g. whether its aim is ‘weight gain’). Interventions did not explicitly report how they were presented to patients, but it could be a factor that may promote or hinder engagement. Van der Pols-Vijlbrief and colleagues [ 57 ] also suggest that easy-to-execute actions such as tips promoting three or more snacks a day and increased physical activity may be adopted more readily.

Previous research shows ONS to be effective in hospital patients in terms of weight gain [ 22 ], reduced complications and mortality, and may be effective in community settings, including care homes, sheltered housing or among free-living older adults, particularly when ONS is initiated during a hospital stay [ 58 ]. However, good quality prospective studies are needed to establish whether ONS is beneficial when initiated in primary care [ 59 ]. Future studies are needed to test whether ONS can make a difference to the nutritional status of free-living older adults who are at risk, but who have not yet had an acute episode that triggers malnutrition screening. However, this is unlikely to address the underlying issue of patients not recognising the problem, for example where malnourishment is related to social factors [ 2 ]. In order to test the effectiveness of ONS in the community, HCPs need to be convinced of the need to test the potential value of ONS and to prescribe according to protocol. Our synthesis therefore emphasises that interventions need to address engagement of HCPs and patients with the idea of prescribing or consuming ONS to treat malnutrition where necessary, otherwise tests of the effectiveness of ONS may not be valid. HCPs’ reservations need to be countered, and patients need to be given practical and psychological support to enhance consumption. For example, ONS may be uncomfortable to consume, though no intervention in this synthesis considered this, but which could be addressed through practical advice (e.g. drinking through a straw). Results showed that interventions providing patients with ONS rarely reported incorporating such education or support. It seems theoretically possible that informed education on the benefits of ONS for HCPs could help, but for this to be effective, further research is needed in order to explore and address the underlying reasons for their reservations.

Strengths and limitations

This synthesis highlights how considering qualitative data alongside quantitative data may help explain quantitative findings and can lead to different conclusions than considering each in isolation [ 60 ]. First, those studies with mixed-methods approaches provided the richest findings, e.g. documenting patients’ reasons for discontinuing an intervention [ 44 ], which can help improve future interventions [ 61 ]. Second, the mixed-methods approach of this synthesis allowed for greater scope and insights into whether interventions can address older, community-dwelling adults’ barriers to nutritional self-care.

Interventions tended to be complex (thus making it difficult to isolate the active ingredient), to involve small, diverse samples, and to vary substantially (e.g. in their duration and geographical location). Some baseline variables, such as HCPs’ existing levels of nutrition knowledge, were unknown. This heterogeneity precluded a meta-analytic approach to quantifying effects and made direct comparisons across studies difficult. However, as the number of interventions being trialled is steadily growing, the available evidence may soon be rich enough to conduct such meta-analyses.

We included only studies published since the Cochrane review on dietary counselling and ONS [ 33 ], yet barriers and facilitators to screen and treat may have been identified in studies published prior to 2012. However, only four studies identified by Baldwin et al. [ 33 ] focused on community-dwelling older adults, and we considered that practice is likely to have changed since these publications from 1985, 1995, 2003 and 2008.

A further limitation was the quality of included studies. Around half the studies were judged to be of low quality and conclusions drawn from these must be treated with caution. This concurs with other reviews on malnutrition interventions [ 14 , 15 , 45 , 62 , 33 ]. It is noteworthy, however, that low scores on the MMAT were often due to reviewers having to assign the category ‘Can’t Tell’ (in 18% of classifications). The MMAT is a relatively new tool designed to assess the quality of a number of study types, and the number of ‘can’t tell’ classifications we made may indicate that improvements are needed. Thus, studies may have been well designed, but insufficient reporting and / or limitations of the MMAT reduced our ability to judge study quality, highlighting the importance of adhering to accepted reporting standards (e.g. [ 63 ]). Insufficient reporting further limited our ability to judge whether some interventions incorporated named facilitators, such as providing evidence on the effectiveness of screening in HCPs’ training.

Comparison with existing literature

Although the synthesis makes an important contribution by identifying key barriers, possible solutions and areas where future interventions must be targeted, it is not yet possible to identify the key ingredients of an effective intervention. We calculated effect sizes where possible (Additional file 4 : Table S4), but only a few studies reported the relevant statistics, limiting our ability to compare and judge effectiveness. This echoes previous reviews on malnutrition interventions targeting older, community-dwelling adults [ 24 , 47 ] and the most recent clinical guidelines in the UK [ 11 ].

The findings regarding HCPs’ barriers and facilitators to screening show coherence with the results of a previous review [ 28 ]. The results further strengthen the argument that screening alone is insufficient [ 26 , 64 ] and must be accompanied with appropriate nutrition care pathways.

Implications for research and practice

When intervention targets (e.g. ONS consumption) are not met, the effectiveness of an intervention should be questioned [ 47 , 65 ]. Two points follow on from this: first, this could explain some of the inconsistent effects observed in this synthesis, as compliance varied overall (and was not reported for ONS). Second, participation in screening should be considered a crucial aspect of intervention fidelity. As this synthesis demonstrates, screening harbours its own set of barriers for both HCPs and patients, and thus it is informative to know how both reacted to screening. Studies should report the number of patients who refused screening (which only one study in this synthesis did [ 46 ]). It would be informative to explore patients’ perceptions of screening and speak to those who refuse screening [ 66 , 67 ].

In this synthesis we have identified multiple barriers to implementing screen and treat policies in primary/community care for both HCPs and patients. We have also identified possible facilitators to address these barriers, both from studies exploring HCPs’ and patients’ perspectives and from previously tested interventions. We have also identified barriers that were not addressed within the reviewed interventions, but which could be addressed with well-designed intervention features (e.g. addressing misconceptions about ‘unhealthy’ food for older adults through education and overcoming HCP scepticism for screening). Future interventions need to be developed with the complex barriers of both HCPs and patients in mind. Research is now needed to establish whether interventions designed to address the identified barriers to screening and treatment of malnutrition are effective.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Healthcare professionals

Mixed Methods Appraisal Tool

Malnutrition Universal Screening Tool

Oral nutritional supplements

Randomised controlled trial

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Acknowledgements

We would like to thank the large, multidisciplinary team of general practitioners, research nurses, dietitians, nutritionists, researchers, programme managers and patient and public involvement representatives who contribute to the STREAM project and were consulted during the creation of this synthesis.

This synthesis is part of the STREAM project, which aims to develop and test a complex intervention targeting both healthcare professionals and older patients in primary care. It is funded from an NIHR Programme Grant for Applied Research, Reference Number RP-PG-0614-20004. PA is an NIHR senior investigator and is funded by NIHR CLAHRC Oxford and the NIHR Oxford Biomedical Research Centre. The funding body approved the project team’s study design, but was not involved in data collection, analysis or write-up.

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LM, LY, LP and PH conceptualised the study design. LP created the search strategy. LP, DG and JS carried out abstract screening. PH and LP carried out full text screening. PH and LP carried out coding and thematic analysis. LM, PH and LP participated in critical interpretation of the data. PH drafted the manuscript. LP and LM adjusted the manuscript in response to peer review comments. LP, LM, SG, DG, CH, EP, PA, HR, MAS, SR, JS, PL, MS and LY contributed to the editing of the manuscript and approved the final version for publication.

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Additional files

Additional file 1:.

Search strategy. (DOCX 13 kb)

Additional file 2:

Inclusion and exclusion criteria. (DOCX 14 kb)

Additional file 3:

Table S1. Synthesis matrix for screening for malnutrition. Table S2. Synthesis matrix for treating malnutrition. Table S3. Synthesis matrix for prescribing or taking ONS. (DOCX 24 kb)

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Table S4. Characteristics of interventions. Table S5. Characteristics of qualitative studies. (DOCX 31 kb)

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Harris, P.S., Payne, L., Morrison, L. et al. Barriers and facilitators to screening and treating malnutrition in older adults living in the community: a mixed-methods synthesis. BMC Fam Pract 20 , 100 (2019). https://doi.org/10.1186/s12875-019-0983-y

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Mapping evidence on malnutrition screening tools for children under 5 years in sub-Saharan Africa: a scoping review protocol

• Tlharihani Phisac Maphosa 1 ,
• Delarise Maud Mulqueeny 1 , 2 ,
• Ernest Osei 1 ,
• Desmond Kuupiel 1 , 3 &
• Tivani P. Mashamba-Thompson 1 , 4  

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In sub-Saharan Africa (SSA), malnutrition remains a major public health challenge, particularly among children under 5 years of age. Despite nutritional screening tools being developed and available to detect early malnutrition in under five-year-old children, malnutrition continues to be a health concern. However, the level of evidence on nutritional screening tools for predicting early malnutrition at the community level in a high disease burden setting is unclear. The objective of this scoping review is to systematically map the evidence on malnutrition screening tools for children under 5 years in sub-Saharan Africa (SSA) and to identify knowledge gaps.

