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Underweight, the Less Discussed Type of Unhealthy Weight and Its Implications: A Review



Underweight is body weight that is too low for a normal healthy adult or child. It is also known by various other names such as wasting, emaciation, thinness, stunting, etc., and is caused by multiple factors especially lack of adequate nutrients in the body. This type of unhealthy weight is not much publicized in developed wealthy countries because it is not very common except under extreme circumstances like some sick geriatric populations, disabled people, chronic diseases sufferers, the homeless people, refugees and people afflicted by wars and natural disasters. The discussion about underweight in developed countries seems to be drowned by the chorus on concerns for the obesity epidemic and its consequences as well as the risks of excessive consumption of calories. However underweight is a front burner issue in some developing poor countries where it is a recognized perennial problem that has led to negative health consequences and sometimes death of preschool children, pregnant and lactating mothers as well as very sick, disabled or aged people. Public health professionals as well as nutritionists, social workers, clinicians and educators need to be skilled in recognizing underweight and its implications on health and wellness. Such skills are necessary in order to effectively counsel consumers & patients on food choices and weight management or to give appropriate referrals to affected individuals to enable them get expert help on maintaining healthy weight. This paper will define what is meant by underweight, with real life examples. Using data from published studies, the paper will discuss consequences and causes of underweight and how caloric intake impacts body weight. It will also highlight and re-emphasize the benefits of adequate caloric intake and healthy weight. Strategies for improving underweight and maintaining adequate body weight for good health and wellness are suggested. Keywords Underweight, Emaciation, Stunting, Causes, Consequences, Weight Restoration, Caloric Intake, Health & Wellness
American Journal of Food Science and Nutrition Research
2016; 3(5): 126-142
ISSN: 2381-621X (Print); ISSN: 2381-6228 (Online)
Underweight, the Less Discussed Type of
Unhealthy Weight and Its Implications: A Review
Stella G. Uzogara
Department of Public Health, Bureau of Family Health & Nutrition, Commonwealth of Massachusetts, Boston Massachusetts, USA
Email address,
To cite this article
Stella G. Uzogara. Underweight, the Less Discussed Type of Unhealthy Weight and Its Implications: A Review. American Journal of Food
Science and Nutrition Research. Vol. 3, No. 5, 2016, pp. 126-142.
Received: July 4, 2016; Accepted: July 30, 2016; Published: August 17, 2016
Underweight is body weight that is too low for a normal healthy adult or child. It is also known by various other names such as
wasting, emaciation, thinness, stunting, etc., and is caused by multiple factors especially lack of adequate nutrients in the body.
This type of unhealthy weight is not much publicized in developed wealthy countries because it is not very common except
under extreme circumstances like some sick geriatric populations, disabled people, chronic diseases sufferers, the homeless
people, refugees, and people afflicted by wars and natural disasters. The discussion about underweight in developed countries
seems to be drowned by the chorus on concerns for the obesity epidemic and its consequences as well as the risks of excessive
consumption of calories. However underweight is a front burner issue in some developing poor countries where it is a
recognized perennial problem that has led to negative health consequences and sometimes death of preschool children,
pregnant and lactating mothers as well as very sick, disabled or aged people. Public health professionals as well as
nutritionists, social workers, clinicians and educators need to be skilled in recognizing underweight and its implications on
health and wellness. Such skills are necessary in order to effectively counsel consumers & patients on food choices and weight
management or to give appropriate referrals to affected individuals to enable them get expert help on maintaining healthy
weight. This paper will define what is meant by underweight, with real life examples. Using data from published studies, the
paper will discuss consequences and causes of underweight and how caloric intake impacts body weight. It will also highlight
and re-emphasize the benefits of adequate caloric intake and healthy weight. Strategies for improving underweight and
maintaining adequate body weight for good health and wellness are suggested.
Underweight, Emaciation, Stunting, Causes, Consequences, Weight Restoration, Caloric Intake, Health & Wellness
1. Introduction
Underweight is described as body weight that is too low to
be considered healthy for a normal adult, adolescent or a
child. It can also occur in the elderly. In street language, an
underweight adult is called by many names or descriptions
such as ‘skinny’, ‘emaciated’, ‘thin’, ‘bony structured’ or
‘lanky’. Such an adult may also be called ‘super slim’, ‘flat-
chest’, ‘lightweight’, ‘lean’, ‘feather’, ‘super slender’, etc. A
child who is underweight is sometimes called in the layman’s
language with names such as ‘teeny-weeny child’, ‘tiny
child’, ‘tiny-Tom’, tiny-Tina’ or said to have stunting,
thinness and wasting. Such a child is sometimes described by
nutritionists as being short-for-age, low weight-for-age or
low weight-for-height.
Underweight can also be described clinically as low BMI-
for-age, where BMI (body mass index) is calculated in the
metric system [1] as a person’s weight in kilograms (Kg)
divided by the height in meter squared (m
). (In the metric
system equation, BMI=Kg/m
). In the imperial system, BMI
is calculated as a person’s weight in pounds (lb) divided by
the height in inches squared (in)
, and the result is multiplied
by a factor, 703, to get the BMI score [1]. (In the imperial
system equation, BMI= {lb/in
} x 703).
Underweight, stunting, wasting and overweight are
indicators of malnutrition and impact child growth. Child
growth is well recognized as a very important indicator of
127 Stella G. Uzogara: Underweight, the Less Discussed Type of Unhealthy Weight and Its Implications: A Review
nutritional status of any population group or any country.
1.1. Unhealthy Weights as Indicators of
Malnutrition and Their Measurement
Underweight (including stunting and wasting), as well as
obesity and overweight are different forms of unhealthy
weight that result in malnutrition. Each form of unhealthy
weight has different clinical measurements as well as many
causes and health consequences.
1.2. Underweight Determinations
Underweight is determined differently in adults, the
elderly and children of various ages.
i. Underweight Determination in Adults and
the Elderly
In adults and the elderly, underweight is defined as BMI
less than 18.5 [1]. Underweight is also a term used to
describe adults who are 15% to 20% or more below their
usual or ideal body weights [2]. Other nutritionists use the
term ‘underweight’ to describe people experiencing
unintentional weight loss [2], [3].
ii. Underweight Determination in Children
Aged Two Years or More
In children aged two years or more, underweight is defined
clinically by the Center for Disease Control and Prevention
(CDC) growth chart established in 2000 [4] as BMI-for-age
less than the 5th percentile; sometimes an underweight child
may also have a short stature or stunting. The CDC chart [4]
defines short stature as height-for-age less than the 5th
iii. Underweight Determination in Children
Aged Less than Two Years
In children aged less than two years, the World Health
Organization (WHO) growth chart of 2006 [5] is applied in
determining underweight, and it defines underweight as
weight-for-length less than or equal to the 2.3rd percentile;
the WHO chart [5] also defines short stature in that age group
as length-for-age percentile less than or equal to the 2.3
Under-weight children who experience stunting or wasting
may have chronic under nutrition arising from many causes
including food shortages, illnesses and other factors.
Underweight in children is sometimes called low weight-for-
age. It can include both stunting and wasting [4]-[6].
iv. Description and Measurement of Stunting
Children who have stunting are described as being short-
for-age or as having low height-for-age, growth retardation
or short stature. The stunted child may look too young for the
declared age. Stunting in children can result from both under-
nutrition and infections and is an indicator of poor
environment, inadequate nutrition and an extended restriction
of a child’s growth. Some consequences of stunting in a child
include delayed mental development, poor academic
performance and decreased cognitive capacity. A country
with a large number of intellectually less developed children
is at a disadvantage as this situation can persist until
adulthood. Intellectually less developed adults can affect the
quality of a country’s national workforce, work productivity
and its economic development according to the WHO [6].
Women of short stature tended to have smaller pelvis
which might impact labor and delivery. Smaller pelvis might
also increase risk of obstetric complications [6]. Such women
with short stature also tended to have low birth weight
infants, preterm infants or infants with intra-uterine growth
retardation. Infants born to short statured women may grow
up to be small adults if they received no early interventions
and will repeat the cycle all over again when they get
pregnant and start having children of their own. Thus
children of short statured mothers may also turn out to be
underweight and stunted.
According to the WHO [6], if a child’s height-for-age is
more than 2 standard deviations below the WHO standard,
then the child is said to have stunted growth, and may be
underweight and /or undernourished. However not all stunted
children are undernourished. Stunting is caused by many
other factors including genetics, environment, inadequate
protein and calorie intake, chronic caloric deficit, stress and
chronic infections like malaria, parasitic infections, various
diseases etc.
v. Description and Measurement of Wasting
Wasting is described as low weight-for-height or
emaciation. If a child’s weight-for-height index is more than
2 standard deviations below the WHO [6] standard, then the
child is said to have wasting, and may be underweight and
undernourished [6], [7]. Unlike stunting, wasting is a
stronger indicator of malnutrition in a child. Wasting is
caused by severe caloric deficit, diarrhea, and dehydration,
excessive loss of body fat and loss of muscle tissue. Wasting
can be reversed with gradual controlled replenishment of
nutritious food, supplements and beverages while treating
any underlying illnesses and infections. Wasting can also
impair the immune system and can increase susceptibility to
infections, thereby increasing length of hospital stay and
hospital cost as well as readmission rates.
