© Borgis - Postępy Nauk Medycznych 12/2012, s. 917-923
*Mirosław Jarosz, Ewa Rychlik
Problem niedożywienia w Polsce i na świecie
The problem of malnutrition in Poland and across the world
Department of Nutrition and Dietetic with Clinic of Metabolic Diseases and Gastroenterology, National Food and Nutrition Institute, Warsaw
Head of Department: prof. Mirosław Jarosz, MD, PhD
Niedożywienie występuje, kiedy dieta nie dostarcza organizmowi dostatecznych ilościowo i/lub jakościowo niezbędnych składników odżywczych. Dotyczy bardzo dużej części populacji krajów rozwijających się, ale może też stanowić problem w krajach rozwiniętych, w tym również w Polsce.
Na ryzyko niedożywienia energetyczno-białkowego wskazuje niedobór masy ciała. W naszym kraju występuje on u 1% mężczyzn i ponad 3% kobiet. Częściej spotykany jest u dzieci i młodzieży, gdzie dotyczy ok. 13% populacji.
Problemem są również niedobory niektórych składników odżywczych, zwłaszcza żelaza, witaminy A i jodu. W Polsce częstym zjawiskiem jest niedobór żelaza wśród małych dzieci i kobiet w ciąży, występujący u ok. 1/4 osób z tych grup. W ostatnich latach nastąpiło wyraźne zmniejszenie zagrożenia niedoborem jodu, w Polsce jego podaż na poziomie populacyjnym została uznana za wystarczającą.
Niedożywieniu sprzyja ubóstwo, w niektórych krajach będące przyczyną głodu, a w innych niekorzystnie wpływające na wartość odżywczą diety. W Polsce poniżej granicy ubóstwa żyje prawie 7% gospodarstw domowych. Szczególnie zagrożone ubóstwem są dzieci i młodzież.
Również nieprawidłowe żywienie może prowadzić do niedoborów składników odżywczych. Dieta Polaków stwarza ryzyko niedoboru witaminy D, folianów, witaminy C, wapnia, żelaza i jodu, zwłaszcza u małych dzieci, nastoletnich dziewcząt i kobiet.
Malnutrition occurs when the diet does not supply the body with sufficient quantity and/or quality of essential nutrients. It concerns a very large population of developing countries, but it can also be a problem in developed countries, including Poland.
Underweight indicates the risk of protein-energy malnutrition. In our country it occurs in 1% of men and more than 3% of women. It is more common in children and adolescents, concerning for about 13% of that population.
Deficiencies of certain nutrients, especially iron, vitamin A and iodine also are the problem. In Poland there is a frequent occurrence of iron deficiency among young children and pregnant women, concerning for about 1/4 of people from these groups. In recent years there has been a marked reduction in risk of iodine deficiency and in Poland its supply at a population level was considered sufficient.
Malnutrition is promoted by poverty and that cause hunger in some countries, or can negatively affect the nutritional value of diets in others. In Poland, nearly 7% of households live below the poverty line. Particularly at risk of poverty are children and adolescents.
Inappropriate diet also can lead to nutrient deficiencies. Poles’ diet poses a risk of vitamin D, folate, vitamin C, calcium, iron and iodine, especially in young children, teenage girls and women.
Nutritional status, according to international terminology, is the health condition being the result of usual food intake, nutrients absorption and utilization, as well as pathological factors which affect those processes (1).
According to this definition, in order to fully assess one’s nutritional status, it is necessary to test the nutrients level in blood and other bodily fluids or tissues, to assess body condition, taking into consideration one’s medical history, as well as to characterize nutritional value of one’s diet for a longer period of time. Such tests are very expensive and laborious, so in practice one’s nutritional status is assessed on the basis of anthropometric measurements. Usually one’s height, weight and circumferences are measured. It enables the assessment of underweight, as well as overweight and obesity (1, 2).
Underweight indicates the risk of protein-energy malnutrition. It may be accompanied by vitamins and minerals deficiencies in the body. Malnutrition occurs when the diet does not supply the body with sufficient quantity and/or quality of essential nutrients (1, 2).
Malnutrition may disturb growth and pubertal timing, and in later periods of life it may lead to fertility disorders and in extreme cases it may even lead to cachexia (3).
That is why it is important to assess one’s nutritional status, including underweight and the risk of malnutrition.