The proposed study will be guided by an improved Arksey and O’Malley’s framework, Levac et al . 2010 recommendations, and the 2015 Joanna Briggs Institute guidelines. We will conduct a systematic search of relevant imperial sources of evidence from the following databases: CINAHL with full text, Academic search complete via EBSCOhost, Google Scholar, Science Direct, and PubMed. We will search for grey literature from the following humanitarian and aid organization websites: World Health Organization (WHO), The United Nations International Children’s Emergency Fund (UNICEF), and governmental departments. Following the database searches and title screening, eligible sources of evidence will be exported to an EndNote X9 reference library. Thereafter, duplicate articles will be removed in preparation for abstract and full article screenings. Data from the included sources of evidence will be extracted, and the emerging themes will be analyzed. The relationship between the emerging themes and the research questions will be critically examined. The quality of the included sources of evidence will be determined by using the Mixed Method Appraisal Tool (MMAT) version 2018. The search results will be presented in adapted Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Reviews chart (PRISMA-ScR).

We anticipate finding relevant literature on malnutrition screening tools for children under 5 years in SSA. This study is likely to reveal research gaps, which could guide future research on malnutrition screening tools.

Peer Review reports

Malnutrition remains a major public health challenge, particularly among children under 5 years of age [ 1 ]. Globally, about 17 million children under 5 years of age suffer from severe acute malnutrition (SAM) and the majority live in southern Asia and sub-Saharan Africa (SSA) [ 2 ]. In this scoping review, SSA refers to 46 African countries that are fully or partially located in the south of the Sahara [ 3 ]. The United Nations International Children’s Emergency Fund (UNICEF), the World Health Organization (WHO), and the World Bank estimate global and regional child malnutrition reports that we are still far from a world free of malnutrition among children under-five, that there is insufficient progress in achieving the World Health Assembly targets set for 2025 and the 2030 Sustainable Development Goals [ 4 ]. As children living in SSA are at a higher risk of malnutrition, improved screening, availability of appropriate paediatric screening tools and their correct use, check-ups, and timely interventions to improve the health outcomes of children is pivotal [ 5 , 6 ].

Malnutrition screening tools (MST) are instruments used for early detection of patients who are nutritionally at risk and those who are already malnourished [ 7 ]. Since 1995, several MST for early detection of malnutrition in hospitalized children have been developed and proposed for use (high-income countries (HIC) [ 8 , 9 ]). In SSA, MST commonly used to classify malnutrition indicators (wasting, stunting, and underweight) in children under 5 years of age include the use of anthropometric assessments such as height-for-age (HFA), weight-for-height (WFH), weight-for-age (WFA), and mid-upper arm circumference (MUAC) [ 10 , 11 ]. Reasons due to the inadequate or incorrect use of malnutrition screening tools include lack of training, health professional’s insufficient awareness, misunderstanding of available tools, shortages of equipment or personnel, and lack of nutritional information given to caregivers. It is important that MST follow effective and efficient processes, as the correct interpretation and use of these tools are crucial to improving early detection and care linkage in malnourished children [ 12 , 13 ].

An initial scoping search of the literature to determine whether systematic reviews and recommendations on our research questions that have been published has found these manuscripts more in HIC. Suitable screening tools for children are scarce with no consensus on the best method to assess their risk of malnutrition despite several recommendations on the importance of its early identification [ 14 , 15 , 16 ]. Moreover, due to a lack of simple validated methods, malnutrition screening is not widely and correctly performed [ 17 , 18 ]. Research studies conducted in South Africa and Uganda have shown that health professionals have inadequate knowledge of available nutritional status interpretation tools as gaps have been identified [ 19 , 20 ]. Moreover, the level of evidence on nutritional screening tools to predict early malnutrition at community levels in high disease burdened settings such as SSA is unclear.

Hence, as this is a broad topic, a scoping review was found to be most useful over a systematic review to map a range of literature that exists and would aid in focusing the research questions by charting existing research findings and identifying research gaps [ 21 , 22 ]. It is anticipated that the results of this review will reveal gaps to guide future research and inform policymakers to ensure the successful implementation of current and future MST for children under-five in disease burdened settings. The results will also ensure that health professionals and educators are aware of the MST that need to be included in local medical curricula. In this sense, there will be early identification of children who are at risk of malnutrition, and it is essential because it allows appropriate nutritional interventions to prevent malnutrition and its consequences.

The objective of this scoping review is to systematically map the evidence on malnutrition screening tools for children under the age of five in sub-Saharan Africa (SSA) and to identify knowledge gaps.

Methodology

A scoping review method was selected as it outlines different types of evidence in the area of interest and highlights gaps for further research. Based on this, the current scoping review uses an enhanced Arksey and O’Malley’s framework, Levac et al. 2010 recommendations, and the 2015 Joanna Briggs Institute guidelines to guide the methodology of this scoping review [ 23 , 24 , 25 ]. The framework involves (1) identifying the research question, (2) identifying relevant sources of evidence, (3) selection of sources of evidence and eligibility, (4) charting the data, and (5) collating, summarizing, and reporting the results. The results of this proposed study will be presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review guidelines (PRISMA-ScR) [ 26 ]. This protocol has not been registered a priori. The PRISMA-P checklist was used for this protocol (Additional file 1 ) [ 28 , 29 ].

Identifying the research question

The research questions are based on the research objective that was formulated using the Population-Concept-Context (PCC) framework designed by the Joanna Briggs Institute [ 25 ]. It was used to determine the eligibility of the scoping review question as shown in Table 1 .

The primary research question is what evidence exists on malnutrition screening tools for children under 5 years living in sub-Saharan Africa?

The secondary research questions are:

What malnutrition screening tools are used for children under 5 years in sub-Saharan Africa?

What evidence exists regarding the performance of malnutrition screening tools for children under 5 years in sub-Saharan Africa?

Identifying relevant sources of evidence

The review will include empirical literature and grey literature that present evidence on malnutrition screening tools for children under 5 years in SSA. We will search for relevant empirical literature from the following electronic databases: CINAHL with full text, Academic search complete via EBSCOhost, Google Scholar, Science Direct, and PubMed. To improve the quality and reduce errors of the electronic search, the search strategies were peer reviewed using the PRESS 2015 Evidence-Based Checklist [ 30 ]. The keywords informing the searches are malnutrition screening tools, nutritional screening tools, children under 5 years, and sub-Saharan countries. We will also search for grey literature from the following sources: humanitarian and aid organization websites such as The World Health Organisation (WHO), The United Nations International Children’s Emergency Fund (UNICEF), and governmental departments’ websites. These websites will be searched for current policies, guidelines, statistics, and interventions. The reference lists of the included articles will be thoroughly searched for relevant articles by a research assistant. Additionally, when relevant sources of evidence are inaccessible, authors will be contacted for the actual articles. A University of KwaZulu-Natal (UKZN) librarian specializing in developing searches in the health sciences was consulted to assist in the development of this search strategy. We have piloted the search strategies to check for the appropriateness of the selected databases and keywords using the Boolean terms “AND” and “OR” to separate the search terms. The results thereof are found in Table 2 .

Selection of sources of evidence and eligibility

To fine-tune the selection of the sources of evidence process and to improve consistency, a pilot test will be conducted prior to the review process commencing. There will be no language restrictions applied to the literature search. About 60 publications will be used for this procedure. To reduce any selection bias, screening of study titles and abstracts from the databases listed above will be conducted by two investigators (TPM and EO) independently. The relevant sources of evidence will be identified with the guidance of the inclusion and exclusion criteria. The eligible sources of evidence will then be exported to an Endnote X9 library created specifically for this review. All duplicates identified will be deleted before sharing the Endnote library with the two reviewers. An abstract screening form with questions will be developed based on our eligibility criteria. Discrepancies between reviewers at the title and abstract stage will be resolved through discussions until a consensus is reached. Following the title and abstract screening, full articles will be screened by the two reviewers (DMM and TPM) independently in parallel. Discrepancies between reviewers at the full article stage will be resolved by a third screener (DK). To ensure the reproducibility of the study, the references of excluded sources of evidence and the rationale for exclusion will be provided in an additional file of the completed review. Figure 1 presents an example of our planned selection of sources of evidence [ 26 , 27 ].

Selection of sources of evidence. PRISMA ScR flowchart which demonstrates the literature search and Selection of Sources of Evidence

Eligibility criteria

To ensure that relevant sources of evidence are selected for this review, the study selection process will be guided by the eligibility criteria as specified under the inclusion/exclusion criteria. The sources of evidence will include information from empirical literature and grey literature that present evidence on malnutrition screening tools for children under 5 years in SSA.

We will include articles presenting evidence of children under 5 years. Under-five in this study refers to children who are less than 5 years old.

We will exclude articles presenting evidence on children who are under-five but with developmental delays (e.g., children with cerebral palsy). This is because the tools that are used to screen children at risk of malnutrition are different from the ones used in children without delays.

Articles reporting evidence on malnutrition screening tools will be included in this study. Malnutrition screening tools refer to tools used to screen patients who are at risk of malnutrition [ 7 ].

Articles and studies that did not include the specificity of malnutrition screening tools will be excluded.

Articles published between 2010 and 2019 will be considered in order to obtain the most recent information on our research topic.

We will include articles reporting evidence from SSA. Sub-Saharan Africa refers to 46 African countries that are fully or partially located south of the Sahara [ 3 ].