1.3 Forms of Unhealthy Weight
Various forms of unhealthy weight have their BMI cut offs
and classifications. They also have various health
1.3.1. Obesity as a Form of Unhealthy Weight
A body mass index (BMI) value of 30.0 or above is
described as obesity and it has many health consequences [1],
[8]. Obesity is further categorized as class 1 or mild obesity
(BMI at 30.0-34.9), class II or moderate obesity (BMI at
35.0-39.9) & class III or extreme /morbid obesity (BMI at
40.0 and above) [1]. In Asian populations, obesity cut off
points are lower. Asians have a higher tendency to develop
metabolic syndrome, so their BMI cut off for obesity is
revised downwards to 25 instead of 30.0 according to
published reports [9]. A simple way of estimating obesity in
American Journal of Food Science and Nutrition Research 2016; 3(5): 126-142 128
a community or rural setting is to measure the waist
circumference with a tape measure as described later; a waist
circumference greater than 35 inches in women or greater
than 40 inches in men is indicative of obesity.
Obesity has reached epidemic proportions in the United
States of America (USA) [10], [11] and other countries [12]-
[14] including developing countries [15]-[17]. Obesity has
several causes, some of which are obvious while others are
hidden [18]. Several efforts have therefore been made in
curbing obesity epidemic both in the USA [19]-[21] and
other parts of the world [17]. Despite the obesity epidemic,
some segments of the US population especially geriatric
and/or very sick or disabled populations suffer from
underweight and inadequate weight gain [22]. Similarly,
people in some developed parts of the world [23] and some
developing countries [16] experience underweight,
overweight and obesity in various segments of their
1.3.2. Overweight as a Form of Unhealthy
In many populations, overweight is described as a BMI
value between 25.0 and 29.9[1]. For Asians, overweight is
described as a BMI value between 23.0 and 24.9 [9]. There
are other methods of estimating overweight in the field and
community settings. Such methods involve using a simple
tape measure to measure waist circumference (WC), hip
circumference (HC) & a person’s height (Ht) in an upright
position. From these measurements, one can calculate the
waist-to- hip ratio (WHR) & waist-to-height ratio (WHtR).
Both WC, WHR, are good estimates of fat distribution in the
body according to the World Health Organization [24] and
high WHR correlates positively with many metabolic
diseases such as Type 2 Diabetes mellitus (T2DM), stroke,
infertility, hypertension & cardiovascular diseases [24].
Anecdotal reports however claim that low WHR is directly
correlated with fertility and female attractiveness. Waist
circumference is the measurement of distance round the
abdomen just above the belly button while hip circumference
is distance round the hip through the widest part of the
buttocks. Waist-to-hip ratio (WHR) is the ratio of waist
circumference (WC) to the hip circumference (HC). (Thus
WHR=WC/HC). Both WC & HC must be measured in the
same units before deriving the ratio (WHR). If the waist to
hip ratio is greater than 0.9 in men, or greater than 0.8 in
women, it is indicative of overweight and obesity and high
risk of metabolic diseases. High WHR and WC correlated
positively with high rates of overweight and obesity as well
as higher risk of cardio-metabolic diseases.
The waist-to-height ratio (WHtR) is another good estimate
of fat distribution in the body. The WHtR is the ratio of waist
circumference to height, both measured in same units. (Thus
WHtR=WC/Ht). The WHtR can be used to estimate
overweight and obesity and predict risk of metabolic diseases
better than BMI according to recent reports [25]. If the
WHtR is less than 0.50, it is indicative of low risk of
metabolic diseases. If the ratio is around 0.50 or higher than
0.50, it indicates overweight and obesity and increased risk
of metabolic diseases like T2DM, stroke, infertility, CVD
and others. Recent studies indicate that keeping WHtR below
0.50 (i.e. keeping a person’s waist circumference at less than
half of the person’s height) is one good way of reducing risk
of metabolic disease and increasing life expectancy [25].
Overweight is very common in many developed countries
and some developing countries where overweight can coexist
with obesity and underweight [8], [13], [16]. If overweight in
an adult is not well controlled by physical activity, behavior
modification and diet, it can result into obesity. Similarly an
overweight child without early intervention to control excess
weight can grow up living with overweight and obesity and
these conditions may continue into adulthood. Adult obesity
can have many consequences such as diabetes, hypertension,
cardiovascular and other diseases [8] as stated above.
1.3.3. Underweight as a Form of Unhealthy
Underweight in an adult is described as a BMI value less
than 18.5 [1]. Underweight does occur in some segments of
populations in some developed countries, but it is not very
common in the USA. Underweight however has been a
perennial problem of many developing countries and is a
result of many causes including diarrhea, poor sanitation and
hunger [7]. It is however ironic that underweight, diet-
related anemia and obesity can coexist in the same country,
but in different segments of the populations in both
developed and developing regions of the world [13], [16],
[18], [22], [23].
1.4. Global Hunger, Under-nutrition &
Unhealthy Weight
The issue of world hunger has been acute and has been
recognized as very problematic by several world bodies
including the United Nations (UN), World Health Organization
(WHO), World Health Assembly Health Ministers, Food and
Agricultural Organization (FAO) and United Nations
Children’s Emergency Fund (UNICEF). The United Nations
made hunger a front burner issue and one of the most
important goals of the Millennium Development Goals
(MDGs) established in the year 2000 at the Millennium
Summit of World Leaders [26]. In that summit, world leaders
resolved to set targets for overcoming not only hunger but also
income poverty, diseases and other shortcomings. Although
few countries experience overt starvation and acute hunger due
to wars, natural disasters and famine, many countries
especially developing countries suffer sporadic food shortages,
chronic food insecurity and chronic under-nutrition. Some
segments of the populations in developing countries are
therefore chronically underweight. In some developed
countries, a few segments of their populations (especially the
elderly and the homeless) experience food insecurity [27],
while other communities designated as ‘food deserts’ lack
nutritious and affordable foods or means of obtaining fresh
foods [28]. Eradication of extreme hunger and poverty by 2015
was some of these UN Millennium Development Goals that
129 Stella G. Uzogara: Underweight, the Less Discussed Type of Unhealthy Weight and Its Implications: A Review
needed to be achieved [26].
As described above, it is obvious that so many forms of
unhealthy weight (obesity, overweight & underweight) exist.
This paper will focus mainly on underweight as a form of
unhealthy weight. It will also review the consequences and
causes of underweight and will discuss strategies for
maintaining healthy weight in many populations.
2. Discussions
2.1. Consequences of Underweight
2.1.1. General Consequences of
Underweight and Inadequate Caloric
Inadequate caloric intake leads to inadequate weight gain
and underweight which may lead to many problems [22],
especially if the inadequate food intake is sustained for a long
period of time. The negative consequences of inadequate
food intake and underweight can be observed in all age
groups, from infants and children, to adolescents, women of
child bearing age, adults and elderly populations (Table 1).
Table 1. General Consequences of Underweight in Various Population
Consequences of Underweight References
Inhibited growth and development in form of
stunting and wasting in children [29]-[35]
Low lean body mass or low muscle mass
Failure to thrive and developmental delays in
[38], [39].
Weakened or compromised immune system that
makes a person prone to infections [40]-[44]
Fragile bones, fracture s and osteoporosis [45]-[49]
Frailty in older adults [50]
Anémia [27], [51], [52]
Vitamin deficiencies in normal and sickle cell
patients [7], [52]-[54]
Fertility issues such as amenorrhea, failed
conception & pregnancy complications [55]-[59]
Poor pregnancy outcomes [60]
Disrupted hormone regulation and menstruation
problems [61]
Hair loss & hair thinning [58], [62], [63]
Poor ingestion, digestion, absorption and
assimilation of food that result in frailty [54], [64]
Chronic and general fatigue, heart rhythm
problems, low energy, weakness and dizziness [65]-[67]
Hypothermia [68]
Hypoglycemia [69]
Burns that take long time to heal [70]
Poor wound healing & pressure ulcers [70],[71]
Chronic diseases [72]
Psychological issues such as poor self image, lack
of self confidence, self esteem issues and stress [67], [73]
Bad mood and unexplained anger or aggression
due to hunger [74]
Poor self-control [75]
Poor sleep and stress [76]
Relative energy deficiency in sports(RED-S) &
female athletic triad [77], [78]
Increased mortality [78]-[83]
2.1.2. Consequences of Underweight in the
Elderly and Adults
Underweight and malnutrition are more common in the
elderly population than other adult population groups and has
many causes and consequences [84]. Some consequences of
underweight and under-nutrition especially in the elderly
include decline in functional status, impaired muscle
function, decreased immune function and reduced cognitive
function [85]. Other consequences of underweight include
decreased muscle mass, sarcopenia, decreased bone mass,
skeletal disorders, weight loss, anemia; poor wound healing
and pressure ulcers as listed in Table 1. Some underweight
consequences in the elderly also include delayed recovery
from surgery, longer length of hospital stay, higher hospital
cost and higher readmission rates [85].
2.1.3. Consequences of Underweight During
& After Pregnancy in Women of Child
Bearing Age
One of the serious consequences of underweight is poor
health in a pregnant or breastfeeding mother. Underweight is
more common in women than in men in some communities
in developing countries [86]. Poor diet during and after
pregnancy can result in underweight and poor health in the
woman and her child [60]. Poor diet is caused by inadequate
food and beverage intake, chronic food shortage, food
insecurity, lack of nutritious food and drink, chronic hunger
and starvation. Although underweight affects all population
age groups (adolescent, adult man/ woman and the elderly),
and occurs more commonly in the elderly, it has very serious
consequences when it occurs in pregnant and breastfeeding
women or in infants and children.
