Research Snapshots.......................................................................................................................................

‘Severe malnutrition’: thinking deeply,

communicating simplyT

here is currently a plethora of complex
technical terminology used to describe
malnutrition which can confuse nonspecialist audiences. Current terminology
has limitations in that it emphasises being severely
small (short or thin) rather than the risk of severe
adverse outcomes such as mortality, morbidity ordevelopmental delay. Furthermore, using anthropometry to define malnutrition, while valuable,
does not distinguish between the state and processof malnutrition and misses children with ‘normal’
anthropometry who are deteriorating and at riskof adverse outcomes. Alternatively, it may include
children who are constitutionally small with nofunctional/clinical impairments who may not benefit from nutrition-based treatment. Terminology
distinctions have also led to nutrition ‘tribalism’Research snapshot1
with different anthropometric deficits being managed by different communities and inadequate
consideration for the context within which malnutrition is experienced.
Given these limitations, the authors propose
the use of the term ‘severe malnutrition’ to define‘any form of malnutrition associated with a highrisk of severe adverse outcomes.’ This definition
includes stunting, underweight, wasting, low midupper arm circumference, concurrence, oedematous malnutrition and micronutrient malnutrition.
It provides a simple, advocacy focused term inwhich ‘severe’ highlights the risk of mortality/morbidity and encompasses different manifestationsof malnutrition, context-appropriate anthropometric cut-offs and underlying causes.

The advantages of this terminology include
providing a bridging language for increased
linkages between different nutrition-related programmes, offering clarity and familiarity (both‘severe’ and ‘malnutrition’ are widely understoodand are easily translatable into most languages)
and the chance to keep important technical arguments internal to avoid giving the impression toexternal audiences that experts do not agree on
core issues. Using this term and guided by local
mortality/morbidity data, countries could be freer
to set context-specific programme admission criteria for ‘severe malnutrition’.
The authors conclude that the use of the term
‘severe malnutrition’ as a complement to current
terminology would enable clear, simple communication while encouraging simultaneous deep
thinking about malnutrition.
1

Kerac M, McGrath M, Connell N, et al., (2020) ‘Severe
malnutrition’: thinking deeply, communicating simply. BMJ
Global Health 2020;5:e003023. doi:10.1136/bmjgh-2020-003023.......................................................................................................................................

Fertility is a key predictor of the double burdenof malnutrition among women of child-bearing
age in sub-Saharan Africa Research snapshot
1G

lobally, countries are undergoing a nutrition transition, shifting from highrates of underweight towards growingrates of overweight and obesity. Insub-Saharan Africa (SSA), this transition has occurred relatively rapidly over the last 40 years. No
study to date has specifically examined the double
burden of malnutrition (DBM) in women of childbearing age within the region. This study aimed toaddress this gap by classifying countries according
to malnutrition prevalence of women of childbearing age and determining key country-level
and individual-level risk indicators associated with
underweight, overweight and obesity within thisgroup. Data from 34 SSA countries were acquired

from Demographic and Health Surveys, the WorldBank and the Swiss Federal Institute of Technology.
National malnutrition prevalence rates were determined and random forest analysis and multinomial logistic regression models used to examine
associated risk indicators.
Of the 34 countries studied, five continue toface significant undernutrition (greater than 10%
prevalence of underweight), 11 countries face DBM(with a greater than 10% prevalence of both underweight and overweight/obesity) and 18 countries
face significant overnutrition (greater than 10%
prevalence of overweight (seven countries) andobesity (11 countries)). Across countries, fertility
rate was the strongest predictor of undernutrition,

overweight and obesity prevalence; fertility rates
were highest in countries with high underweight
prevalence and lowest in countries with high overweight/obesity prevalence. Economic and equality
indicators (measured via Gross Domestic Productand Gini coefficient indicators) were also noted to
be strong predictors of nutrition outcomes. Withincountries, parity was a risk factor for underweightin countries with a high burden of underweight
and a risk factor for overweight/obesity in overweight/obesity burdened countries. Age and wealthwere noted to be protective factors for underweight
but risk factors for overweight/obesity.
This study highlights the important role offertility and parity in nutrition outcomes for
women of child-bearing age and urges healthprofessionals to consider integrating reproductive
services and nutrition programmes in SSA.
1

Were, J. M., Stranges, S., & Creed, I. F. (2020). Fertility is a key
predictor of the double burden of malnutrition among
women of child-bearing age in sub-Saharan Africa. Journalof global health, 10(2), 020423.
https://doi.org/10.7189/jogh.10.020423.......................................................................................................................................
by any of the trials. This represents a
The missing focus on women’s health in the ‘First ported
measurement gap in the evidence base, particularly
in health outcomes for women.
1,000 days’ approach to nutrition Research snapshot
The gap in knowledge of the effect of maternal
1T

he First 1,000 Days approach emphasises
the time between conception and a child’s
second birthday as a critical period whereadequate nutrition is essential for subsequent healthy growth and development throughout
the child’s life. Based on a review of the relevant literature, this commentary explores the First 1,000
Days approach with a maternal lens.
The focus of nutrition-specific and nutritionsensitive interventions within the first 1,000 daysis on child health benefits with very little attention
given to maternal nutritional status and healthoutcomes. Interventions indirectly place emphasis
on mothers through interventions to strengthen
their nutritional status during pregnancy and lactation, for example, through vitamin and mineral

supplementation and multiple micronutrient(MMN) supplementation to reduce the risk oflow birthweight (LBW) infants.
However, women’s health indicators are rarely
tracked and measured. As an example, the authors
highlight a 2017 Cochrane review of MMN supplementation for women during pregnancy which
included 16 trials that reported the effects onpreterm births and LBW and 15 trials that reported
small-for-gestational-age but only five trials thatreported maternal anaemia, four trials reporting
caesarean section rates, three that reported maternalmortality rates and one trial that reported preeclampsia. Other maternal health outcomes (placental abruption, premature rupture of membranes,maternal wellbeing or satisfaction) were not re-nutrition interventions on women themselves
perpetuates the lack of prioritisation and researchin this area. Nutritional interventions within theFirst 1,000 Days approach have not had the expected magnitude of effects on reducing childhoodstunting and potentially the lack of attention
given to the nutritional status of women has beena contributing factor to this. The authors conclude
that there is a need to understand the processesof entrenching poverty and malnutrition between
inadequacies in maternal diet, adverse health outcomes for women and contextual factors, withmothers at the centre.
1Kinshella, M., Moore, S., & Elango, R. (2020). The missing
focus on women’s health in the First 1,000 days approach tonutrition. Public Health Nutrition, 1-5.
doi:10.1017/S1368980020003894.......................................................................................................................................

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Field Exchange issue 64, January 2021, www.ennonline.net/fex