Charting/extraction of data

A data charting form will be created using a Google form where all the necessary extracted data from the included sources of evidence can be populated (Table 3 ). The standard bibliographical information (i.e., authors, title, and year of publication), geographical setting, study setting, study design, and aim of the study will be reported in the form. For each of the included sources of evidence, information on the target population, type of intervention, nature of the outcome, key findings, most significant findings, conclusions, and notes will also be tabled. The data extraction will be conducted by two investigators (TPM and EO) independently, and the extraction form will continually be updated to ensure accuracy and consistency of extracted data. All disagreements between investigators in the data extraction process will be addressed through discussion until consensus is reached. Persistent disagreements will be resolved by involving a third screener (DK).

Collating, summarizing, and reporting the results

We will present a narrative account of the findings from the included sources of evidence and present themes. Thematic content analysis will be employed to extract the themes, which will be critically examined in relation to the study research question, the aim of the study, literature, gaps for future research, and MST for under 5 years in SSA countries. The implications of the study results for future research, policy, and practice will be examined and reported on.

Quality appraisal

We will utilize the Mixed Method Appraisal Tool (MMAT) version 2018 to appraise the methodological quality of included sources of evidence [ 31 ]. The criteria for the appropriateness of included sources of evidence will be determined by the aim of the study, appropriate methodology, study design, recruitment strategy, and appropriate sampling technique. Other items include suitable data collection procedures, appropriate data analysis, appropriate data interpretation, presentation of findings, discussion, and conclusions of the author from the included articles. A quality appraisal will be carried out to examine the strengths, weaknesses, and quality of research evidence and presented for each included article. The quality of all the included articles will be calculated and rated using the MMAT guidelines with 25% accounting for low-quality articles, 50% being average, 75% being above average, and 100% being high average. This will ensure that the study designs of the included sources of evidence are appropriate for the research objectives. The quality assessment will also assist us in reporting on the risk of bias and the quality of evidence of the included sources.

Differences between the protocol and the review

All differences between the protocol and the final research study will be reported together with the rationale for these changes. The consequences of these modifications on the magnitude, direction, and validity of the outcomes will also be presented [ 32 ].

Timely treatment of malnutrition in children of five years of age at primary healthcare facilities could prevent 500,000 deaths annually [ 33 ]. Hence, the importance of best practices regarding malnutrition screening tools for children under 5 years. This study will encourage the correct use of MST for children under-five and its findings could assist with the achievement of the Sustainable Development Goals (SDGs). As the focus of this review is on malnutrition screening tools, sources of evidence that do not focus on malnutrition screening tools will be excluded since such data is irrelevant and will not address the study research questions.

The limitations of this research study include the following: (1) it may omit sources of evidence that include participants older than five and may result in the exclusion of important sources of evidence and (2) including sources of evidence published between 2010 and 2019 could introduce the risk of publication bias. However, this period was chosen because it will represent the most recent information on our research topic. The study will focus on children under the age of 5 years in SSA as literature has shown that this region has the highest under-five mortality rate in the world [ 34 ]. Moreover, prior to 2011, a Road to Health Card (RTHC) was used as an essential monitoring tool for children under five-year-old’s health. However, the Road to Health Booklet (RTHB) is currently being used to monitor children under-five health and its correct use assists in the early detection of malnutrition [ 35 ]. Hence, the limitation of our literature to 2010 and 2019 will result in us obtaining the most recent information during this period.

The current scoping review strength is that it addresses objectives that are important for patients, clinicians, and policymakers. We expect that the scoping review results will provide a comprehensive overview of the evidence on the topic and highlight areas where evidence is controversial or missing. Additionally, it will provide key information to policymakers and health professionals interested in planning, funding, and delivering evidence-based effective interventions aimed at preventing malnutrition in children under 5 years. Moreover, identified research gaps could inform future studies and guide policy decisions to enhance healthcare outcomes in SSA. We plan to disseminate the study’s findings in peer-reviewed journals and at conference proceedings that focus on nutritional and disease screening. Additionally, the study findings will be disseminated to professionals and stakeholders involved in malnutrition prevention and treatment.

Availability of data and materials

All data generated or analyzed during this study will be included in the published scoping review article and will be available upon request.

Abbreviations

Height-for-age

Higher income countries

• Malnutrition screening tools

Mid-upper arm circumference

Population-Concept-Context

Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Reviews

Sub-Saharan Africa

United Nations International Children’s Emergency Fund

Weight-for-age

Weight-for-height

World Health Organization

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Acknowledgments

The authors express their gratitude to the University of KwaZulu-Natal for the support of this study.

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The study was conceptualized by TPM and TPMT. TPM wrote the first draft and DMM, OE, and TPMT critically reviewed the manuscript. All authors (TPM, DMM, OE, DK, and TPMT) reviewed the final drafted manuscript and approved it.

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PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 checklist: recommended items to address in a systematic review protocol*.

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Maphosa, T.P., Mulqueeny, D.M., Osei, E. et al. Mapping evidence on malnutrition screening tools for children under 5 years in sub-Saharan Africa: a scoping review protocol. Syst Rev 9 , 52 (2020). https://doi.org/10.1186/s13643-020-01309-6

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MALNUTRITION RESEARCH BY ORYEM JOSEPH

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Irene Sumbele

International Journal Foundation

This is cross-sectional community based study conducted in Angola area in Khartoum State of Sudan during period of 2015-2017. The aim of the study was to assess nutritional status of under five years old children and its associated risk factors using anthropometric measurements, interview of childcare givers, and observation on nutrition status indicators and socioeconomic profile of families. 282 children and their caregivers were selected and investigated using cluster sampling techniques and predesigned questionnaires and checklist. The results revealed that 19.1 of the studied children were severely malnourished, and 4.7 were moderately malnourished with children in age of one to two years were mostly affective with P value of < 0.05. Family size and parent education level also were reported among the major risk factors of malnutrition with P value of < 0.05. 96.6% of the children had episode of diarrhea at least once, and 81.1% had respiratory tract infection at least once. Few were exposed to frequently to those infectious diseases. The study concluded that severe and moderate malnutrition affect almost quarter of the children in the area especially in the age group of one to two years. Poor education and awareness on how to maintain children health generally is the main risk factor especially knowledge and skills on the causes of malnutrition, proper young children food and feeding practices, breastfeeding, and utilization of available health services. The study recommended extensive health education program along with family support through provision of nutrients high density food. Study Area: The area has a total population of the area 56,534 with 10,386 under five year old children according to the area popular committees. Household with children aged 6 to 59 months were selected for the study along with their mothers. Diarrheal diseases, malaria and acute respiratory infections were the major health problem among young children in the areas. There are five health centers providing PHC services and 5 private clinics. Diarrheal diseases, malaria and acute respiratory infections were the major health problem among young children in the areas. There are five health centers providing PHC services and 5 private clinics. Sample size: 282 children and their mother were selected using the following formula and based on prevalence rate of nutritional deficiency diseases in Khartoum State of which was estimated to be 10% according Khartoum State Ministry of Health, 2009 n = z 2 pq* design defect (d) 2 Where: n = sample size, Z = 1.96, P = prevalence rate of nutritional deficiency diseases= (10%), q = 1-p, d = 0.05, Design defect=2 n =(1.96) 2 X 0.9 X0.X 2 = 138.2976 X 2 = 276.59 (0.05) 2 (14) The number was rounded to 282 children taken into account the refusal which was estimated to be 9%. Cluster sampling techniques was used by dividing the area into 6 clusters, in each 47 children's and their mothers/caretakers were selected randomly (15). Data were collected in predesigned questionnaire and check list through interview with mothers and measuring weight and high of their children. Indicators used during this study were: height –for –age (for chronic malnutrition), weight for weight (for acute malnutrition) and edema (16,17). Weight: The Staler 25kg hanging spring scale marked out in steps 0.1 kg, was used instrument was adjusted to zero before used, the child freed from heavy clothing (16,17). Height: Children up to 2years (23 months 85 cm length) of age were measured on horizontal measuring board. Children over two years of age (or over 85cm) were measured standing on horizontal surface against vertical measuring device. The height was read out as before, to nearest 0.1cm (29) Age: The birth data was entered on the recording form from birth certificates where this document was not available we used date of birth given by mothers Edema: Presence of edema also was recording after examination of children using finger press on the abdomen and legs.

Geleta Asebe

Abdul-Rasheed L Sulaiman , Ahmed Olusi

The road to good health is through good food which depends on the socioeconomic condition of the giver of the food. Numerous studies had been conducted on the causes of child malnutrition among children less than 5 years, that of children between 8 and 16 years with keen interest on the socioeconomic context of the giver has not been well documented. This lacuna is what this paper filled. Cross-sectional household survey was used for the study. 322 respondents were selected using a multi stage cluster sampling design. A well-structured pretested questionnaire was used to elicit the socio-demographic data from the respondents, while the respondents' nutritional status was calculated using the Body Mass Index (B.M.I) method. Chi-square and bivariate logistics regression were used to test the hypotheses. The study discovered that parental education and parental income were the fundamental factors affecting child malnutrition in the study location. Hence, government should ensure that education is made compulsory and affordable to everyone. Also, the menace of poverty should be adequately addressed.

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78 Malnutrition Essay Topic Ideas & Examples

🏆 best malnutrition topic ideas & essay examples, 👍 simple & easy malnutrition essay titles, 🎓 good research topics about malnutrition, ❓ research question about malnutrition.