Extreme underweight can negatively impact the health of both
a pregnant undernourished woman and that of the unborn child
in the womb. Such a woman can have complications in
pregnancy and delivery [55], [56], [59] & [60]. An underweight
pregnant mother can deliver premature or preterm baby, and/ or
low birth weight infant or an infant described as ‘small for
gestational age’ [60]. The infant of an undernourished pregnant
woman may be born underweight, and may develop
malnutrition, stunting or wasting and/or decreased mental and
physical capacities [60]. A chronically undernourished and
underweight woman may not be capable of making enough
breast milk to feed her baby or to rebuild her body tissues
following delivery; she may also not be able to replenish all
blood lost during child birth. An undernourished and
underweight woman may easily succumb to fatigue and diseases
and may be unable to meet the energy demands of caring for her
newborn baby or other children in her family. Such a woman
may be prone to anemia, weakness and various infections which
can lead to increased maternal illness and even mortality [60].
2.1.4. Malnutrition and Underweight as a
Result of Poor Food Intake in Children
A child who is not well fed, will start displaying poor
nutritional symptoms within six months or less, and can
succumb to underweight; such a child may develop
malnutrition which can lead to appetite loss. A chronically
American Journal of Food Science and Nutrition Research 2016; 3(5): 126-142 130
hungry underweight child that developed under-nutrition at the
critical period of brain development (from pregnancy & birth
to preschool) may become physically and cognitively impaired
and not functional unless there is an early intervention to
improve nutrition and health of the child [87]-[91].
2.2. Caloric Intake, Storage and Bodyweight
Caloric intake affects caloric storage and body weight.
Inadequate caloric storage occurs when energy expenditures
(through exercise, physical activity or metabolism) exceed
energy intake (through food, supplements and drinks), and
can result in weight loss, malnutrition, underweight and other
problems. In extreme cases, underweight can lead to chronic
diseases and death [79] - [82]. Inadequate caloric intake has
many consequences and causes as observed in children,
adults and the elderly [29], [73], [83], [85], [93].
2.3. Major Factors Causing Inadequate
Calorie Intake and Underweight
Many factors cause underweight in children, adults,
women and the elderly and sometimes result in both
morbidity and mortality at national, regional and global
levels. A list of some possible factors that cause underweight
is shown in Table 2a and will be discussed thereafter.
Table 2a. Major Factors that Cause Underweight
Major Factors that Cause Underweight References
Poor food intake
Insufficient food intake
[94], [95];
[36], [94]-[96]
Difficulty chewing or swallowing
Loss of teeth, gum & denture problems
Age related issues: mobility issues & difficulties in
tasting, smelling & eating of food
Loss of appetite
Loss of sense of taste /smell
Lack of motivation to cook or eat out
[85], [98], [99];
Parasitic or helminthes infections e.g. amebiasis,
round worms, malaria, hookworms, giardiasis,
[40]-[43], [52],
Bacterial infections, urinary tract infections (UTI),
pneumonia, E. coli, Staphylococcus & Salmonella
[40], [41], [43],
Irritable bowel diseases [22]
Malnutrition and deficiencies of vitamins/minerals ;
Being put on ‘NPO’ (‘Nothing by Mouth’) for a long
period of time while preparing for surgery or lab tests.
[7], [103];
[22], [23], [98].
Use of Stimulant /appetite suppressing drugs
Voluntary consumption of fad diets
Food allergies and food intolerances
[141], [142]
Lifestyle and social factors (such as poverty, poor
socialization, loneliness, Inabilities to shop, prepare,
cook and store food; lack of knowledge of nutritious
food and their functions in body.
[27], [72], [117]-
Environmental factors such as
- limited food choice and variety while in hospital,
-poor texture, flavor and appearance of food, poor
food quality,
-dependent on assistance to feed self,
-inability to reach food, hold cutlery or open packages,
-temperature of food not adequate, unpleasant sight,
sound, or smell of food or unpleasant food
[72], [118]-[121]
Major Factors that Cause Underweight References
Limited cultural, ethnic or religious foods available to
choose from [24],[ 25], [98]
Orphans & vulnerable children (OVC) [122], [123]
Fatigue and emotional factors [65], [67], [76]
Burns, pressure ulcers, immobility and chronic pain [22], [54],[98];
Old age and related issues
[22], [37], [48],
[49], [50], [54],
[85], [98], [103],
[124], [145]-
Table 2b. Other Factors that Cause Underweight
Other Factors that Cause Underweight References
Side effects of some medications;
Cancer medications
[3], [98],
[104], [105];
[3], [98],
Anorexia, bulimia, eating disorders
Fatigue, Over-exercising or over-training
[28], [29],
[65], [67],
[76]; [77],
Underlying illnesses [22], [54],
Chronic & Wasting diseases e.g.
Lou Gehrig’s disease & Multiple sclerosis or MS;
Tuberculosis or TB
Cancer, Pancreatitis, Cystic fibrosis,
HIV/AIDS (Human Immunodeficiency Virus/Acquired
Immune Deficiency Syndrome),
Other diseases & viral infections such as Ebola, Zika
Organic diseases
[22], [113]
[129], [130],
High basal metabolic rate or BMR ;
Hyper-active thyroid
Lower Gastro Intestinal (GI) problems e.g. cancer of
intestine, irritable bowel disease, pancreatitis,
appendicitis, that result in mal-absorption, tube feeding
Diarrhea, nausea, vomiting
[40], [44],
Upper GI problems e.g. cancer of mouth, tongue,
pharynx, esophagus, stomach, that result in tube feeding
[40], [44],
Genetics (some people inherit lean or skinny genes) [108], [109],
Psychosocial, economic & political problems:
Trauma, fear, violence, bereavement
Refugee/migrant status
Psychological factors like confusion, dementia,
depression, bereavement anxiety and even paranoia;
Stress, anxiety, depression
[106], [107];
[106], [127];
106], [107];
[106], [107];
Toxic or unsafe drinking and cooking water [126]
Smoking [103], [143],
Excess Alcohol intake 153
Hunger suppressing herbs such as ‘khat’ [154]-[157]
2.3.1. Poor Food Intake in Children
A child must be well fed with breast milk or formula to
grow and develop well. There are many causes of
underweight in small children, and most of these causes can
lead to death [94], [95]. These causes include:
-Not feeding a child with breast milk or formula;
-Irregular feeding of child with breast milk or formula;
- Food rationing for a young child;
-Early feeding of solid foods while withholding breast
milk and formula;
-Lack of nutrient dense foods;
131 Stella G. Uzogara: Underweight, the Less Discussed Type of Unhealthy Weight and Its Implications: A Review
-Lack of essential nutrients (such as essential amino acids,
essential fatty acids, critical vitamins and minerals) in food
given to child;
-Insufficient food fed to the infant irregularly;
-Poor feeding practices;
-Non-exposure of child to adequate sunlight to make
vitamin D necessary for proper bone development;
-Early introduction of child to weaning and
complementary foods that consist of cultural adult foods
(such as tea, high fiber foods) containing anti-nutrients
(phytates, tannins) that decrease absorption of vitamins and
2.3.2. Insufficient Food Intake and Poor Diet
in Adults and the Elderly
Poor diet can be a result of several factors such as:
inadequate food and beverage intake, lack of available food
and drink, chronic food shortage, chronic hunger, starvation
and food insecurity. People who eat infrequently, or those
who do not eat at all, or people who do not consume enough
nutritious food and beverages easily become underweight.
Such people do not get energy to function and live their lives
fully and actively. Consequently their weight progressively
decreases and they eventually become malnourished and
severely underweight [36]. Underweight due to poor diet can
occur in men or women. An underweight man or woman is
not strong enough to perform physical and mental activities
expected of a normal man or woman of same age [94]-[96].
2.3.3. Refugee and Migrant Status
In the case of refugees, migrants and children fleeing war
zones and natural disasters, they are under a lot of stress.
Such stress arising from moving from their familiar towns
and villages to unfamiliar cities in other countries with
different lifestyles and food habits can lead to underweight
and malnutrition [106], [127].
2.3.4. Orphans and Vulnerable Children
In the case of children orphaned by AIDS, infectious
diseases or other environmental factors, stress from
transitioning from birth mother to adoptive mother or care
giver can affect food intake and cause underweight and
malnutrition [122], [123].
2.3.5. Voluntary Consumption of Fad Diets
Some people especially adolescents follow certain fad
diets because such diets are in vogue or because of peer
pressure. Others follow fad diets if such diets were
recommended by friends as a way to manage weight. Some
fad diets are very restrictive in the type and quantity of food
eaten or in their nutrient content. Following strict fad diets
tend to result in under-nutrition and underweight [140].
2.3.6. Underweight Causes in the Elderly
i. Old Age & Related Issues
Some people especially the elderly are underweight
because of age related factors. An extensive review by
Hickson [98] showed that factors that cause underweight and
malnutrition in the elderly can be grouped into medical,
lifestyle, social factors as well as psychological and
environmental factors. Other risk factors that affect
underweight and malnutrition in the elderly include weight
loss caused by wasting, sarcopenia and cachexia as well as,
mobility issues [54], [145]. Some older people become
underweight because of sarcopenia due to not exercising their
muscles [37], [50].
Underweight in the elderly is also caused by difficulty
tasting, chewing or swallowing food and loss of teeth [146],
lack of motivation to cook or eat outside the home [22],
poverty due to diminished income at retirement that makes it
difficult for the elderly to purchase nutritious food; other
factors contributing to underweight in the elderly population
include social isolation and loss of appetite [22, 54, 124].
