Introduction Malnutrition is a medical condition caused by an improper or insufficient diet.

[23] Malnutrition is technically a category of diseases that includes: undernutrition, obesity and overweight, and micronutrient deficiency among others.[24] However it is frequently used to mean just undernutrition from either inadequate calories or inadequate specific dietary components for whatever reason.[25] People who are malnourished may:

not consume adequate calories and protein for growth and maintenance, such as undernutrition or proteinenergy malnutrition (PEM)[3] consume too many calories (overnutrition)[3] have abnormal nutrient loss (due to diarrhoea or chronic illness) or increased energy expenditure (secondary malnutrition)[3][26]

Malnutrition remains one of the most common underlying causes of morbidity and mortality among children worldwide. Severe malnutrition in children under 5 years of age is the end result of chronic nutritional and, frequently, emotional deprivation by carers. Successful management of the severely malnourished child requires that medical, nutritional and social problems be recognized and corrected. If malnutrition is viewed as being only a medical disorder, the child is likely to replace when he or she returns home, and other children in the family will remain at risk of developing the same problem.

Conventional methods of classifying causes of death suggest that about 70% of the deaths of children (aged 0-4 years) worldwide are due to diarrhoeal illness, acute respiratory infection, malaria, and immunizable diseases. The results from 53 developing countries with nationally representative data on child weight-for-age indicate that 56% of child deaths were attributable to malnutrition's potentiating effects, and 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition. For individual countries, malnutrition's total potentiating effects on mortality ranged from 13% to 66%, with at least three-quarters of this arising from mild-tomoderate malnutrition in each case. These results show that malnutrition has a far more powerful impact on child mortality.

Effect of malnutrition on mortality

Mortality According to the World Health Organization, malnutrition is by far the biggest contributor to child mortality, present in half of all cases.[6] Six million children die of hunger every year.[39] Underweight births and intrauterine growth restrictions cause 2.2 million child deaths a year. Poor or non-existent breastfeeding causes another 1.4 million. Other deficiencies, such as lack of vitamin A or zinc, for example, account for 1 million. Malnutrition in the first two years is irreversible. Malnourished children grow up with worse health and lower educational achievements. Their own children also tend to be smaller. Malnutrition was previously seen as something that exacerbates the problems of diseases as measles, pneumonia and diarrhea. But malnutrition actually causes diseases as well, and can be fatal in its own right.[6]

Causes of malnutrition

Major causes of malnutrition include poverty and food prices, dietary practices and agricultural productivity, with many individual cases being a mixture of several factors. Clinical malnutrition, such as in cachexia, is a major burden also in developed countries. Various scales of analysis also have to be considered in order to determine the sociopolitical causes of malnutrition. For example, the population of a community may be at risk if the area lacks healthrelated services, but on a smaller scale certain households or individuals may be at even higher risk due to differences in income levels, access to land, or levels of education Effect of malnutrition on a child and its growth
Children suffering from severe acute malnutrition are very thin, but they often also have swollen hands and feet, making the internal problems more evident to health workers.[4] Undernutrition in children causes direct structural damage to the brain and impairs infant motor development and exploratory behavior.[106] Children who are undernourished before age two and gain weight quickly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition.[106] Inadequate food intake, infections, psychosocial deprivation, the environment, and perhaps genetics contribute.[28] Children with severe malnutrition are very susceptible to infection Studies have found a strong association between undernutrition and child mortality.[11] Once malnutrition is treated, adequate growth is an indication of health and recovery.[28] Even after recovering from severe malnutrition, children often remain stunted for the rest of their lives.

Physical effects
The physical effects of malnutrition include; Fatigue, low energy and dizziness. Swollen, bleeding gums and decaying teeth. Underweight, muscle weakness and poor growth.

 Poor immune function leaving the body vulnerable to infection. Problems with organ function, that may lead to disease states such as Coronary Heart Disease or Osteoporosis Insulin-resistance resulting from a diet with low nutritional value, eg high fats and sugar content, can result in Diabetes. Diseases such as Marasmus and Obesity result from under, or over, eating respectively. Poor cognitive functions such as learning memory and attention. Cancer risk is increased by eating certain foods and additives that are high in carcinogens Effect of malnutrition on brain development Malnutrition not only harms the body but leaves an imprint on the minds of those who survive it. Research has revealed that poor diet during early development (0-3yrs) leads to learning and memory deficits, lower IQ and school achievement, and behavioral problems in childhood and adolescence (Mcgregor, (1995), Lui et al, 2005). There has also been links between food deficiencies and mental health problems in young people. Conditions such as ADHD, Bipolar Disorder and Schizophrenia, seem to involve functional deficiencies of certain highly unsaturated fatty acids, such as Omega-3 (Richardson et al., 2005). Furthermore, researchers have found that antisocial behavior in prisons, including violence, can be reduced by supplementing diets with vitamins, minerals and essential fatty acids (Gesch et al., 2002). This research provides important evidence for the beneficial effects, both to individuals and society, of ensuring that our children receive the nutrition they deserve.