• Obesity as a Form of Malnutrition and Its Effects Obesity is considered a malnutrition because the extended consumption of nutrients can still lead to the lack macro- and microelements. Overweight and obesity are serious disorders affecting a substantial part of the current population.
• Healthy Nutrition: Case Study of Malnutrition Sofia’s possible malnutrition might be owing to her demanding schedule and lack of prenatal care, which is an important part of a healthy pregnancy. We will write a custom essay specifically for you by our professional experts 808 writers online Learn More
• Malnutrition in Hospitalized Patients: Intended and Potential Outcomes Furthermore, there is a chance that the patients will be able to determine malnutrition at its early stages and inform nurses about the problem. As a result, a rise in the number of positive patient […]
• Malnutrition in South Africa: Public Health Policy The global food systems are highly dysfunctional, creating malnutrition crises in certain parts of the world which are the primary cause of death and disease.
• Malnutrition: Criteria and Description of Statement of the Problem Between adequate nutrition programs and malnutrition primary prevention programs, what approach is the most effective to enhance children’s development? What are the dissimilarities between adequate nutrition programs and malnutrition primary prevention programs?
• Obesity and Malnutrition: Who Is at Fault I would like to note that in both the interview and the article Nestle states that malnutrition is not only the responsibility of the consumers.
• Child Malnutrition in the GCC Countries Countries which have faired badly in the recent past include Kuwait and Qatar which saw an increase in their child malnutrition rates from 5% in the 1990s to 10% in the mid-2000s.
• Child Malnutrition: Term Definition Majority of the people in the globe specifically in the rural areas do not have access to safe drinking water and most of them lack the access of good sanitation.
• The Issues of Malnutrition and the Healing Process The issues of malnutrition and the healing process are regarded in lots of journals and scientific literature. The nutritional status of the patient previous to and after a surgical procedure is significant for speedy and […]
• Integrated Nursing Practice Addressing Malnutrition The benefits of the specified intervention include an opportunity to reduce the extent of stress experienced by the patient and create the basis for the future patient education.
• Malnutrition in Children as a Global Health Issue The peculiarity of this initiative is not to support children and control their feeding processes but prevent pediatric malnutrition even before a child is born.
• Malnutrition: Major Risk Factors and Causes The normal functioning of body organs is something that requires an adequate amount of mineral salts, fluids, and nutrients that are derived from different food materials. The purpose of this paper, therefore, is to analyze […]
• Early Enteral Nutrition to Prevent Malnutrition The choice of the method depends on the state of a patient, his/her disease, and the peculiarities of the health problem that should be solved at the moment.
• Accelerating Progress Toward Reducing Child Malnutrition in India
• Addressing Chronic Malnutrition Through Multi-Sectoral, Sustainable Approaches
• Addressing the Double Burden of Malnutrition in ASEAN
• Battle Against Starvation and Malnutrition
• Behaviors Associated With Child Malnutrition
• Childhood Malnutrition and Schooling in the Terai Region of Nepal
• Chronic Malnutrition and Its Effects on Children
• Closing the Rural-Urban Gap in Child Malnutrition: Evidence From Paraguay
• Child Malnutrition and Antenatal Care: Evidence From Three Latin American Countries
• Combating Child Chronic Malnutrition and Anemia in Peru
• Death From Stroke During the Danish Malnutrition Period 1999-2007
• Comparing Peri-Urban Versus Rural Poverty and Child Malnutrition Reduction
• Deforestation and Household- And Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa
• Combining Insights From Quantile and Ordinal Regression: Child Malnutrition in Guatemala
• Child Malnutrition and Poverty: The Case of Pakistan
• Developing Countries Suffer From Poverty and Malnutrition
• Diets, Malnutrition, and Disease: The Indian Experience
• Child Malnutrition and Mortality in China and Vietnam in a Comparative Perspective
• Effects of Parental Education on Malnutrition Among Children in Brazil
• How Hunger and Malnutrition Influence the Health and Development of Communities
• Child Malnutrition and the Provision of Water and Sanitation in the Philippines
• Linking Economic Growth and Child Malnutrition in Egypt
• Economic Growth, Poverty, and Malnutrition in India
• Child Malnutrition, Social Development, and Health Services in the Andean Region
• Ending Malnutrition: From Commitment to Action
• Environmental Factors and Children’s Malnutrition in Ethiopia
• Children’s Malnutrition and Horizontal Inequalities in Sub-Saharan Africa
• Difference Between Undernutrition and Malnutrition
• The Impact of Public Expenditure on Child Malnutrition in Peru
• Factors Affecting the Prevalence of Malnutrition
• Fetal Malnutrition and Academic Success: Evidence From Muslim Immigrants in Denmark
• Fighting Poverty and Child Malnutrition: On the Design of Foreign Aid Policies
• Factors Influencing the Occurrence of Malnutrition Health and Social Care
• An Opportunity to Minimize Malnutrition and Hunger in Developing Countries
• Geography and Culture Matter for Malnutrition in Bolivia
• Household and Community HIV/AIDS Status and Child Malnutrition in Sub-Saharan Africa
• Hunger and Malnutrition Are a Problem Everywhere
• Identifying Risk Factors for Severe Childhood Malnutrition by Boosting Additive Quantile Regression
• Inequality, Hunger, and Malnutrition: Power Matters
• Hunger, Malnutrition and Millennium Development Goals: What Can Be Done
• What Happens to Your Body Durimg Malnutrition?
• What Causes Malnutrition?
• What Is the Treatment for Malnutrition?
• How Long Does It Take To Recover From Malnutrition in Adults?
• How Do Doctors Test for Malnutrition?
• What Is the Largest Reason for Malnutrition?
• How Do Doctors Diagnose Malnutrition?
• How Long Can You Live With Malnutrition?
• Which Medicine Is Best for Malnutrition?
• What Drugs Cause Malnutrition?
• Can Blood Test Detect Malnutrition?
• What Bloodwork Shows Malnutrition?
• What Are the Most Common Signs of Malnutrition?
• How Is Malnutrition Best Managed?
• What Social Factors Cause Malnutrition?
• What Are the Long Term Effects of Malnutrition?
• What Are Immediate Cause of Malnutrition?
• What Is the Best Way for Early Detection of Malnutrition?
• What Are the Complications of Malnutrition?
• How Is Severe Malnutrition Diagnosed?
• What Infection Causes Malnutrition?
• What Are the Diseases Caused by Malnutrition?
• How Is Malnutrition Treated in Adults?
• How Does Malnutrition Affect the Brain in Adults?
• Can You Get Brain Damage From Malnutrition?
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Research: Boards Still Have an ESG Expertise Gap — But They’re Improving

• Tensie Whelan

Over the last five years, the percentage of Fortune 100 board members possessing relevant credentials rose from 29% to 43%.

The role of U.S. public boards in managing environmental, social, and governance (ESG) issues has significantly evolved over the past five years. Initially, boards were largely unprepared to handle materially financial ESG topics, lacking the necessary background and credentials. However, recent developments show a positive shift, with the percentage of Fortune 100 board members possessing relevant ESG credentials rising from 29% to 43%. This increase is primarily in environmental and governance credentials, while social credentials have seen less growth. Despite this progress, major gaps remain, particularly in climate change and worker welfare expertise. Notably, the creation of dedicated ESG/sustainability committees has surged, promoting better oversight of sustainability issues. This shift is crucial as companies increasingly face both regulatory pressures and strategic opportunities in transitioning to a low carbon economy.

Knowing the right questions to ask management on material environmental, social, and governance issues has become an important part of a board’s role. Five years ago, our research at NYU Stern Center for Sustainable Business found U.S. public boards were not fit for this purpose — very few had the background and credentials necessary to provide oversight of  ESG topics such as climate, employee welfare, financial hygiene, and cybersecurity. Today, we find that while boards are still woefully underprepared in certain areas, there has been some important progress .

• TW Tensie Whelan is a clinical professor of business and society and the director of the NYU Stern Center for Sustainable Business, and she sits on the advisory boards of Arabesque and Inherent Group.

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April 22, 2024

Boilermaker Butcher Block adds eggs from chickens fed orange corn

The eggs from chickens fed orange corn tend to have dark orange yolks because of an increased amount of carotenoids from the chickens’ diets. (Purdue Agricultural Communications photo/Tom Campbell)

WEST LAFAYETTE, Ind. — Purdue University’s Boilermaker Butcher Block, located in the Land O’Lakes Inc. Center for Experiential Learning at 720 Clinic Drive in West Lafayette, will now offer farm-fresh eggs laid by Purdue chickens that are fed orange corn. The eggs are being sold for $6 a dozen, with the proceeds helping to support the Butcher Block’s educational mission.

Orange corn is a nutritionally enhanced type of corn developed by Purdue agronomy professor Torbert Rocheford as part of an international humanitarian effort aimed at addressing malnutrition globally. Since 2017, Rocheford’s startup company, NutraMaize , has worked closely with the Purdue Department of Animal Sciences to demonstrate the benefits of orange corn for poultry.

A team of researchers, including Rocheford and Darrin Karcher , associate professor of animal sciences, has found orange corn to have some benefits, such as having more antioxidant carotenoids, which are associated with darker, richer yolks and reducing the risk of age-related macular degeneration . Additional research from Purdue’s agronomy and animal sciences departments and NutraMaize found that orange corn produces healthier hens .