Some elderly people do not remember to eat and drink
because of senile dementia and Alzheimer’s disease hence
they become underweight and sometimes get dehydrated
Other elderly people have decreased gastro-intestinal (GI)
motility and decreased GI function as a result of aging and
this can lead to poor absorption and sometimes constipation
[98], [103], [148]-150]. Some elderly people have small
bowel bacterial overgrowth and consequently not able to
absorb nutrients efficiently from food and this also
contributes to underweight [54], [151]. Many elderly people
become underweight because they are no longer able to make
tissue building anabolic hormones like growth hormone and
sex hormones because of aging [54], [85] & [103].
ii. Fatigue and Emotional Factors
Some people are underweight because of fatigue and
emotional issues such as stress, anxiety and depression [65],
[67] & [76].
iii. Poor Mastication of Food & Loss of
Senses of Smell & Taste
The loss of teeth leads to poor food mastication and
decreased food intake which can result in underweight.
Similarly loss of sense of taste and problems with upper
gastro-intestinal (GI) tract such as cancer of the mouth,
tongue, pharynx, esophagus, stomach, stroke and general GI
malfunction can lead to decreased food intake, resulting in
underweight in both young and old people [54], [99], [110],
[146] & [152].
iv. Loss of Appetite
Loss of appetite reduces amount of food consumed, can
lead to food aversion and results in decreased food intake,
weight loss and underweight [85], [98] & [99].
2.3.7. Parasitic Infestation
Underweight and weight loss can be caused by parasites
(insects, fungi, viruses and helminthes or parasitic worms)
that attack an individual’s body especially in some
developing regions of the world as well as some developed
countries. These parasites tend to infect various body systems
including the cardiovascular and gastrointestinal systems,
American Journal of Food Science and Nutrition Research 2016; 3(5): 126-142 132
resulting in poor food intake, poor absorption and utilization
of the consumed food, leading to weight loss, anemia and
underweight [40], [41], [43], [52], [100]-[102].
2.3.8. Bacterial Food Infection and Food
Food poisoning can cause underweight. This is due to
excessive diarrhea, loss of electrolytes, nausea and vomiting
from food poisoning. Underweight can also result from
deficiencies of digestive enzymes & stomach acid. In
addition, bacterial & viral infections that affect the gastro-
intestinal tract can also cause underweight [40], [41], [43],
and [44].
2.3.9. Food Allergies and Food Intolerances
Hidden food allergies like gluten, soy and milk allergies or
intolerances for lactose and gluten can lead to mal-absorption
of nutrients and result in underweight especially in children
[141, 142].
2.3.10. Mineral and Vitamin Deficiencies
Malnutrition especially deficiencies of minerals and
vitamins as well as deficiencies of essential nutrients also
cause underweight [7], [103].
2.4. Other Factors Causing Inadequate
Calorie Intake and Underweight
Other factors mainly medical, genetic, behavioral,
economic and psycho-social problems also contribute to
causing underweight as listed in Table 2b; these are discussed
2.4.1. Medications
Sometimes underweight is caused by food-drug
interactions or drug–drug interactions that affect food intake
and body weight or cause bleeding problems. Underweight
could also be due to side effects of medications, that decrease
appetite or induce vomiting and diarrhea [104], [105]. Some
stimulant medications used in treating attention deficit
disorders are known to cause weight loss and/or underweight
[3]. Sometimes drug –drug interactions can also cause lack of
appetite and lead to underweight and malnutrition especially
in the elderly who practice poly-pharmacy [98].
2.4.2. Overtraining & Exercise
Too much physical training and exercise without a
corresponding consumption of nutritious food, coupled with
not taking adequate rest, can lead to nutrient depletion,
fatigue, loss of muscle mass and underweight, leading to
syndromes like female athletic triad and RED-S [77], [78].
2.4.3. Underlying Illnesses and Disorders
Sometimes some underlying illnesses, especially organic
diseases, lead to underweight even when a person eats ample
amount of food [22], 98]. These underlying illnesses
affecting different organ systems include:
-Endocrine disorders (diabetes type 1, newly diagnosed
diabetes type 2, thyrotoxicosis),
-Gastrointestinal disorders, (dysphagia, mal-absorption
syndromes, lactose intolerances, nutrient allergy, irritable
bowel diseases, pancreatitis, ulcers, gastro esophageal reflux
disease or GERD),
-Respiratory disorders (tuberculosis, chronic obstructive
pulmonary disease or COPD, emphysema, whooping cough),
-Musculo-skeletal disorders such as arthritis, immobility or
reduced mobility, muscle wasting disease, muscle atrophy,
-Neurological disorders (Alzheimer ’s disease, dementia,
stroke, alcoholism, Parkinson’s disease) etc
-Debilitating disorders affecting multiple body systems
(cancers, Lou Gehrig’s disease, multiple sclerosis, sickle cell
diseases, TB, anemia),
-Various parasitic infections, for example, infections from
helminthes (roundworms, hookworms, filarial worms), from
insects (malaria parasites in mosquitoes), from bacteria
(urinary tract infections or UTI, pneumonia, E.coli, Staph.
aureus), from yeast & fungi (candidiasis, ringworm,
aspergillosis), as well as viral infections (AIDS, Ebola, Zika,
2.4.4. Chronic and Wasting Diseases
Some people are chronically underweight because they
have chronic diseases that cause weight loss and
underweight. Others are underweight because they are living
with wasting diseases that make them shrink in size once the
diseases strike them. Such wasting diseases include
tuberculosis or TB [114]-[116], multiple sclerosis or MS
[113], cancer [129], pancreatitis [130], cystic fibrosis [131],
HIV/AIDS [132], Lou Gehrig’s disease [22] or people with
idiopathic weight loss, as well as some viral diseases like
Ebola viral disease [133], [134]. It should be noted that once
a patient’s tissue starts wasting, it is a sign of disease
progression and a strong warning signal for clinicians [22] to
do serious intervention on the patient.
2.4.5. Hyperactive Thyroid
Hyperactive thyroid leads to hyperthyroidism, a condition
which produces high level of thyroid hormones namely, tri-
iodo-thyronine (T3) and thyroxin (T4). The high level of
thyroid hormones increases basal metabolic rate (BMR) and
weight loss. People with high BMR hardly gain weight and
tend to be underweight [110]-[112].
2.4.6. Lower and Upper GI Diseases
Diseases of upper and lower gastro intestinal tract that tend
to negatively affect ingestion, digestion, absorption,
metabolism and utilization of food lead to underweight, for
example, irritable bowel disease (Cohn’s and Celiac diseases)
[40], [52], [103].
2.4.7. Genetics
Sometimes people are naturally underweight because of
genetics, that is, they inherited ‘lean genes’ or ‘skinny
genes’. Such people do not gain weight even if they eat a lot
of food because they have high basal metabolic rate (BMR)
which was inherited. People with skinny genes tend to burn
more body calories faster than their counterparts without
133 Stella G. Uzogara: Underweight, the Less Discussed Type of Unhealthy Weight and Its Implications: A Review
skinny genes [108], [109].
2.4.8. Food Avoidance and Eating Disorders
Deliberate starvation as occurs in people observing a
hunger-strike can result in weight loss and underweight.
Similarly, willful avoidance of food over a long period of
time as done by some people during religious fasting can
result in underweight. In addition, withholding food from a
patient because of preparation for hospital procedures, before
or after surgery, or in preparation for lab tests can negatively
impact food intake and can result in underweight [22] if
normal food consumption is not resumed soon afterwards.
Eating disorders especially in people living with anorexia
nervosa & bulimia nervosa result in weight loss and
underweight [36], [57], [93], [124], [125], [128].
2.4.9. Smoking
Smokers tend not to gain weight. This may be due to
anorectic effects of nicotine, as reported in some studies
[103,143]. Since nicotine in tobacco has anorectic effect,
smokers therefore tend to be underweight [103], [143].
However sudden cessation of smoking tends to result in
weight gain according to a published report [144].
2.4.10. Psycho-social, Economic and Political
i. Food Insecurity
For many children and orphans in both developed and
developing countries, the cause of underweight may include
socio-economic as well as political causes. These include
household food insecurity [27], [117]-[121], inadequate care
of the children, war, famine, natural disasters, unhealthy
household, poor health services and lack of access to good
healthcare for mothers and children [72], [120].
ii. Unsafe and Unsanitary Drinking and
Cooking Water
Underweight in children may also be caused by unsafe and
unsanitary drinking and cooking water from toxic water
supply. Unsafe water adversely affects the health and
development of children in both developed and developing
countries. Toxic chemicals in water supply include lead,
arsenic, mercury, pesticides, herbicides and others. The
recent lead crises due to toxic lead in the water supply in
Flint Michigan USA negatively impacted the growth and
health of many children in that community according to a
recent report [126].
iii. Psycho-Social Causes of Underweight
Sometimes bereavement, trauma, fear, war, refugee status,
sudden displacement, migration, and domestic violence can
suppress appetite and lead to weight loss and underweight
[106], [107].
iv. Excess Alcohol Intake in Lieu of
Nutritious Food
Consuming excess alcohol while neglecting to eat
balanced nutritious meals can cause underweight as essential
nutrients and calories necessary for the body and tissue
building are not consumed [153].
v. Use of Hunger Suppressing Herbs
Certain herbs are reported to have hunger suppressing
properties [154]. One such herb is known as ‘khat’ (Catha
edulis), an evergreen shrub that grows in parts of the
Middle East as well as the Sahel region of Africa (Yemen,
Ethiopia, Somalia, and East Africa). Khat produces leaves
that have narcotic and stimulant effects when the leaf is
chewed or drunk as tea. The khat suppresses both appetite
and hunger, so that people (especially men and nomadic
herdsmen) who consume this stimulant herb, look lanky or
lean, and can go for several days or weeks in the field or
desert without food. Such men do not feel hungry or tired,
but they lose weight since their caloric intake is low.