Underweight occurs more or less frequently in particular regions of the world. According to the data collected by the World Health Organization (WHO), in the countries of European Region this abnormality occurs in a relatively small percentage of adults, at the same time it occurs more often in women than in men (4). Depending on the country in recent years underweight has been observed in 0.5-2.0% of men and in 3.0-7.4% of women. Norway, France and Slovakia were the countries where underweight occurred most often, while the fewest cases of underweight were observed in Spain and Sweden. Changes in this field have been monitored only in some countries for more than ten years. Most often a reduction in underweight has been observed, among others in Denmark, Portugal and Estonia. However, there are countries, such as Norway, where underweight has increased in recent years.
In other developed countries outside Europe underweight does not occur very frequently. In the United States in the years 2007-2008 underweight was observed in 1.0% of men and in 2.2% of women, however it has decreased by almost 2.5 times since the beginning of the 1960s (5). Also relatively low percentages of people with this abnormality was observed in Canada (in 1.2% of men and in 4.1% of women), Mexico (1.5% and 1.4% respectively), Australia (1.3% and 2.8% respectively) or New Zealand (1.3% and 1.6% respectively) (4). It is worth noticing that the smallest number of people with underweight is reported in Kuwait: in 2009 it was observed in 0.7% of men and women. On the other hand, Japan is an interesting case. Underweight is noted there more often than in other developed countries: in 2008 it was observed in 4.3% of men and in 10.8% of women.
India and Pakistan are countries with the highest levels of underweight (4). In India in 2005 it was reported in 33.7% of men and in 35.6% of women, but only younger age groups were examined – men under 54 and women under 49 years old. In Pakistan underweight was observed in 30.8% of men and in 31.6% of women. However, this data was collected between the years of 1990 and 1994 and there is no current data in this matter.
There is also an unfavourable situation in many African countries (4). The country where underweight occurs more often is Madagascar: in 2005 underweight was reported in 19.2% of people, irrespective of sex. The situation is much better in the Republic of South Africa (in 12.5% of men and in 6.2% of women) and in Zambia (11.6% and 6.2%, respectively). Most data from Africa concerns only women aged 15-49. In this group the highest percentage of persons with underweight was observed in Ethiopia (26.5%), Burkina Faso (20.8%), Niger (19.2%), the Democratic Republic of the Congo (18.5%) and Senegal (18.2%).
The most comprehensive data concerning the occurrence of underweight in Poland comes from representative nationwide research carried out in 2000 as part of the project “Household Food Consumption and Anthropometric Survey” (HFCAS) among people aged 1-96 (6). The data can be found in the above-mentioned WHO database. The results of the research show that underweight was observed in 1.0% of men and in 3.2% of women. In men the abnormality occurred in the youngest and the oldest age groups – in about 2% of men. In women underweight was the most frequently reported between the ages of 19 and 29 – it occurred in 11.0% of women. In older age groups the percentage of underweight women was much lower, in women over the age of 50 it amounted to 1%.
The occurrence of underweight in Poland was also assessed by the Central Statistical Office (CSO) (7). This is the most recent data on this problem in our country. However, it should be noticed that anthropometric measurements were not carried out there, and researchers used the information they received from respondents. It was estimated that in 2009 underweight was observed in 1.3% of men and in 4.3% of women aged 15 and above. In spite of the fact that the percentage was a bit higher than in 2000, especially among women, the prevalence of underweight does not seem to have increased among adults for the last few years. In the case of data collected by the CSO some underestimation of weight is possible, especially by women, and a real number of persons with underweight might have been a bit lower than the estimated one.
In the world the problem of underweight in children, especially under the age 5, is more often raised than the problem of underweight in adults. This concerns above all citizens of developing countries (8). Malnutrition, which includes underweight and insufficient height for age, as well as nutrients deficiency, is the main cause of mortality in under-five children in those countries, amounting to 35%.
WHO estimates that in 2010 in developing countries underweight occurred in 103 mln under-five children that is in 18% of this population (8). The worst situation was in the countries of South-central Asia (30%), Eastern, Western and Middle Africa (21-22%) and South-Eastern Asia (17%). Moreover, in some countries underweight occurs much more often than it is shown by the data collected in a particular region. India is an example of a country where in recent years underweight has been observed in 43.5% of people, also Yemen – 43.1%, Bangladesh – 41.3% and Niger – 39.9% (9).
However, over the last two decades a significant improvement has been observed. In 1990 the prevalence of underweight in the mentioned group of countries was estimated to be 29% (8). A significant improvement has been observed in Eastern Asia, Latin America and the Caribbean, as well as in the South-central Asia. However, in the last region the percentage is still very high.
In developed countries underweight in small children occurs much more rarely (9). In Europe in countries where research has been conducted in recent years the prevalence of underweight was estimated to fluctuate from 0.9% in Ukraine to 3.5% in Romania and Turkey. Most often, however, it did not exceed 2%. In the United States the prevalence was 1.3%.