“We decided to sell the eggs because of the introduction of orange corn,” poultry unit manager Jason Fields said. “We thought it would be a way to introduce a product that nobody else had. We have a lot of pride in our birds and in the programs that we’re doing.”

Nearly every part of the egg production process takes place on campus.

“The orange corn is grown at the Agronomy Center for Research and Education ,” Emily Ford, manager of the Butcher Block, explained. “The chickens are raised at the Animal Sciences Research and Education Center farms. The eggs are washed and packaged at the farms. Then we sell the eggs at the Butcher Block. It’s Purdue farm to fork.”

Fields said, “It’s great that we can provide food to people under the Purdue name, but it’s also another way that we can educate our consumers about the food and where it comes from.”

In the future, the Butcher Block plans to get students involved in the egg production. “We want to get all hands on deck,” Ford said. “We want to expose interested students to the process. Initially, however, we want to have a good idea of the process before we extend that knowledge to students.”

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Writer: Olivia DeYoung

Sources: Torbert Rocheford, [email protected] ; Evan Rocheford, [email protected]

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Discrimination Experiences Shape Most Asian Americans’ Lives

4. asian americans and discrimination during the covid-19 pandemic, table of contents.

• Key findings from the survey
• Most Asian Americans have been treated as foreigners in some way, no matter where they were born
• Most Asian Americans have been subjected to ‘model minority’ stereotypes, but many haven’t heard of the term
• Experiences with other daily and race-based discrimination incidents
• In their own words: Key findings from qualitative research on Asian Americans and discrimination experiences
• Discrimination in interpersonal encounters with strangers
• Racial discrimination at security checkpoints
• Encounters with police because of race or ethnicity
• Racial discrimination in the workplace
• Quality of service in restaurants and stores
• Discrimination in neighborhoods
• Experiences with name mispronunciation
• Discrimination experiences of being treated as foreigners
• In their own words: How Asian Americans would react if their friend was told to ‘go back to their home country’
• Awareness of the term ‘model minority’
• Views of the term ‘model minority’
• How knowledge of Asian American history impacts awareness and views of the ‘model minority’ label
• Most Asian Americans have experienced ‘model minority’ stereotypes
• In their own words: Asian Americans’ experiences with the ‘model minority’ stereotype
• Asian adults who personally know an Asian person who has been threatened or attacked since COVID-19
• In their own words: Asian Americans’ experiences with discrimination during the COVID-19 pandemic
• Experiences with talking about racial discrimination while growing up
• Is enough attention being paid to anti-Asian racism in the U.S.?
• Acknowledgments
• Sample design
• Data collection
• Weighting and variance estimation
• Methodology: 2021 focus groups of Asian Americans
• Appendix: Supplemental tables

Following the coronavirus outbreak, reports of discrimination and violence toward Asian Americans increased. A previous Pew Research Center survey of English-speaking Asian adults showed that as of 2021, one-third said they feared someone might threaten or physically attack them. English-speaking Asian adults in 2022 were also more likely than other racial or ethnic groups to say they had changed their daily routines due to concerns they might be threatened or attacked. 19

In this new 2022-23 survey, Asian adults were asked if they personally know another Asian person in the U.S. who had been attacked since the pandemic began.

About one-third of Asian adults (32%) say they personally know an Asian person in the U.S. who has been threatened or attacked because of their race or ethnicity since the COVID-19 pandemic began in 2020.

Whether Asian adults know someone with this experience varies across Asian ethnic origin groups:

• About four-in-ten Chinese adults (39%) say they personally know another Asian person who has been threatened or attacked since the coronavirus outbreak. Similar shares of Korean adults (35%) and those who belong to less populous Asian origin groups (39%) – those categorized as “other” in this report – say the same.
• About three-in-ten Vietnamese (31%), Japanese (28%) and Filipino (28%) Americans and about two-in-ten Indian adults (21%) say they know another Asian person in the U.S. who has been the victim of a racially motivated threat or attack. 

Additionally, there are some differences by regional origin groups:

• Overall, similar shares of East and Southeast Asian adults say they know another Asian person who’s been threatened or attacked because of their race or ethnicity (36% and 33%, respectively).
• A somewhat smaller share of South Asian adults say the same (24%).

There are also differences across nativity and immigrant generations:

• U.S.-born Asian adults are more likely than Asian immigrants to say they know another Asian person who has been threatened or attacked during the COVID-19 pandemic  (40% vs. 28%, respectively).
• Among immigrants, those who are 1.5 generation – those who came to the U.S. as children – are more likely than the first generation – those who immigrated as adults – to say they know someone with this experience (37% vs. 25%).
• And among U.S.-born Asian Americans, 44% of second-generation adults say this, compared with 28% of third- or higher-generation Asian adults.

Whether Asian Americans personally know another Asian person who was threatened or attacked because of their race or ethnicity since the beginning of the pandemic also varies across other demographic groups:

• Age: 44% of Asian adults under 30 years old say they know someone who has been threatened or attacked during the pandemic, compared with 18% of those 65 and older.
• Gender: Asian women are somewhat more likely than men to say they know an Asian person in the U.S. who has been threatened or attacked during the COVID-19 pandemic (35% vs. 28%, respectively).
• Party: 36% of Asian Democrats and Democratic leaners say they know another Asian person who has been threatened or attacked because of their race or ethnicity, higher than the share among Republicans and Republican leaners (25%).

Heightened anti-Asian discrimination during the COVID-19 pandemic

These survey findings follow a spike in reports of discrimination against Asian Americans during the COVID-19 pandemic. The number of federally recognized hate crime incidents of anti-Asian bias increased from 158 in 2019 to 279 in 2020 and 746 in 2021, according to hate crime statistics published by the FBI . In 2022, the number of anti-Asian hate crimes decreased for the first time since the coronavirus outbreak, to 499 incidents. Between March 2020 and May 2023, the organization Stop AAPI Hate received more than 11,000 self-reported incidents of anti-Asian bias, the vast majority of which involved harassment, bullying, shunning and other discrimination incidents.

Additionally, previous research found that calling COVID-19 the “Chinese Virus,” “Asian Virus” or other names that attach location or ethnicity to the disease was associated with anti-Asian sentiment in online discourse. Use of these phrases by politicians or other prominent public officials, such as by former President Donald Trump , coincided with greater use among the general public and more frequent instances of bias against Asian Americans.

In the 2021 Pew Research Center focus groups of Asian Americans, participants discussed their experiences of being discriminated against because of their race or ethnicity during the COVID-19 pandemic.

Participants talked about being shamed in both public and private spaces. Some Asian immigrant participants talked about being afraid to speak out because of how it might impact their immigration status:

“I was walking in [the city where I live], and a White old woman was poking me in the face saying, ‘You are disgusting,’ and she was trying to hit me. I ran away crying. … At the time, I was with my boyfriend, but he also just came to the U.S., so we ran away together thinking that if we cause trouble, we could be deported.”

–Immigrant woman of Korean origin in late 20s (translated from Korean)

“[A very close friend of mine] lived at [a] school dormitory, and when the pandemic just happened … his room was directly pasted with the adhesive tape saying things like ‘Chinese virus quarantine.’”

–Immigrant man of Chinese origin in early 30s (translated from Mandarin)

Many participants talked about being targeted because others perceive them as Chinese , regardless of their ethnicity:

“I think the crimes [that happened] against other Asian people can happen to me while going through COVID-19. When I see a White person, I don’t know if their ancestors are Scottish or German, so they will look at me and think the same. It seems that they can’t distinguish between Korean and Chinese and think that we are from Asia and the onset of COVID-19 is our fault. This is something that can happen to all of us. So I think Asian Americans should come together and let people know that we are also human and we have rights. I came to think about Asian Americans that they shouldn’t stay still even if they’re trampled on.”

–Immigrant woman of Korean origin in early 50s (translated from Korean)

“Even when I was just getting on the bus, [people acted] as if I was carrying the virus. People would not sit with me, they would sit a bit far. It was because I look Chinese.”

–Immigrant woman of Bhutanese origin in early 30s (translated from Dzongkha)

Amid these incidents, some participants talked about feeling in community and kinship with other Asian people:

“[When I hear stories about Asian people in the news,] I feel like automatically you just have a sense of connection to someone that’s Asian. … [I]t makes me and my family and everyone else that I know that is Asian super mad and upset that this is happening. [For example,] the subway attacks where there was a mother who got dragged down the stairs for absolutely no reason. It just kind of makes you scared because you are Asian, and I would tell my mom, ‘You’re not going anywhere without me.’ We got pepper spray and all of that. But there is definitely a difference because you just feel a connection with them no matter if you don’t know them.”

–U.S.-born woman of Taiwanese origin in early 20s

“[A]s a result of the pandemic, I think we saw an increase in Asian hate in the media. I think that was one time where I realized as an Asian person, I felt a lot of pain. I felt a lot of fear, I felt a lot of anger and frustration for my community. … I think it was just at that specific moment when I saw the Asian hate, Asian hate crimes, and I realized, ‘Oh, they’re targeting my people.’  I don’t know how to explain it exactly. I never really referred to myself just plainly as an Asian American, but when I saw it in that media and I saw people who looked like me or people who I related with getting hurt and mistreated, I felt anger for that community, for my community.””