However chronic use of the herb has been reported to have
serious adverse effects on the liver, nervous and
cardiovascular system and the herb has been described as a
drug of addiction [154], [155]. Khat chewers tend to be
underweight and lanky. The herb is not allowed to be used
by pregnant women and children because of its
toxicological effects [155]-[157], though some women
ignore medical advice and still take the stimulant herb. Khat
is a controlled substance in many countries and banned in
some others.
2.5. Management of Underweight
Based on the facts listed above, it is obvious that several
causes of underweight exist and new causes are
encountered in the field regularly. Although underweight is
a public health problem especially in some developing
countries, it has not reached epidemic proportions in
developed countries like the USA, where underweight
afflicts a small segment of their population, mainly some
geriatric populations, some premature children, refugees
and some children in very poor communities. Underweight
problem can be more easily rectified with supervised
nutritious diet, proper hydration, liquid supplements as well
as vitamin and mineral supplements. In addition,
underweight can be rectified by use of nutritious foods and
beverages, and treating underlying disease conditions and
symptoms, as well as supervised physical activity and
medications. However rectifying overweight and obesity
problems in developed countries require long term problem
solving and interventions as shown by several government
programs such as Healthy People Programs [158], [159].
These programs have addressed overweight and obesity
issues for several years and there is still more work to be
2.6. Strategies to Rectify Underweight and
Several strategies have been found useful in rectifying
underweight and malnutrition as listed in Table 3. These are
discussed fully below.
American Journal of Food Science and Nutrition Research 2016; 3(5): 126-142 134
2.6.1. Offer Foods of High Nutrient Density &
High Energy Density in Small Amounts
To rectify underweight in affected people requires a
balanced diet that is high in nutrients and energy.
Underweight people should be given nutritious and well
balanced food in small quantities, at a slow pace to avoid re-
feeding syndrome, especially in patients living with anorexia
[160]. This protocol is necessary to allow the body to adjust
to presence of these nutrients, maintain electrolyte balance
and to avoid overwhelming the undernourished body with
excess nutrients that can affect the functions of vital body
organs such as heart, kidney and the organs of the gastro-
intestinal system.
Soft drinks or sodas even though high in sugar tend to
suppress appetite and prevent weight gain, therefore intake
of these should be minimized to allow room for nutrient
dense foods. In children, a moderate amount of 100% fruit
juice taken after food is preferable to soft drinks; excess
juice should however be disallowed to enable children have
space in their GI tract to accommodate intake of
macronutrients. In addition, ample amount of animal
protein, plant proteins, healthy fats, and starchy vegetables
as well as less fibrous foods, milk, other dairy and
beverages should be given in small portions to ensure
rebuilding of tissues. The menu should include items such
as lean meat, oily fish, poultry and eggs, legumes (beans
and peas), milk, avocado, various nuts and seeds. It should
also include vegetable oils like olive oil which is high in
mono-unsaturated fatty acids as well as more starchy
vegetables like rice, pasta and potatoes, and less non-
starchy vegetables. Non-starchy vegetables are high in fiber
which easily fill up the consumer and prevent consumption
of weight enhancing caloric macronutrients. The nutritionist
should discuss food allergy and intolerances with the person
living with underweight to ensure that all foods given to the
person is allergen-free and well tolerated.
2.6.2. Offer Nutritional Supplements
Underweight people or malnourished patients are
sometimes given oral nutritional supplements, energy dense
formula, nutrient dense bars, multivitamin and minerals pills,
fortified foods, medical foods, beverages, healthy snacks &
shakes(such as Boost, Ensure, etc). In addition, full fat milk
or full fat yogurt, high in calories and various nutrients, are
also given.
2.6.3. Increase Food Frequency and Snacks
Increasing the frequency of food eaten is very helpful.
Eating six small meals instead of two or three very big meals
is also very helpful. Healthy snacks should be given after the
main meals to help in weight gain and to fight the
underweight problem.
2.6.4. Increase Organoleptic Properties of
Food Served
Sensory appeal of food (good appearance, improved
flavor-smell, aroma, & taste) as well as food texture
(softness, hardness, mouth feel) improves consumption of
food for the child, adult or the elderly living with
underweight [54].
2.6.5. Programmed Exercise
Training the underweight person in strength and flexibility
exercises using weights such as dumb bells or resistance
bands can build and tone muscle especially if done with
several repetitions and under expert supervision [103].
Children and adolescents should be allowed to play regularly
and get exposed to sunshine to absorb the sun’s rays
necessary to make vitamin D for absorbing calcium from
food, for building strong bones and muscles as well as for
bone growth [161]. Adults and the elderly should take gentle
walks and get some sunshine regularly when possible and
should also eat nutritious food to build bone and muscle
2.6.6. Rest and Relaxation
In addition to exercise, people living with underweight
issues need frequent rest and relaxation to regain or improve
their energy levels [103].
2.6.7. Smoking Cessation
Smoking has anorectic effect on smokers, so anybody who
wants to gain weight should stop smoking [143], [144].
2.6.8. Alcohol Cessation
Alcohol tends to fill the gut volume and make the
consumer to eat less caloric food as there is no space to
accommodate extra food if a person drank so much already.
Eating caloric nutrients while avoiding or minimizing alcohol
intake can improve appetite and weight gain and reduce
underweight [162].
2.6.9. Use of Medications that Stimulate
Appetite or Build Tissues
Appetite stimulators (e.g. megestrol, dronabinol) [163], or
tissue building medications that boost anabolism (e.g. growth
hormone, testosterone) are sometimes recommended and
should be checked with the prescribing physician and
licensed nutritionist before they are taken.
Conversely people using hunger suppressing herbs or
appetite suppressing drugs should discontinue such products
so as to stimulate appetite, increase food intake that will
result in body weight gain.
Table 3. Strategies to Rectify Underweight and Malnutrition.
(i) Offer foods of high nutrient density and high energy density in small
(ii) Offer nutritional supplements, beverages & shakes
(iii) Increase food frequency and snacks.
(iv) Increase organoleptic properties of food served.
(v) Encourage programmed exercise,
(vi) Encourage frequent rest and relaxation
(vii) Encourage smoking cessation
(vii) Encourage Alcohol cessation
(viii) Offer medications that stimulate appetite or build tissues.
(ix) Discontinue stimulant drugs or herbs that inhibit appetite or suppress
135 Stella G. Uzogara: Underweight, the Less Discussed Type of Unhealthy Weight and Its Implications: A Review
2.7. Benefits of Adequate Caloric Intake
from Food
Intake of adequate amount of calories from food is
encouraged since the human body needs food calories to
function properly. A problem only arises when there is
excessive, uncontrolled or inadequate caloric consumption
that negatively impacts health. There are several benefits of
food calories when taken in moderation or to meet the body’s
energy needs. Food calories influence body weight, provide
energy and macronutrients for body function and work. Food
calories go hand in hand with various micro nutrients to fight
malnutrition and underweight. Food calories ensure growth
and they give strength and cultural pleasure.
2.7.1. Calorie Intake Influences Body Weight:
Body Weight Impacts Health Status
Calories taken into the body through food can be
metabolized to release energy or stored in the body as fat.
When stored in the body, calories lead to weight gain and
influence overall body weight. Body weight in the normal
range is healthy and positively affects health status. Good
nutrition which involves intake of healthy food calories is
essential not only for growth and healthy development of a
child, but also to fight infections and for repair and
maintenance of tissues in both adult and children.
Healthy body weight is an essential metric used in many
nutritional calculations to determine parameters for
making important decisions in medical nutrition therapy
(MNT) such as weight status and weight changes. Nutrient
and energy needs as well as drug dosages are based on
kilogram body weights. Similarly, tube feeding and
intravenous feeds are also dependent on body weight
status. The effects of adequate body weight on health
status cannot be over-emphasized and these are discussed
i. Body Weight Determines Weight Status
and Impacts Weight Changes
Calculation of nutrition parameters involves adequate body
weight. Such parameters include BMI, ideal body weight
(IBW), usual body weight (UBW) and actual or current body
weight, which are used clinically to determine a person’s
weight status such as obesity, overweight, underweight or
normal weight. Current body weight is also used to calculate
percent changes in body weight such as %IBW, %UBW,
usual body weight, calculated metabolic weight and adjusted
weight for amputation. Body weight is also factored into the
calculation of weight loss, involuntary weight loss, weight
gain or weight regain.
ii. Body Weight Is Used to Determine
Nutrient, Fluid, Energy Needs and Amount
of Feeds
Body weight is taken into consideration when
calculating energy, protein and fluid needs of hospitalized
patients or patients on parenteral nutrition. Body weight is
also used in calculation of amount of feed needed for tube
feeding and intravenous (i.v.) feeding of patients. Body
weight is factored into the energy equations for
determining daily energy or caloric requirements such as
basal energy requirement and total energy expenditure.