Assessing underweight in under-five children, the World Health Organization recommends to use weight-for-age based on WHO child growth standards (9). In epidemiological study, which involves also older children, most often Body Mass Index (BMI) is used, at the same time using international standards recommended by the International Obesity Task Force (IOTF) (10). That is why the results of epidemiological study may differ from the data collected by WHO. Standards recommended by IOTF enable determining not only a serious risk of malnutrition but also moderate and small risk. The percentage of persons with underweight estimated with the use of these standards is often much higher than the percentage estimated on the basis of weight-for-age.
In Poland on the basis of the above-mentioned nationwide research, carried out as part of the HFCAS project, it was assessed that underweight occurred in 12.8% of boys and in 13.5% of girls aged 2-18 (11). The percentage of underweight boys was highest among the persons aged 2-6, among girls – the percentage was highest in girls aged 7-12. The least often the abnormality occurred in the older age group – between the ages 16 and 18 years.
The results of other research carried out at the same time in the whole Poland among children aged 11-12, and 3 years later at the age of 14-15, showed that the prevalence of underweight decreased with age: from 9.5% to 4.6.% in boys and from 17.9% to 9.1% in girls (11).
Due to the fact that underweight is much less frequently assessed than overweight and obesity, involving various age groups into research and using various standards handicaps the comparison of underweight occurrence in Poland and in other countries. When comparing particular age groups it was noted, among others, that underweight among young Poles occurs more often than among their peers in the United States, France or Serbia and it occurs almost as frequently as in Russia (11).
The most common problem in the world connected with malnutrition is iron deficiency (12). It concerns a big number of people, especially children and women in developing countries, but it is also quite common in industrialized countries. It may cause anaemia, physical disorder and mental retardation, perinatal mortality in women, and in developing countries it results in the development of infectious diseases, such as malaria, HIV/AIDS and tuberculosis. This, in turn, causes serious economic consequences by reducing the work capacity of individuals and entire populations, bringing serious economic consequences and obstacles to national development.
WHO report assessing occurrence of anaemia in the world between the years 1993 and 2005 shows that anaemia occurred in 24.8% of population (13). Most often it was observed in preschool-age children – 47.4% and in pregnant women – 41.8%. The most affected regions were Africa (64.6% of preschool-age children and 55.8% of pregnant women) and Asia (47.7% and 41.6%, respectively). The highest percentage of small children with anaemia was reported in Liberia – 86.7% and the Central African Republic – 84.2%. In the case of pregnant women anaemia most often occurred in the Gambia – 75.1% and Nepal – 74.6%.
In Europe the percentages were lower. Nevertheless, they showed the significance of the problem (13). 16.7% of preschool-age children and 18.7% of pregnant women suffered from anaemia. Most often anaemia occurred in Moldova (in 40.6% of small children and 35.5% of pregnant women) and Romania (39.8% and 30.0%, respectively), and most rarely it occurred in Monaco (5.0% and 6.3%), Switzerland (6.3% and 9.7%) and Norway (6.4% and 9.3%). Poland belongs to countries where the occurrence of the problem is considered to be moderate. Anaemia in our country has been observed in 22.7% of preschool-age children and in 25.3% of pregnant women.
The most favourable situation is in the United States, where anaemia has been observed only in 3.1% of preschool-age children and in 5.7% of pregnant women (13).
Also vitamin A deficiency is a worldwide problem (14). Small children and women are most exposed to the consequences of vitamin A deficiency. In children the deficiency is the main cause of preventable blindness and increases the risk of disease and death from severe infections. In women it is additionally a risk factor associated with perinatal mortality.
WHO estimates that between the years 1995 and 2005 33.3% of preschool-age children and 15.3% of pregnant women suffered from retinol deficiency in blood. However, the assessment concerned only countries with the risk of vitamin A deficiency (15). Most often the deficiency occurred in Africa (in 41.6% of children and in 14.3% of pregnant women) and in Asia (33.5% and 18.4%, respectively). Among children the worst situation was observed on the islands of São Tomé and Príncipe (95.6%) and in Kenya (84.4%), among pregnant women in the Gambia (34.0%) and in Nepal (31.5%).
In the case of Western Europe and Scandinavia vitamin A deficiency does not pose a public health problem (15). In other European countries retinol deficiency in blood was observed in 14.9% of preschool-age children and in 2.2% of pregnant women. In Poland the percentages were 9.3% and 2.2%, respectively. On their basis the problem was considered to be minor.
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