–U.S.-born woman of Korean origin in late teens

Some connected discrimination during the pandemic to other times of heightened anti-Asian discrimination . For example, one woman connected anti-Asian discrimination during COVID-19 to the period after Sept. 11:

“[T]he hate crimes I’m reading about now are towards Chinese [people] because of COVID, but I remember after 9/11, that was – I remember the looks that people would give me on the subway but also reading the violent acts committed towards Indians of all types, just the confusion – I mean, I say confusion but I mean really they wanted to attack Muslims, but they didn’t care, they were just looking for a brown person to attack. So there’s always something that happens that then suddenly falls on one community or another.”

–U.S.-born man of Indian origin in late 40s

• Pew Research Center’s American Trends Panel surveys of Asian adults were conducted only in English and are representative of the English-speaking Asian adult population. In 2021, 70% of Asian adults spoke only English or said they speak English “very well,” according to a Pew Research Center analysis of the 2021 American Community Survey. By contrast, the Center’s 2022-23 survey of Asian Americans was conducted in six languages, including Chinese (Simplified and Traditional), English, Hindi, Korean, Tagalog and Vietnamese. ↩

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Key facts about Asian Americans living in poverty

Methodology: 2023 focus groups of asian americans, 1 in 10: redefining the asian american dream (short film), the hardships and dreams of asian americans living in poverty, key facts about asian american eligible voters in 2024, most popular, report materials.

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• Int J Environ Res Public Health

Risk Factors Associated with Malnutrition among Children Under-Five Years in Sub-Saharan African Countries: A Scoping Review

Phillips edomwonyi obasohan.

1 School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA, UK; [email protected] (S.J.W.); [email protected] (R.J.)

2 Department of Liberal Studies, College of Administrative and Business Studies, Niger State Polytechnic. Bida Campus, Bida 912231, Nigeria

Stephen J. Walters

Richard jacques, khaled khatab.

3 Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield S10 2BP, UK; [email protected]

Background/Purpose : Malnutrition is a significant global public health burden with greater concern among children under five years in Sub-Saharan Africa (SSA). To effectively address the problem of malnutrition, especially in resource-scarce communities, knowing the prevalence, causes and risk factors associated with it are essential steps. This scoping review aimed to identify the existing literature that uses classical regression analysis on nationally representative health survey data sets to find the individual socioeconomic, demographic and contextual risk factors associated with malnutrition among children under five years of age in Sub-Sahara Africa (SSA). Methods : The electronic databases searched include EMBASE (OVID platform), PubMed (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science (WoS) and Cochrane Library. Only papers written in the English language, and for which the publication date was between 1 January 1990 and 31 July 2020, were included. Results : A total of 229 papers were identified, of which 26 were studies that have been included in the review. The risk factors for malnutrition identified were classified as child-related, parental/household-related and community or area-related. Conclusions : Study-interest bias toward stunting over other anthropometric indicators of malnutrition could be addressed with a holistic research approach to equally address the various dimension of the anthropometric indicators of malnutrition in a population.

1. Introduction

Malnutrition is the intake of an insufficient, surplus or disproportionate amount of energy and/or nutrients [ 1 ]. Malnutrition is a significant global public health burden with greater concern among children under five years [ 2 ]. In an attempt to address this global challenge of malnutrition, the World Health Organization (WHO) member states recently signed into effect a commitment to nine global targets by 2025, including a 40% reduction in childhood stunting, a less than 5% prevalence of childhood wasting, to ensure no increase in the number of children who are overweight [ 3 ], and to end all forms of malnutrition by 2030 [ 3 , 4 ]. With less than five years to the target date, the progress has remained relatively slow, with no country working toward full actualization of the nine targets [ 5 ]. Though there has been considerable global decline that has been noticed in childhood stunting, there are over 150 million, 50 million and 38 million children remaining stunted, wasted and overweight, respectively [ 5 ]. However, contrary to the expectation and in line with a global target on malnutrition to keep the rate of overweight in children constant, in 2018 there were over 40 million children under five who were overweight [ 6 ], indicating a gradual global increase in overweight children. There is the possibility that the number of overweight children will increase further in the aftermath of covid-19 global lockdown. Just as most countries are witnessing multiple forms of malnutrition indices, in the same way, individual children are found to suffer from two or more forms of malnutrition indicators globally [ 5 ].

In recent times, Sub-Saharan Africa (SSA) has had so much to grapple with in terms of the malnutrition burden. In 2015, SSA accounted for more than 30% of global underweight children [ 7 ]. Additionally, in 2018, despite a worldwide decline in childhood stunting, the African region witnessed a rise in the relative figure from 50.3 million to 58.8 million children [ 6 ]. Interestingly, the 7.1% prevalence of children under five wasting in Africa is lower than the global rate of 7.3% [ 8 ]. Within the SSA region, sub-regional variations in malnutrition are reported in the literature. Akombi et al. [ 9 ] concluded in their study that countries in East and West Africa bore the greatest burden of malnutrition in the SSA region. Malnutrition is expressed through either undernutrition (the most common in less developed countries), a situation of low protein-energy intake [ 10 ] (which usually manifests at different anthropometric indices in stunting, wasting and underweight), and/or overnutrition, which is commonly associated with too great an intake of protein-energy (a situation widely associated with developed society, but of less concern in the developing countries [ 11 ], perhaps a dangerous position to assume especially in Africa).

Beside the SSA region, malnutrition has posed some serious public health challenges in other regions of the world. For instance, in Asia, though considerable steps have made towards the global target, there are lapses in achieving the targets that still exist. The region has experienced a prevalence of overweight among children under five years, which is less than the global average, but it also experienced more than the global average in stunting and wasting, which stood at 22.7% and 9.4%, respectively [ 5 ]. Similarly, the Latin American region has in the last three decades been working to deal with the burden of malnutrition, and is yet to achieve significant progress in some parts of the region. UNICEF’s 2019 report states that almost 20% of children under five in Latin America and the Caribbean were either suffering from any of the indices of malnutrition or overlapping in any two of them [ 12 ]. Galasco and Wagstaff stated that by 2030, and with the current space for an annual reduction rate in stunting, Brazil, Costa Rica, the Dominican Republic and Mexico are on course to reduce the stunting rate by 50% [ 13 ]. Overnutrition is a burden in most developed regions of the world. In 2017, more than a quarter of children in more than 80% of the states in America were either overweight or obese due to inconsistent access to good food. The public health outcomes of malnutrition, manifesting in stunting, wasting, underweight, marasmus, kwashiorkor, edema and perhaps death, are functions of macronutrients and micronutrients missing from the child’s meal [ 14 ].

Generally, malnutrition can lead to cognitive and physical impairment in children, especially those under five years old, with a high rate of morbidity and mortality [ 15 , 16 ]. A child’s fundamental right to a higher level of physical and mental health development worldwide is boosted with access to good nutrition [ 13 ]. Martinez and Fernandez identified three analytical areas of concerns in addressing the burden of malnutrition. First is the analyses of the capacity of any society to be self-sufficient in terms of food security for all. Secondly, they look at how variations in the demographic and epidemiological set-up have affected the nutrition status of the population, and thirdly, they look at how the life-style of the people has affected their nutrition status [ 13 ]. To effectively address the problem of malnutrition, especially in resource-scarce communities, knowing the prevalence, causes and risk factors associated with it are essential steps. This review is part of a doctoral degree work on multi-morbidities in children of under five years in Nigeria. Studies that have addressed malnutrition in Nigeria with a nationally representative sample are few, and this has necessitated a broader coverage in this scoping review to other areas with similar socio-economic and demographic set-ups as in SSA. Additionally, the methodology involved in the scoping review includes qualitatively reviewing the content of study, with a view to identifying the study gaps in the outcomes of interest, the analytical methods and the study population, which have all influenced the use of a scoping review in this study.

The Aim of the Scoping Review

This scoping review aimed to identify existing literature that used classical regression analysis, (analysis that is based on frequentist statistics), on nationally representative health survey data sets to find the individual socioeconomic, demographic and contextual risk factors associated with malnutrition among children under five years of age in Sub-Sahara Africa (SSA).

2. Methodology

2.1. design.

The methodological pattern used in this scoping review followed Arkey and O’Malley [ 17 ], Lecac et al. [ 18 ], and the Agency for Healthcare Research and Quality (AHRQ) [ 19 ]-enhanced framework, recommendations and guidelines, respectively. The steps include the following: (1) identify the research question, (2) identify the relevant study sources, (3) select sources of evidence and eligibility criteria, and (4) chart data [ 20 ]. However, the pattern of reporting the results in this scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [ 21 , 22 ].

2.2. Protocol and Registration Declaration

There was no review protocol and registration done for this scoping review.

2.3. Identification of the Research Questions

The research question was stated having been guided by PICOTS (population, intervention, comparators, outcomes, timing and study design) framework of Agency for Healthcare Research and Quality (AHRQ) [ 19 ].

The primary research question for this scoping review is what risk factors are associated with the malnutrition status of children less than five years of age in Sub-Saharan Africa countries that used classical regression methods to analyze a nationally representative survey data set?