Such equations including Mifflin St Jeor Equation, Harris-
Benedict equations and other energy equations for energy
requirement estimation have been described in literature
iii. Body Weight is Needed to Calculate Some
Drug Dosages
Body weight is also used in calculation of dosage of drugs
for patients; some drug dosages and feeds are based on units
per kilogram body weight.
iv. Body Weight as an Indicator of
Body weight is an important indicator of nutritional or
health status. Well nourished cancer or HIV/AIDS patients
for example, with adequate body weight and good protein
stores, have good survivability, while patients losing 10 or
more percent of their body weight have diminished prognosis
[22]. Similarly, children who have normal weight-for-age
status or BMI-for-age percentile or children born with normal
birth weight (≥2500grams) are healthier, and more likely to
fight infection and grow better than their counterparts with
lower weight-for-age or lower BMI-for-age status. Infants
born with normal birth weight or higher are also more likely
to survive than those born with low birth weight or preterm.
2.7.2. Food Calories Prevent Malnutrition,
Maintain Body Weight and Bone Mass
Good caloric intake helps to reduce risk of general
malnutrition or protein energy malnutrition (formerly known
as protein calorie malnutrition) in pre-school (<6years of age)
children and older adults. Food calories are used in treating
under-nutrition of macronutrients and deficiencies of
vitamins and minerals; these micronutrients are also present
in caloric foods. Food calories are also used to reverse both
intentional and unintentional weight loss, to fight frailty and
to maintain adequate body weight [50]. Food calories lead to
weight gain which protects bones and prevents fractures [46]-
2.7.3. The Food Calories Are Essential to
Provide Energy
The energy from food calories is necessary to perform
bodily metabolic activities and other physical and mental
activities including sports and exercise as well as learning
[66], [77]. Inadequate food calorie consumption leads to
fatigue, weakness and lack of concentration [65].
2.7.4. Food Calories Support Growth, Build
Blood and Tissues & Help Fight
Food calories are also essential for growth of children and
adolescents and for repair and maintenance of body tissues in
adults and the elderly. Food calories fight diseases and
infections, prevent anemia and help to build strong bones.
American Journal of Food Science and Nutrition Research 2016; 3(5): 126-142 136
They help to heal wounds, prevent bedsores and to re-grow
tissues that suffered burns or trauma. Food calories also help
to build body tissues (bones, muscles and blood etc) and
regulate chemical processes in the body [71].
2.7.5. Food Macronutrients Provide Calories
and Essential Nutrients
Food macronutrients provide calories and essential
nutrients including essential and non essential amino acids,
essential fatty acids, vitamins and minerals necessary for the
body to function well. Macronutrients build important bio-
molecules like hormones, antibodies, enzymes, transport
proteins, growth factors, neuro-transmitters etc. The food
calories along with other nutrients nourish the body properly
and are needed by people suffering wasting diseases, as well
as normal healthy people who need calories for body
maintenance, tissue building and general body function.
2.7.6. Food Calories Give Cultural Pleasure
Caloric foods help many communities to perform social,
physical, psychological and cultural functions in their
neighborhoods and good food gives pleasure. These foods
are used as celebratory foods or daily meals and they provide
energy for both physical and mental work.
2.7.7. Food Calories Maintain Body
Calories from food increase body temperature. Body
temperature maintenance is very important in cold regions of
the world especially during the winter months [68].
3. Conclusion
Underweight is unhealthy weight arising from
unintentional weight loss from many causes especially poor
food intake. It is prevalent in children, pregnant and lactating
women, adults and even the elderly in many countries
especially developing countries. In developed countries,
underweight is less talked about, less common, and under-
recognized compared to obesity which is given more
prominence. However in the USA, underweight is observed
in some geriatric populations, a group where underweight
can lead to malnutrition if there are barriers to appropriate
nutritional care [165]. Underweight has various causes and
adverse consequences that impact the health and quality of
life of those affected.
Gradual diet restoration involving high caloric and
nutritious food and beverages, fed in small portions, at a slow
pace to avoid re-feeding syndrome, is the best approach to
reverse underweight. Other strategies to reduce underweight
and progress to healthy weight gain include gradual strength-
training exercises that build muscle, frequent rest and good
sleep, healthier life style and behavior modification. In
addition, avoidance of smoking, alcohol, street drugs,
hunger/appetite suppressants or quitting smoking and street
drugs altogether, are helpful in weight regain. Offering
nutritious foods to an underweight person, while concurrently
treating underlying diseases and syndromes, removing
barriers to the access of healthy food and safe water, as well
as good health policy initiatives help to treat underweight.
A joint action by public health and healthcare
professionals, nutritionists, educators and policy makers is
important to recognize, treat and prevent under-nutrition and
underweight in many populations. Public health education on
good nutrition and healthy weight maintenance will improve,
maintain and promote overall good health and wellness in
many countries.
Special thanks go to Dr Lisa Brown, Associate Professor
of Nutrition, Simmons College, Boston Massachusetts, USA,
for helpful discussions and advice on the manuscript.
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... This deters them from achieving the recommended levels of PA and negatively impacts their satisfaction levels and the social capital of the neighborhood [20]. Thus, the built environment factors such as the land use mix, residential density, and street connectivity around homes and schools need to be assessed to accommodate a higher concentration of pedestrians and provide design and policy recommendations [21,22]. ...
... Most adolescent studies analyze the impact of health determinants on overweight or obesity [21] and not on overall health, including being underweight, even when undernutrition remains a cause of death in children worldwide [22]. Few studies in the last decade have investigated the determinants of obesity in the UAE or the Emirati population and even less specifically target the adolescent population [3]. ...
... The emirates of Abu Dhabi consists of three regions: Abu Dhabi-the capital central region, the Al Ain region, and the Western region, as shown in Figure 1. Most adolescent studies analyze the impact of health determinants on overweight or obesity [21] and not on overall health, including being underweight, even when undernutrition remains a cause of death in children worldwide [22]. Few studies in the last decade have investigated the determinants of obesity in the UAE or the Emirati population and even less specifically target the adolescent population [3]. ...
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The UN Human Development Report 2020 ranked the United Arab Emirates (UAE) as having achieved ‘very high human development’ and as being at the 31st position among all countries. Despite this, the ever increasing obesity rates among Emirati youth, higher than international standards, is alarming. This research aims at identifying how different perceptions of the built environment by parents and adolescents are likely to affect physical activity (PA) choices among male and female Emirati youth. This can help inform better health and education policies to achieve three of the interconnected UN Sustainable Development Goals (SDGs), namely good quality health and well-being, quality education, and gender equality, that the UAE strives to achieve. Responses from 335 students (aged 14–20) from six schools and 250 parent responses in the Al Ain region of Abu Dhabi Emirate were used to understand the mean variation in perception of five built environment constructs. Further, multinomial logit regression was used to assess the health condition using the perception, behavior, and built environment measures. Results indicate that Emirati males perceive the built environment factors as barriers more than female adolescents. Parents perceive street crossing (p < 0.016) and sidewalk characteristics (p < 0.020) to be more of a hindrance. Traffic exposure, self-reported physical activity, and walkability near homes and schools significantly affect Emirati adolescents’ health conditions. Recommendations are made for various stakeholders including parents, school authorities, Abu Dhabi Municipality and Transportation, and the Urban Planning department on ways to enhance the built environment and encourage PA and well-being of Emirati adolescents.
... fractures, frailty in later times, hair loss and hair thinning, general fatigue, and psychological issues and increased risks of morbidity and mortality 24,25,26,27 . ...
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Background: Information on current gaps in the breakfast practice is important to design appropriate intervention message and strategies to promote appropriate breakfast practices among school age children. Objective: This study was therefore designed to assess the breakfast practice and anthropometric characteristics of school age children in Oyo metropolis, Nigeria. Methodology: This descriptive cross-sectional study involved 1038 public school pupils selected using a three-stage sampling technique across Oyo metropolis, southwest Nigeria.A semi-structured, interviewer-administered questionnaire was used to elicit information on the socio-demographic characteristics and breakfast consumption of the pupils. Height and weight were assessed and analysed using standard procedure. Data were analysed using descriptive statistics at p<0.05. Results: Age was 11.18±4.7 years, 54.3% were females, 16.9% were underweight and 5.5% were overweight/obese.The rates of breakfast intake and skipping were 91.5% and 8.5%, respectively. About 95% of pupilsconsumed breakfast before the 9.00amand92.2% had satisfaction with breakfast intake. About 49% had experienced hunger pang in school, of which 72.8% usually occurred between the 11:00am and 1.00pm of the day. Most pupils (94.2%) had access to school living allowance, and most purchased item was drinks and beverages (52.0%). The predominant breakfast meals were rice(61.5%), beans (31.2%) and bread (9.5%). Conclusion: Breakfast habit among school age children in Oyo metropolis was characterized by low but unacceptable level of meal skipping, low intake of fruits, seeds and nuts, and animal based foods including eggs and dairy products.
... While childhood underweight is not as prevalent a concern as childhood obesity, the consequence of being underweight during childhood is inhibited growth and development in the form of stunting or wasting [8]. The National Pre-school Nutrition Survey (2010)(2011) found that only one out of 126 participants aged 3 years of age was classified as thin [7]. ...
Background: Childhood obesity is a growing concern in Ireland. Childhood obesity can increase the risk of developing many non-communicable diseases and have lasting psychological and social consequences. Aim: The aim of this study is to explore if weight at birth and breastfeeding status influence the weight status of 3-year-olds in an Irish cohort. Method: This retrospective cohort study utilised data (National Child Health Screening Programme) on 3-year-olds born between 1 January 2011 and 3 March 2014 in the North West of Ireland. Results: Overall, 4144 children were included in the study. The main findings of this study were that 5.4% (n = 222) and 7.1% (n = 296) of the cohort were overweight or obese respectively with a higher percent of males than females in each category. Just under 55% (n = 2266) of the cohort were never breastfed, with only 7.4% breastfed for greater than 6 months. Those born with a high birthweight were more likely to be overweight or obese at 3 years (p ≤ 0.001). Conclusion: These findings provide regionally specific data and highlight the need for focussed public health efforts to reduce the prevalence of overweight and obesity in children aged 3 years in this area. Interventions from pregnancy through childhood are warranted, with an initial emphasis on breast feeding initiation and maintenance.