What should be done? development, and healthy tissue and organ function. Whilst malnutrition can have severely damaging consequences for health and wellbeing, scientific research demonstrates that improving the nutritional status of poorly nourished children can have therapeutic effects. It is important that we recognize this need and stop hunger from ruining the lives of our most vulnerable children. Kids Company is committed to supporting the emotional and practical needs of vulnerable children and to campaigning for the way in which vulnerable children are supported throughout the U.K. Kids Company are working with other third sector organisations such as FARESHARE the TRUSSELL TRUST and The School Food Trust to help reduce the nutritional aspect impact of poverty and deprivation. www.fareshare.org.uk www.trusselltrust.org

case study

News UK news Crime

The tragedy of Khyra Ishaq's death

The tragedy that befell Khyra Ishaq is hard to take. The seven-year-old starved to death as bowls of fresh fruit, tins of sweets and shelves of groceries filled the kitchen of her family home. A lock had been fitted high up on the kitchen doors to keep Khyra and the four other children in the house away from the food. If the children were caught taking any of the food they were made to stand outside in the cold, and were beaten or forced to overeat until they vomited. At the time of her death, in May 2008, Khyra weighed 16.8kg (2st 9lb). She had lost about 40% of her body fat, and her body mass index was so low it was off the bottom of the scale of medical charts. Two other children at the house in Handsworth, Birmingham, who cannot be identified for legal reasons, were also found in a serious state of malnutrition and at risk of dying. Only her mother, Angela Gordon, and Gordon's partner, Junaid Abuhamza, know why Khyra and the other children were not fed, but there were many warning signs that something was seriously amiss in the months beforehand. Khyra had been withdrawn from school by Gordon, who was said to be educating the child at home. Her emaciated body had 60 injuries, the outcome of a sadistic regime which included punishment beatings, cold baths and being forced to overeat until she was sick. A neighbour believed Khyra scavenged stale bread she left out for the birds. Gordon claimed Khyra was adequately fed. However, this assertion was part of an elaborate lie designed to convince the authorities that nothing was amiss. In January 2000, Suraj Ahmed, a doctor at Birmingham city hospital, examined a seven-year-old boy who lived at the house after teachers expressed concern about his welfare. "He was searching cupboards looking for food as soon as he got into school," Ahmed said. "At lunchtime, he would grab food from other children's plates and eat it, and that was a cause of concern for the school staff." His weight was below average.

Ahmed pointed out to Gordon that the child was not getting enough calories and suggested a dietician was consulted, but she rejected this advice and said she did not want the school feeding him any snacks without her permission. During a brief stay in hospital, the boy would constantly approach people and ask them for food. A 12-year-old girl who also lived at the house recalled the regime. "Khyra stole bread from the kitchen or something from the cooker," she said. "Junaid told her 'you've won a prize, you've got a nice treat'. He gave her a jar of chocolate and told her to eat it all. It made her feel really ill and it made her vomit." Another child recalled Khyra being asleep in her mother's lap two days before her death. Gordon was spraying her daughter's face with water, but she did not wake. In the days leading up to her death, he said, he could see the bones through her skin as she slept. The children, he said, took lessons in the lounge and were punished if they did not answer correctly. Screams and cries of "let me out" had reportedly been heard coming from the house. One neighbour said she saw Khyra whimpering in the back garden before her death, dressed just in her underwear. A forensic pathologist who carried out a postmortem examination on the seven-year-old found 60 marks, 34 of which could have happened in the week before her death. Eight were consistent with being struck by a cane. Roger Malcolmson, the doctor who examined Khyra's body, said he had never seen such a high fat loss. "It was shocking, in fact, to see her for the first time." He described how the joints of her elbows were particularly prominent and her face was sunken. There was little skin fat and her jawbone was prominent. Khyra's maternal grandmother, Eartha Gordon, last saw her in January 2008. She said Gordon had used a variety of excuses to avoid contact. "She would say one of the children was sick or had the flu. One time she said they were decorating that the place was in a mess and it was not suitable for anyone to come around." She said she met Khyra's stepfather, Abuhamza, once but was unaware he was living in the house. Abuhamza himself had "lived in a harsh and punitive environment" as a child, Birmingham crown court had heard earlier. He said his father beat his three-year-old sister to death for failing to flush the toilet. He was punished by being deprived of meals and several times was caught stealing food at school. The court ruling told of his "strong belief" in evil spirits. It described Gordon as feisty and outspoken but often "highly dependent upon the men in her life". At one point she took up a "healthy eating" diet. "Food was an issue for her and she seemed unable to understand that whilst

it may well have been appropriate for her to lose weight, it was certainly not appropriate for these growing children to do the same," said the ruling. Food was intimately connected to behaviour in the home and Khyra told a teacher "of getting nice porridge if she is good and horrible porridge if she is bad". Detective Inspector Sean Russell, who investigated Khyra's starvation, said the harrowing nature of her death had made the most hardened officers cry. He believed the little girl had been kept a prisoner in a bedroom. "The very people who should have been looking after Khyra, her mother and Junaid Abuhamza, killed her through systematic abuse." Khyra, the officer noted, had suffered beatings and been starved while isolated from other children for whom her mother was also responsible. "The defendants created a situation in which the children, who were being educated at home, had been kept away from their extended family, friends and the outside world. They were also prevented from doing the things that an ordinary child does. Khyra's untimely death was ultimately caused by an overwhelming infection brought on by severe malnutrition a cause of death you don't expect to see in the western world, let alone Birmingham, in the 21st century."