Other secondary research questions are:

• What are the existing examples of evidence of individual and contextual risk factors associated with the malnutrition status of children under five years in Sub-Saharan Africa countries?
• What evidence exists in the use of classical regression analysis methods to determine the risk factors related to the malnutrition of children under five years in Sub-Saharan African countries?

2.4. Eligibility Criteria

The studies included in the review followed the PICOTS (population, interventions, comparators, outcomes, timing and study design) criteria enumerated and defined in Table 1 below.

Structure for eligibility criteria in malnutrition studies.

2.5. Identify the Relevant Sources of Evidence

Information sources.

The first author (PEO) of the School of Health and Related Research (ScHARR), the University of Sheffield, United Kingdom, carried out the literature search. The process was done at least twice on each of the databases consulted and we compared the outcomes to ensure that relevant papers were not excluded. The selection of bibliographies for screening was done on the basis of keywords and subject headings. The electronic databases searched include EMBASE (OVID platform), PubMed (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science (WoS) and Cochrane Library. Only papers written in the English language, and published between 1 January 1990 and 31 July 2020, were included.

2.6. Selection of Sources for Evidence and Eligibility Criteria

Search strategy.

In this scoping review the search strategy involved searching for key terms or text words individually. The phrases were first searched in EMBASE (OVID platform) using “map terms to subject heading”. The search terms applied were derived from the PICOTS categories and they include the variants of Sub-Saharan Africa, under five years, the determinants or risk factors, malnutrition status, and (with/without) regression techniques. These various terms were used with appropriate Boolean connectors, ‘AND/OR’, and with publication dates and research designs applied as restrictions. The sample of the search strategy in EMBASE is displayed in Table 2 below.

Draft search strategy and terms for EMBASE (OVID).

In the EMBASE search strategy result ( Table 2 ), the publication period was set as ‘limit to last 30 years’, (because the default search time was set at 1974 to July 2020). However, for other electronic databases, the publication period was restricted to between 1990 and 2020. The timing was informed over the periods when (i) Demographics and Health Surveys had been conducted in Nigeria, (ii) the UNICEF conceptual framework on causes of malnutrition began, (iii) the Millennium Development Goals were in effect, (iv) the WHO nine targets for malnutrition were on course, and (v) the Sustainable Development Goals were in progress. The search was conducted in the last week of July 2020.

2.7. Selection Process

The reviewer, PEO, screened all the selected literature for titles and abstracts using the inclusion and extraction criteria as a benchmark ( Table 1 ). This process was also done twice in two citation managers platforms (Endnote and Zotero). Any discrepancy observed was resolved by examining them more closely. A full-text reading was conducted for all the selected articles. Papers excluded were noted with reasons. Three overseeing team members vetted this process.

2.8. Data Charting Management

Initially the data extracted from the included articles were deposited into a Microsoft Excel spreadsheet designed by the reviewer specifically for this review. The relevant information obtained includes authors/year of publication, the survey type, the sample size, classical regression type and country of study. Other information includes the study aim, the outcomes (malnutrition status), the prevalence, various predictor variables assessed (child-related variables, parental/household-related variables and contextual or community-related variables), significant risk factors found for each of the malnutrition-related indicators, the specific conclusion reached, and the statistical software used for computation.

The results section reports the profile of the quantitative analysis of risk factors associated with malnutrition in under five children in SSA following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklists [ 21 , 22 ].

3.1. Selection of Sources of Evidence

Figure 1 represents the flowchart of the included studies. A total of 224 unique papers were identified from the various electronic databases (EMBASE = 12, PUBMED = 18, WOS = 74, Scopus = 103, Cochran Library = 0, CINAHL = 12). Additionally, five other studies were retrieved from others sources (the reviewer’s files).

Flowchart of inclusion of studies for malnutrition review.

Twenty-five studies were duplicated in the search at different times (twice, thrice, four or five times). The duplication led to the removal of 47 titles. Out of a total of 177 studies screened for titles and abstract, 138 studies were removed for not meeting the inclusion criteria. A total of 26 studies were finally selected for this study after excluding 13 papers. The reasons for excluding these papers are listed in the chart above ( Figure 1 ).

3.2. Characteristics of Sources of Evidence

To answer the questions raised in this scoping review, the relevant information was extracted from the selected papers and is presented in Table 3 and Table 4 . This section describes the characteristics of the sources of evidence.

Characteristics of the 26 studies included in the review/synthesis.

Characteristics of outcomes of interest.

3.2.1. Characteristics of Study Setting

Table 3 includes elements of the study setting. The unit of analysis in this scoping review is the country of study. Though there were 26 articles selected in this review, two studies (Kennedy et al., 2006 and Ntoimo et al., 2014) analyzed the data separately for three countries each, resulting in risk factor estimates for 30 country unique studies (and16 unique countries). The highest number of publications came from Nigeria, having five studies representing 16.7% [ 15 , 23 , 24 , 25 , 26 ], followed by Ethiopia [ 27 , 28 , 29 , 30 ], and articles with multi-countries [ 31 , 32 , 33 , 34 ] have four studies each. The multi-country articles are studies that focused on more than one country, with the countries’ data sets pooled together and analyzed as one study. Ten countries (Swaziland, Senegal, Rwanda, Malawi, Kenya, Ghana, Equatorial Guinea, Democratic Republic of Congo (DRC), Cameroon, and Central Africa Republic (CAR)) had one study each.

3.2.2. Characteristics of Study Analytical Methods

One of the inclusion criteria for this scoping review was that the statistical analytical techniques must be classical statistical regression methods. Table 3 contains the listing of various statistical analysis techniques used for each study. The most frequently used technique was logistic regression (LR). There were 21 studies (70%) out of the 30 selected country-based studies that used one form of LR or another (multivariate LR, multiple LR, ordinal LR or conditional LR). Five studies applied multilevel regression analysis, two studies used multinomial regression analysis and two other studies, including Aheto [ 36 ], used a relatively unpopular statistical approach, Simultaneous Quantile Regression (SQR), a technique used in modeling regression concerning quantiles (or percentiles) instead of the usual modeling about the mean (mean regression), while Takele et al. [ 30 ] used a Generalized Linear Mixed Model (GLMM).

3.2.3. Characteristics of Study Outcomes

In Table 4 , it was observed that the most studied outcome was stunting. It was the focus of 28 (representing 93.3%) out of the 30 country-based articles (with stunting appearing in 16 publications as the only outcome variable and 12 studies paired with other malnutrition indicators). Wasting and underweight appeared in 13 reports, while overweight was only included in two papers. Furthermore, undernutrition (stunting, wasting and undernutrition) was the outcome of interest in six studies. However, there was only one study that focused on all the four indicators of malnutrition (stunting, wasting, underweight and overweight) [ 45 ].

3.2.4. Characteristics of Significant Risk Factors

Table 4 also contains the list of predictor variables considered for each study selected for this scoping review. It lists the significant risk factors concerning stunting, wasting, underweight and overweight of children less than five years old. The choice of predictor variables studied in some of the articles selected was guided by the UNICEF framework of causes of undernutrition in children [ 46 ]. These were classified as child-related (CR), parental/household-related (PHR) and community- or area-related factors (AR).

Among the child-related risk factors, gender and age (in months categories) were the most frequent significant predictors of stunting (13 studies), wasting (four reports), underweight (4 studies), overweight (no study) and stunting (12 articles), wasting (six reports), underweight (4 studies) and overweight (1 study), respectively. In the parental category, maternal education was the most active predictor in 14, 3, 5 and 1 studies for stunting, wasting, underweight and overweight, respectively. Out of the 28 studies that investigated stunting, 16 reported a significant association of household wealth status with stunting. Place of residence from the community-related category was significant in stunting (five studies), wasting (three studies) and underweight (one study). Significant comorbidity was found for a child having diarrhea in the last two weeks before the survey with stunting (four studies) and underweight (two studies) captured in this review.

4. Discussion

This scoping review aimed to identify the existing literature that used classical regression analysis on nationally representative health survey data sets to find the individual socioeconomic, demographic and contextual risk factors associated with malnutrition among children under five years of age in Sub-Sahara Africa (SSA). The review identified 26 studies and the risk factors for malnutrition, which were classified as child-related, parental/household-related and community or area-related factors. The risk factors for malnutrition identified included age, gender, comorbidities (such as diarrhoea), maternal education, household wealth and place of residence.

This scoping review has demonstrated the importance researchers have attached to studying malnutrition (especially in children under five years) in order to provide a basis for evidence-based decision-making toward meeting the WHO’s nine targets on malnutrition by 2025. Some of the most common determinants of malnutrition indicators include child’s age, sex, birth size, breastfeeding status, and whether the child had a fever in the last two weeks before the survey. Other indicators are the mother’s age, education level, Body Mass Index, and father’s education level. In the household category, wealth status, number of children under five years in the household, source of information, and improved building materials, and from the community-related category, place and region of residence, and Gross Domestic Product (GDP). However, there are a few issues from these studies that need to be discussed here.