... Malnutrition is widespread in developing countries in preschool girls and the condition worsens in the school years. Underweight is mainly related to undernutrition and several other factors which cause an imbalance in calorie intake and expenditure [17]. Due to the ill impacts of this dual burden of abnormal nutrition on population health, it is imperative to understand its prevalence in school-aged girls. ...
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Background A sizable proportion of school-going children from developing countries has abnormal growth parameters, often not standardized with international reference values. We aimed to assess the prevalence of underweight, overweight, and obesity in the schoolgirls of Punjab according to international and local references. Methods In this population-based cross-sectional study, 10,050 school-going girls aged 8–16 years from 12 districts of northern, central, and southern Punjab were recruited. Estimates of normal weight, underweight, overweight and obesity were calculated in the girls according to three international BMI references including centers for disease control (CDC) 2000, the international obesity task force (IOTF) 2012 and world health organisation (WHO) 2007 in addition to a local reference for the population under study. We used Cohen’s kappa statistics to analyse the agreement of our data with reference values. Results There was marked overestimation of underweight (23.9%, 14.5%, 15.2% and 4.37%), slight underestimation of overweight (5.3%, 7.3%, 7.9% and 8.97%) and moderate underestimation of obesity (1.9%, 1.5%, 2.2% and 5.67%) according to CDC, IOTF, WHO and local reference, respectively. When the weight status of the study cohort was compared with the local data, we found comparable results in all four weight categories. Conclusion We recommend population-wide further studies to estimate the prevalence of weight status in school-age girls for devising appropriate references and for planning strategies for public health policy and management.
... alımının ve düşük vücut ağırlığının olumsuz sonuçları özellikle bebekler, okul öncesi çocuklar, yaşlılar, engelliler, kronik hastalıkları olanlar, evsizler, mülteciler ve doğal afetlerden etkilenen insanlar olmak üzere tüm yaş gruplarında görülebilir. Yetişkinlerde zayıflık, BKİ'nin 18.5'in altında olması olarak tanımlanmaktadır (39). ...
The Importance of Ideal Body Weight in the COVID-19 Pandemia Period Obesity is an important public health problem that is common worldwide. With obesity, there is an increase in many diseases, including hypertension, cardiovascular diseases and diabetes, which are risk factors for COVID-19. In 2009, obesity was first defined as a risk factor for disease severity and mortality in infected individuals in the pandemic caused by H1N1 Influenza A virus affecting the upper respiratory tract. Then, Middle East Respiratory Syndrome Coronavirus (MERS-CoV), which emerged in 2012, was also found to be more common in individuals with obesity. These findings, which show that obesity increases the risk of disease severity and death in viral respiratory infections, suggest that obesity may increase the risk of another viral respiratory disease, COVID-19. Studies show that individuals with obesity suffer from COVID-19 disease more severely than individuals with normal body weight, and their intensive care unit needs are higher. Obesity is a risk factor for more severe COVID-19 disease due to a low-grade inflammatory condition and weakened immunity. There are studies in the literature showing that obesity as well as low body weight negatively affect the outcomes of COVID-19 disease. These studies revealed that COVID-19 patients with low body weight are at greater risk of mechanical ventilation and death. It has been observed that low body mass index and low body weight especially in infected elderly individuals increase the severity of COVID-19. Therefore, individuals having ideal body weight can prevent the negative consequences of COVID-19 disease. In addition, healthy nutrition plays an important role in the optimal functioning of the immune system and weight control. Keywords: COVID-19, obesity, underweight, immunity, nutrition
... Nonetheless, malnourished individuals demonstrate a higher risk of infection with enteropathogens [31]. It is, perhaps, due to compromised immune status which increases the susceptibility to enteric infections [32]. As we observed a positive association between Blastocystis and high crowding index, and all of our study participants were malnourished, it may explain the higher prevalence of Blastocystis in this study. ...
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Background Blastocystis spp. ( Blastocystis ) is a widely distributed gastrointestinal protist frequently reported in countries with tropical and sub-tropical climate. We sought to determine the factors associated with Blastocystis infection and investigate its role on biomarkers of intestinal health among slum-dwelling malnourished adults in Bangladesh. Methodology Total 524 malnourished adults with a body mass index ≤18.5 kg/m ² were included in this analysis. Presence of Blastocystis in feces was evaluated by TaqMan Array Card assays. Principal findings Blastocystis was tested positive in 78.6% of the participants. Prevalence of infection with atypical strains of enteropathogenic Escherichia coli (aEPEC) (56% vs. 38%, p<0.001), and Trichuris trichiura (28% vs. 15%, p-value = 0.02) was significantly greater in adults with Blastocystis , while Giardia intestinalis was significantly lower (8% vs. 14%, p-value = 0.04) in Blastocystis positive adults. Malnourished adults who were living in households with high crowding index (aOR = 2.18; 95% CI = 1.11, 4.65; p-value = 0.03), and infected with aEPEC (aOR = 2.14; 95% CI = 1.35, 3.44; p-value = 0.001) and Trichuris trichiura (aOR = 1.97; 95% CI = 1.08, 3.77; p = 0.03) were more likely to be infected with Blastocystis . A significant negative relationship was observed between Blastocystis and fecal concentrations of alpha-1 antitrypsin (β = -0.1; 95% CI = -1.7, -0.1; p-value<0.001) and Reg1B (β = -3.6; 95% CI = -6.9, -3.0; p-value = 0.03). Conclusions The study findings suggest that the presence of Blastocystis in human intestine influences gut health and may have potential pathogenic role in presence of other pathogens.
India has made considerable progress towards tackling child malnutrition since the launch of the ICDS scheme in 1975, with currently 1.3 million centres across the country. The latest NFHS‐5 data (2018–20), however, shows limited improvement in the percentage of stunted, wasted, and underweight children, at 36%, 19%, and 32%, respectively. Given the persistent state of malnutrition in India, we probe, are there more nuances and unexplored dimensions to malnutrition issue that can add to the existing literature and support policy making? Demographic and Health Survey (2015–16) data of 70,618 children between the age of 2 and 5 years, from underprivileged communities in India, were investigated using the Bronfenbrenner's Bioecological Theory Model. Three malnutrition outcome measures were calculated as per WHO standards, namely, height‐for‐age, weight‐for‐height, and weight‐for‐age. Binary and multinomial logistic regression models brought out two noteworthy results, namely, the importance of vaccination and the paradox of maternal working status. Vaccination status positively impacts the outcome measures, and maternal working status demonstrates a paradoxical situation. The children of non‐working mothers had better health statistics, indicating positive impact of a higher amount of time spent on direct childcare. However, working women in poor households bring economic capital to the house, indirectly bringing positive impacts on family health and nutrition. The results also confirmed the significance of maternal and child health status, access to healthcare, and need for dietary diversity. The importance of vaccination, especially in the context of COVID‐19, has been emphasized by policymakers. The policymakers need to relook at the existing welfare programs like ICDS and Creche Scheme to incorporate better‐supporting structures for working mothers for health access and childcare activities.
Background Underweight among adolescents is an important clinical and public health issue. It is associated with adverse health outcomes throughout the life-span and may reflect food poverty, unhealthy eating habits, or some underlying health conditions. Objective To study prevalence and trends in underweight among adolescents 1998–2018, to examine social inequality in underweight, and whether social inequality changed over time. Methods Data were derived from 6 cross-sectional school surveys from The Health Behaviour in School-aged Children study in Denmark. The study included 11-, 13-, and 15-year-old schoolchildren in random samples of schools in 1998, 2002, 2006, 2010, 2014, and 2018 (n = 22,177). Underweight was determined by body mass index-for-age thinness grade 2–3 (the Cole and Lobstein method). Socioeconomic status was determined using occupational social class (the Danish OSC Measurement). Results The overall prevalence of underweight was 3.1% among boys and 5.3% among girls (P < 0.0001) and decreased by age (P < 0.0001) among both boys and girls. The prevalence of underweight was almost stable from 1998 to 2018. There was no observed absolute or relative social inequality in the prevalence of underweight among boys or girls. Conclusion The prevalence of underweight in 11- to 15-year-olds was significantly higher among girls than boys. The prevalence remained stable from 1998 to 2018. There was no significant association between SES and prevalence of underweight. It is important to elucidate the underlying causes of underweight such as malnutrition, eating disorders, eating problems, loss of appetite, chronic diseases, insufficient knowledge of nutrients effects on bodily functions, and persistent pain.
Purpose This study contributes to the growing literature on the association between sleep and obesity by examining the associations between hours of sleep, consistency of bedtime, and obesity among children in the US. Design Analysis of a nationally representative sample of non-institutionalized children from the 2016-17 National Survey of Children’s Health. Setting US, national. Subjects Children ages 10-17 years (n = 34,640) Measures Parent reported weeknight average hours of sleep and consistency of bedtime. Body mass index classified as underweight, normal, overweight or obesity using parent-reported child height and weight information, classified using CDC BMI-for-Age Growth Charts. Analysis Multivariate logistic regression models were used to estimate associations between measures of sleep and body mass index weight category adjusting for individual, household and neighborhood characteristics. Results An additional hour of sleep was associated with 10.8% lower odds of obesity, net of consistency in bedtime. After controlling for sleep duration, children who usually went to bed at the same time on weeknights had lower odds of obesity (24.8%) relative to children who always went to bed at the same time. Conclusion Sleep duration is predictive of lower odds of obesity in US children and adolescents. Some variability in weeknight bedtime is associated with lower odds of obesity, though there were no additional benefits to extensive variability in bedtime.
