Lack of money means there is still a dearth of research into both the short- and long-term impacts of malnutrition.
“This is not a subject that people put a lot of medical research into. The money is in obesity and overnutrition, and research follows money." Dr Neal Russell, a paediatric adviser with Médecins Sans Frontières, explains. Though malnutrition affects millions of people, especially children, there is still much that is unknown about it. “Much of what we thought we knew 20 years ago has since been questioned,” Russell says.
If it [the human body] doesn’t have enough food to convert into energy it will burn through its own fat reserves, breaking down fat cells into fatty acids to be used for energy or converted into glucose by the liver.
How long it takes for the body to use up all its fat deposits depends on multiple factors: the amount and nutritional value of food being eaten; the individual’s metabolism; their activity levels; their body mass index; and their age and overall health.
It could take a month, six months, a year. People don’t go from some food to zero food. They start to reduce the number of meals. In places like the Horn of Africa, people may go entire days without a meal.
After a sustained period of severe lack of food, the only fat left in the body will be between muscles, in joints and organ cells. In women, in the worst-case scenario, you will notice they have no more breast tissue because every single ounce of fat is converted in places that are usually spared.
While this is happening, low glucose levels in the blood make the person feel weak and dizzy. It is at this point – feeling woozy, irritable and struggling to concentrate – that many people are forced to make difficult decisions.
If food deprivation continues once the fat is gone, the body will start to break down muscle cells to access the fatty acids and proteins contained within them. The result of this is muscle atrophy – the medical term for loss of muscle mass – as the muscle cells lose their structural integrity. Within a few weeks, there’s no longer enough muscle to support the body, even in a seated position. Lying down is the only option.
As muscle cells break down they release chemicals, including potassium, chloride and sodium, and cellular debris into the bloodstream. These chemicals, combined with a lack of vital minerals and vitamins from malnutrition, cause an imbalance that affects multiple parts of the body, from individual cells to organ function. Lack of zinc can cause diarrhoea and cracked skin, and reduces the ability to fight infections. Salt imbalance may be associated with oedema or swelling, which can also lead to kwashiorkor, or severe malnutrition in young children, causing swollen bellies and faces.
Until they are at a late stage, deficiencies can be corrected by giving food, but beyond a certain point the body cannot regulate itself, even with treatment.
The last thing to stop is the heart – in some cases, because the weakened heart is simply not powerful enough to pump blood around the body; in others, chemical imbalance in the bloodstream stops the heart. A person may not be conscious at this point: unable to function without energy, the brain begins to shut down. In the last hours before falling into a coma, a person may lose their vision as the brain zones in and out.
Globally, malnutrition underlies almost half of child deaths in under-fives. The majority will die of infection because their immune systems suffer by lack of nutrients. Your general defences against infection are reduced, your skin becomes thinner, your gut wall is thinner, the defences in your respiratory tract are weaker [and] less likely to cough things up.
What is known is that most people suffering from malnutrition die from disease or infection rather than starvation itself. Lack of food affects the immune system, shrinking the lymph nodes so they produce fewer white blood cells. The existing white blood cells don’t have sufficient energy to do their job in fighting off bacteria or healing a wound. A person is much more vulnerable to diseases such as malaria or conditions such as pneumonia and sepsis.
Measles, malaria, pneumonia and diarrhoea are all common killers among children suffering from malnourishment; in many cases these children are moderately, as opposed to severely, malnourished. The malnutrition can be just enough to tip the balance in children, causing them to contract an infection that will kill them.
For every 10 children admitted to an intensive therapeutic feeding centre, one will probably die. Research published in the Lancet in May 2022 suggests that for every one that dies in hospital another will die after they are discharged.
Children who survive can suffer long-lasting effects. Impaired cognitive and physical and behavioural development can affect their education. The condition is also intergenerational – an adolescent girl or young woman who is undernourished may give birth to an undernourished baby.
Russell describes watching this crisis unfold before his eyes as “dystopian”. He struggles to find the right words. “... I have never found the language to describe the horror and injustice of seeing a child dying from malnutrition...One of the most haunting things about a children’s malnutrition centre is the deadly quiet of some children,” Russell says. “Their childhood has evaporated away. Young children regress, and stop walking or become incontinent – and they stop doing normal things like playing.” He continued, “Hunger takes something away from you. You can see how that breaks down a society and leads to more insecurity, conflict and anger.”
A letter to UN member states, “In a world of plenty, leaving people to starve is a policy choice.” The letter signed by 238 NGOs says, “The lack of political will and institutional failure to act quickly before the worst case hits means people are being left to lurch from crisis to crisis. People are not starving; they are being starved.”
These are needless deaths that will be largely ignored by a world distracted by extreme weather, the cost of living crisis and political upheavals says Alexandra Rutishauser-Perera, head of nutrition at Action Against Hunger UK.
A study published by BMC Pediatrics found the prevalence of moderate to severe depression among mothers of malnourished children was significantly higher (64.1%) compared with mothers of normal weight children (5.1%).
“When you don’t have the money to have psychologists onboard, agencies don’t have the means to identify and measure the extent of the problem, and offer appropriate support,” Alexandra Rutishauser-Perera points out.