Firstly, malnutrition in children is a situation where children are either undernourished (less necessary energy and nutrient intake) or ‘over-nourished’ (too much necessary energy and nutrient intake) [ 1 ]. The authors believed that ‘malnutrition’ and ‘malnourished’ are two different things. Malnourishment (or undernourished or undernutrition) is a component of malnutrition. However, most studies often show some inconsistencies in the classification of malnutrition in this direction. The anthropometric indices generally used by the World Health Organization to measure nutritional status stipulate height-for-age, weight-for-height and weight-for-age for measuring stunting, wasting and underweight, respectively. These indices are computed as ‘standard deviation units (Z-scores) from the median of the reference population’ [ 47 ]. In the 2018 NDHS, for instance, malnutrition was classified into four areas, as follows: (i) stunting in a child too short for his/her age with a height-for-age Z-score less than minus two standard deviations (−2SD) from the median; (ii) wasting in a child is acute undernutrition status, which describes a child’s status whose weight-for-height Z-score is less than minus two standard deviations (−2SD) from the median; (iii) underweight is a composite extraction of both stunting and wasting, giving a weight-for-age Z-score of below minus two standard deviations (−2SD) from the median; and (iv) overweight, in this case, refers to a child whose weight-for-height Z-score is above two standard deviations (+2SD) from the median of the reference population [ 47 ]. So, most studies that focused on malnutrition have always considered stunting, wasting and underweight as only proxies for nutritional status without including overweight [ 48 ]. Some of these studies that have excluded overweight in their nutritional status often used the word ‘undernutrition’, while others used ‘malnutrition’, and some used the terms interchangeably [ 48 , 49 ]. The argument here surrounds the exclusion of overweight when determining the nutritional or malnutrition status of children in a population. Magadi et al. [ 32 ] reported that overweight was excluded from among the malnutrition indicators because it is not of greater importance in the least developed countries. This measure of excluding overweight in effect can lead to underestimating the nutrition status of the population under study. In a recent paper, WHO grouped malnutrition into three essential areas, as follows: undernutrition, micronutrient deficiency and overweight related malnutrition [ 1 ]. Undernutrition involves not getting the adequate nutrients necessary for daily activities, while overnutrition is getting more nutrients than you can utilize daily [ 50 ]. So, malnutrition is a composite of undernutrition and overnutrition [ 49 ]; as such, we submit that overweight should always be included when determining the malnutrition status. In our opinion, the reasons why researchers often exclude overweight in nutritional (or malnutrition) status is that the analysis involves some statistical manipulations, and the fact that overweight’s anthropometric measures obviously connect with those of wasting. Resolving the problem in computation is done by including overweight into the application of ‘Composite Index of Anthropometric Failure (CIAF)’ [ 51 ], or by simple use of ‘composite index’ computation [ 52 ].

The second issue of concern from some of the studies in the scoping review is in the attention given to stunting over other anthropometric indices of malnutrition. This scoping review identified that for every ten studies on malnutrition, at least nine studies are investigating stunting. This trend in studying stunting may be related to the need to meet the WHO target of 40% reduction in stunting prevalence by 2025 [ 5 ], and stunting’s obvious association with poverty and hunger, which are major characteristics of the least developed and war/conflict-torn nations. These reasons, however, cannot justify the almost absence of equal attention being paid to other malnutrition indicators, especially overweight, which is seen to be increasing in some populations [ 53 ], and may increase further in the aftermath of covid-19 global lockdown.

The third issue of concern is the multiple overlaps in the malnutrition indicators. Though few studies have focused on two or more anthropometric indicators of malnutrition, they were analyzed individually using classical logistic regression methods. In some populations, there are tendencies for multiple forms of malnutrition indicators in children [ 5 , 51 , 54 ]. Not many of the studies considered in this review evaluated the multiple overlaps in these anthropometric indices. This observation is a gap in the study. However, with appropriate statistical techniques, it becomes easy to determine the prevalence of the simultaneous occurrence of anthropometric indices among children in a population [ 51 ], thereby determining their risk factors in a population. There are over 3.6% and 1.8% children under five globally who are both stunted and wasted, and stunted and overweight, respectively [ 5 ]. However, wasting and overweight are mutually exclusive; as such, we do not expect multiple overlaps in them.

Finally, the issue of inconsistencies found in some studies concerns the proper way of categorizing undernutrition indicators (stunting, wasting and underweight) into moderate and severe undernourishment [ 24 , 32 , 47 ].

For instance, a stunted child has height-for-age (HAZ < −2SD), on a scale, a severely stunted child has HAZ < −3SD. Since stunted is moderate plus severe, then the moderately stunted child is −3SD ≤ HAZ ≤ −2SD. The same classification holds for other anthropometric indicators for undernutrition as displayed in the chart above ( Figure 2 ).

Showing the classifications of Anthropometric indicators of malnutrition.

5. Strengths and Limitations

This scoping review has some level of strengths. (i) This study is about the first scoping review on risk factors associated with malnutrition in children under five in SSA countries that used classical statistical regression modeling techniques on nationally representative survey samples. (ii) The identification of some grey areas that urgently need research cover, especially in the field of using appropriate statistical methods that will compositely determine the actual index of malnutrition in a population. However, there are some limitations, which include but are not restricted to the following: (i) Some potential studies may have been excluded due to the search strategies adopted. (ii) The grey literature search to seek for possible papers was not done. (iii) The references of the included publications were not searched through to ascertain more pieces of evidence. (iv) SSA countries include other countries that are not English-speaking, so some potential papers not written in English from these countries may have been lost to our search. (v) The studies included had analytical techniques restricted to classical statistics regression methods (analysis based on frequentist statistical methods); therefore, potential papers that used Bayesian statistical methods in their analyses were excluded. (vi) Linear regression as an analytic technique was omitted in the search and this may have excluded some potential papers. (vii) There was no assessment of the potential risk or publication bias conducted.

6. Future Work

Areas not covered in this review, especially to satisfy the limitations highlighted above, are potential work for future studies. More important is a review that will map out a piece of study evidence on malnutrition that used either classical regression analysis or Bayesian analysis methods, or both. In addition, studies that include overweight and/or micronutrient deficiencies as part of the indicators of malnutrition among children under five years are urgently needed. Furthermore, studies that will explore the interrelationship between malnutrition and other childhood diseases using appropriate statistical techniques while recognizing the interdependencies of these diseases are areas of future interest.

7. Conclusions

In this scoping review, we have identified several significant risk factors that predict the probability that a child under five years of age in an SSA country will develop malnutrition status. These factors were classified as child-related (CR), parental/household-related (PHR) and area-related (AR) variables. The CR include child’s age, sex, birth weight, type of birth, birth type, diarrhoeal, and place delivered. Factors related to parental/household include mother’s education, breastfeeding, BMI, birth interval, mother’s health-seeking status, mother’s age, household wealth status, improved sanitation, number of children under 5 years in the household, maternal health insurance, type of toilet facilities and cooking fuel, while among the area-related (AR) variables were forest cover lost, community region, and community illiteracy rate. To prevent the wide spread of malnutrition in developing countries, these significant risk factors must be taken into consideration when developing practice and policy formulation. Central to these controls are the maternal education and health status. Pregnant and nursing mothers should have access to a balanced diet.

The review also discovered that there was a study-interest bias toward stunting as an index over other anthropometric indicators of malnutrition. Furthermore, the review also identified some limitations in the current studies reviewed when overweight and/or micronutrient deficiencies were excluded as indices of malnutrition. In the authors’ opinion, the exclusion may be partly related to the methodological complications involved in determining the true status of malnutrition when these indices are included. Some of the nationally representative surveys used in the studies reviewed collected information regarding the overweight and/or micronutrient status of children under five years. Micronutrient deficiencies in children of under five years in developing countries are measured by the levels of iron, iodine and vitamin A intake [ 55 ]. Apart from iron, which was measured through a biomarker examination of blood samples to establish the anaemia status, iodine and vitamin A were determined subjectively through examining the nature of the foods the child consumed a day before the survey [ 47 ]. This cannot give an objective assessment of the status of the micronutrients present in a child. As such, researchers often find it difficult to include them while determining the true malnutrition status of children under five years old in developing countries. In addition, the review identified some inconsistences in the sub classifications of the malnutrition indicators into severe, moderate and mild, while applying the WHO anthropometric cut off points.

Finally, barely five years to the set date of achieving the WHO’s nine targets of malnutrition in children, in this scoping review we conclude that a holistic research approach to equally address the various dimensions of anthropometric indicators of malnutrition in a population is needed. Evidence from such findings will be valuable documents in the hands of many planners/policymakers for informed decision making.

Acknowledgments

The authors recognized the contributions of some members of the ScHARR community. Also, Phillips would like to appreciate the Rector and Management staff of Niger State Polytechnic, Nigeria for the nomination and receipt of TETFUND (Nigeria) sponsorship for the doctoral program.

Author Contributions

The conceptualization of this study was carried out by P.E.O. and K.K.; the formal literature searching, screening and drafting of manuscript were done by P.E.O.; S.J.W., R.J. and K.K. supervised, revised and edited the manuscript. All authors have read and agreed to the published version of the manuscript.

This study is an integral part of Phillips’ doctoral study at the School of Health and Related Research (ScHARR) of the University of Sheffield, United Kingdom. The funding for the doctoral study was granted by TETFUND (Nigeria). The publication received an APC waiver from MDPI.

Conflicts of Interest

The authors declare no conflict of interest.

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