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Background: The United Arab Emirates (UAE) is one of the developed nations in the middle-east with the obesity rate among the youth two to three times greater than the international standards. Therefore, this research aims to study the variation of perception of the built environment among Emirati male and female adolescents and their parents. Also, the role of determinants of the health condition of Emirati adolescents is analyzed. Method: A total of 335 students (aged 14-20) from six schools in the Al Ain region of Abu Dhabi Emirate and 250 parent responses were used to conduct the mean-test of perception of hindrances and multinomial logit of the health condition using the perception, behavior and built environment measures. Results: Emirati males perceive the built environment factors as barriers more than female adolescents. Parents perceive street-crossing (p<0.016) and sidewalk characteristics (p<0.020) to be more of a hindrance to walking to school than students. Traffic exposure and walkability at home and schools report a significant effect on the health condition of the Emirati adolescents along with the self-reported physical activity. Marginal effect reports sedentary and low-levels of activity predicts the probability of an Emirati adolescent being not just overweight or obese (p<0.001), but also underweight (p<0.05) Conclusion: Recommendations for parents and school authorities, Abu Dhabi Municipality and Urban Planning department, and to enhance the built environment are discussed. Also recommendation to address both, levels of obesity and being underweight, are discussed.
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Abstract Nutritionists, health and food professionals need to be skilled in recognizing the various sources of calories in consumed foods and the implications of excessive caloric intake. Such skills are necessary in order to effectively counsel consumers and patients on food choices & weight management, or to advise food manufacturers to make and market products for better health. This paper will address the growing concern on overweight and obesity epidemic and the risks of excessive consumption of calories from various sources in our food supply, especially obvious and hidden calories. The paper will define what is meant by obvious and hidden sources of calories, with real life examples. Using data from published studies, the paper will discuss how caloric consumption impacts weight gain, obesity, health and wellness. Strategies for recognizing and reducing excessive caloric intake especially from hidden calories will be suggested. Such strategies would include lifestyle changes, dietary habits, physical activity, behavior modification, reading food labels, proper food selection & preparation, food substitution, food processing & consumption among others. A joint action by food consumers and regulators, food manufacturers & marketers, nutritionists, food and healthcare professionals will help consumers in managing weight and in fighting the overweight and obesity epidemic in many populations. Keywords: Hidden calories; Obvious calories; Impact; Obesity; Epidemic; Food choices; Weight management; Health; Wellness
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This study assessed the geohelminth and nutritional status of preschoolers in a periurban community of Ogun state. Fresh stool specimens were collected for laboratory analysis, processed using ether concentration method, and examined under the microscope for geohelminth ova. Demographic characteristics and daily nutrient intake of children were subjectively assessed during an interview session with parents, following anthropometric data collection. Data obtained were analysed using a statistical software for Windows. Nutritional indicators such as underweight, stunting, and wasting were computed from anthropometric data. Results showed an overall prevalence of 39.2% and 12.4% for Ascariasis and Hookworm infection, respectively, with no significant difference ( P > 0.05 ) between the sexes. Prevalence of nutritional indicators was 52.6%, 35.1%, 34.0%, and 9.3% for underweight, stunting, wasting, and thinness conditions, respectively. A good proportion of the malnourished preschoolers were free of Ascaris infection but infected with Hookworm parasite. The adverse effect of geohelminth infection cannot still be ignored in impaired growth, reduced survival, poor development, and cognitive performance of preschoolers. Therefore promotion of adequate health education program on measures of preventing geohelminth infections is needed.
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Background: Stunting increases the risk of obesity in developing countries, particularly in girls and women, but the underlying reason is not known. Objective: Our objective was to test the hypothesis that stunted children have lower energy expenditure than do nonstunted children , a factor that has predicted an increased risk of obesity in other high-risk populations. Design: A cross-sectional study was conducted in shantytown children from São Paulo, Brazil. Twenty-eight stunted children aged 8–11 y were compared with 30 nonstunted children with similar weight-for-height. Free-living total energy expenditure (TEE) was measured over 7 d by using the doubly labeled water method. In addition, resting energy expenditure (REE) was measured by indirect calorimetry and body composition was measured by dual-energy X-ray absorptiometry. Results: There were no significant associations between stunting and any measured energy expenditure parameter, including REE adjusted for weight (x – ± SEM: 4575 ± 95 compared with 4742 ± 91 kJ/d, in stunted and nonstunted children, respectively) and TEE adjusted for weight (8424 ± 239 compared with 8009 ± 221 kJ/d, in stunted and nonstunted children, respectively). In multiple regression models that included fat-free mass and fat mass, girls had significantly lower TEE than did boys (P < 0.05) but not significantly lower REE (P = 0.17). Conclusions: There was no association between stunting and energy expenditure after differences between groups in body size and composition were accounted for. However, the girls had lower TEE than did boys, which may help to explain the particularly high risk of obesity in stunted adolescent girls and women in urban areas of developing countries.
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Key findings: Obesity is associated with health risks (1,2). Monitoring the prevalence of obesity is relevant for public health programs that focus on reducing or preventing obesity. No significant changes were seen in either adult or childhood obesity prevalence in the United States between 2003-2004 and 2011-2012 (3). This report provides the most recent national data on obesity prevalence by sex, age, and race and Hispanic origin, using data for 2011- 2014. Overall prevalence estimates from 1999-2000 through 2013-2014 are also presented.
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Abundances of study in different population have noted that obese cardiovascular disease (CVD) patients have a better prognosis than leaner patients, which refer to the phenomenon of obesity paradox. However, data on the association between body mass index (BMI) and mortality among Asian patients are limited, especially in patients with type 2 diabetes mellitus (T2DM). We investigate the association between BMI and all-cause mortality in Taiwanese patients with T2DM to define the optimal body weight for health. We conducted a longitudinal cohort study of 2161 T2DM patients with a mean follow-up period of 66.7 ± 7.5 months. Using Cox regression models, BMI was related to the risk of all-cause mortality after adjusting all confounding factors. A U-shaped association between BMI and all-cause mortality was observed among all participants. Those with BMIs <22.5 kg/m2 had a significantly elevated all-cause mortality as compared with those with BMIs 22.5 to 25.0 kg/m2, (BMIs 17.5–20.0 kg/m2: hazard ratio 1.989, P < 0.001; BMIs 20.0–22.5 kg/m2: hazard ratio 1.286, P = 0.02), as did those with BMIs >30.0 kg/m2 (BMIs 30.0–32.5 kg/m2: hazard ratio 1.670, P < 0.001; BMIs 32.5–35.0 kg/m2: hazard ratio, 2.632, P < 0.001). This U-shaped association remained when we examined the data by sex, age, smoking, and kidney function. Our study found a U-shaped relationship between all-cause mortality and BMI in Asian patients with T2DM, irrespective of age, sex, smoking, and kidney function. BMI <30 kg/m2 should be regarded as a potentially important target in the weight management of T2DM.
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Ebola virus disease (EVD) has mostly affected economically deprived countries as limited resources adversely affect a country’s infrastructure and administration. Probing into the factors that led to the widespread outbreak, setting forth plans to counter EVD cases in developing countries, and devising definitive measures to limit the spread of the disease are essential steps that must be immediately taken. In this review we summarize the pathogenesis of EVD and the factors that led to its spread. We also highlight interventions employed by certain countries that have successfully limited the epidemic, and add a few preventive measures after studying the current data. According to the available data, barriers to prevent and control the disease in affected countries include irresolute and disorganized health systems, substandard sanitary conditions, poor personal hygiene practices, and false beliefs and stigma related to EVD. The public health sector along with the respective chief authorities in developing countries must devise strategies, keeping the available resources in mind, to deal with the outbreak before it occurs. As a first step, communities should be educated on EVD’s symptoms, history, mode of transmission, and methods of protection, including the importance of personal hygiene practices, via seminars, newspapers, and other social media. A popular opinion leader (POL) giving this information would further help to remove the misconception about the nature of the disease and indirectly improve the quality of life of affected patients and their families. Electronic supplementary material The online version of this article (doi:10.1186/s40249-015-0048-y) contains supplementary material, which is available to authorized users.
Objectives: We analyzed differences in pediatric elevated blood lead level incidence before and after Flint, Michigan, introduced a more corrosive water source into an aging water system without adequate corrosion control. Methods: We reviewed blood lead levels for children younger than 5 years before (2013) and after (2015) water source change in Greater Flint, Michigan. We assessed the percentage of elevated blood lead levels in both time periods, and identified geographical locations through spatial analysis. Results: Incidence of elevated blood lead levels increased from 2.4% to 4.9% (P < .05) after water source change, and neighborhoods with the highest water lead levels experienced a 6.6% increase. No significant change was seen outside the city. Geospatial analysis identified disadvantaged neighborhoods as having the greatest elevated blood lead level increases and informed response prioritization during the now-declared public health emergency. Conclusions: The percentage of children with elevated blood lead levels increased after water source change, particularly in socioeconomically disadvantaged neighborhoods. Water is a growing source of childhood lead exposure because of aging infrastructure. (Am J Public Health. Published online ahead of print December 21, 2015: e1-e8. doi:10.2105/AJPH.2015.303003).