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A systematic review of obstacles to treatment of adult undernutrition

Summary of MMedSci research1

By Claire Bader

Since graduating as a Registered Nurse in 1995, Claire has spent over 12 years working in a variety of health and nutritional programmes throughout Africa. She is an appointed member of the Isle of Man Overseas Aid Committee and has recently joined the Save the Children team in Sierra Leone as their Health Advisor.

Claire would like to acknowledge her dissertation supervisor, Dr Tony Blackett, for his support through the process and also to Dr Peter King for inspiring her to share my work.

This research dissertation reviewed some of the obstacles to treatment of adult undernutrition in adults – particularly in a humanitarian context, where inclusion of adults in nutritional response programmes remains limited. It is important to identify what are the common obstacles experienced by humanitarian health professionals around the provision of care for adults with undernutrition during emergency response programmes.

This issue is not new. In 1999, Salama and Collins reviewed the humanitarian response in Bahr a Ghazal in South Sudan (1999) where adult undernutrition had presented itself as a large challenge2. The highlighted key issues underpinning why international non-governmental organisations (INGOs) were not considering adults for nutritional treatment projects:

The review concluded that despite gaps in guidance and capacity, it is certain that in famine situations, adult malnutrition is a public health problem and that successful adult treatment is possible and is essential for the survival of individuals and communities. The South Sudan response in 1999 failed in this regard.

Thousands of Somalis have been displaced by what is described as the worst floods in the country in 10 years.


For this latest review, reports and documents were collected using the words ‘adult’ ‘malnutrition’ and ‘humanitarian’ from a variety of sources and websites. Literature in both English and French were selected. The inclusion criteria were literature reviewing nutritional responses in the context of a humanitarian emergency and relating to adolescents and adults including those older than 65 years of age. Given the wide range of types of papers and methods of research involved, the Critical Appraisal Skills Programme (CASP) tool (2006)3 was selected and adapted to screen the literature.

A key limitation was that much of the literature existed as grey literature, e.g. on agency websites and accessed through internet searches. There were very few peer review publications. Also, the majority of reports on undernutrition focus solely on children under the age of 5 years. Occasionally, reports include a token reference to adults in relation to the impact childhood chronic undernutrition has later in life or on women in relation to infant nutritional status (PLW).


A total number of 2,280 reports were identified and screened. Of these 2,280 reports, approximately 107 were eligible for the final detailed screening. Of the 107 reports, 105 were written in English and only 2 (1.5%) in French.

All 107 documents were screened a second time using the detailed questions on the CASP tool, narrowing down the final selection to 38 reports all published or released between January 2000 and February 2011. These final 38 reports met the proposed selection criteria for the review, all involved an actual type of research methodology and showed a higher quality of robust research methods or reflection on programmatic practice.

Fourteen (37%) of the selected reports focused on reviews of emergency response programmes and 24 (63%) were nutritional reviews or focused on nutrition research. Analysis of the 38 selected reports revealed that 19 (47%) were written by individual authors or teams of researchers, 13 (37%) by INGOs and 6 (16%) by international organisations (UN, donors and institutions). Reports reflected programming/research in Kenya, Sudan, Ethiopia, Niger, Chad, Malawi and Guinea, Haiti and Myanmar.

The author assumed that most of the obstacles noted by Salama and Collins in 1999 would emerge in this review. However, on screening the 38 documents, the findings were surprisingly different. The main obstacles identified in this review were 'weak coordination”, “limited resources”, “poorly integrated response” and “weak human capacity”. These obstacles combined to a total of 72.5% of all the points noted. “Weak coordination” was noted most frequently (23.5%) and “weak human capacity” was rated 4th (14%). Other obstacles noted were continuing lack of standardised adult treatment guidelines and diagnostic criteria, lack of focus and interest in adults with overall priority given to children under 5 years of age, and adults regarded as a national government responsibility, not one for INGOs. Each of these obstacles scored 7% or less.


Prior to this systematic review, it was presumed by the author that the lack of recognised international adult treatment guidelines or assessment tools that was directly affecting the implementation of nutritional care for this age group. However the results suggest that guidelines and tools are widely available and accessible, but it is the training and subsequent ability of health care workers to regularly use them that is not adequate. Signs of poor nutrition in adults are easily confused with the symptoms and presentations of chronic illness and old age, as such it is often felt that these adults should be cared for within the national health system rather than as part of emergency response facilities. However, national nutrition departments remain under funded and under staffed in many developing countries and may have challenges coping with the extra burden in an emergency context.

Identification of limited resources as an obstacle relates not only to the limitation of funding to enable the inclusion of adults, but also to the type and quantity of nutritional resources available. Access to treatment products for adult undernutrition itself will remain a challenge until funding opportunities are increased and specific nutritional products for adult undernutrition are developed.

The review suggests that there is still a lack of information and understanding around the scale, depth and causes of adult undernutrition and that this is still not being addressed through early warning systems and nutritional surveys. A number of reports advocate for greater funding to enable both the wider collection of information and the implementation of essential packages and community safety nets.

Thirteen out of the 38 reports reviewed identified weak coordination as an obstacle, with many raising issues around cluster coordination and sharing of information between cluster partners.

The obstacles highlighted above are interlinked and impact on each other, e.g. without effective coordination, sharing and maximising of resources and human capacity development may not be needs based and may be inequitable.


There are five main recommendations that emerge from this review:

It is important that clarity on the inclusion of adults within Nutrition Cluster coordination is reached and agreed, leading to strengthened coordination around programming and information sharing.

Increased flexibility of funding for INGOs will enable them to implement a broader integrated response package to include vulnerable adults and interventions that address the dietary coping mechanisms that often lead to micronutrient deficiencies in women, teenagers and older adults in particular.

Greater efforts and resources are needed to help develop an adult version ready to use therapeutic food (RUTF) that would enable treatment regimens to be adult specific. Under the present recognised treatment guidelines, the volume of RUTF or fortified milk required by adults to be consumed per day is large and often leads to non-compliance.

A key priority is to enhance capacity building programme in treatment and prevention of undernutrition for adults and the elderly. It is important to build the confidence of health workers in differentiating symptoms of acute weight loss or micronutrient deficiencies from other chronic health problems or general effects of old age.

Finally, as the majority of nutritional assessments focus on the under 5 age group, it is often difficult to estimate the nutritional challenges faced by older members of the communities. Until more systematic collection and analysis of data on teenagers, adults and older people is undertaken, an accurate overall picture of the spectrum of hidden vulnerability will continue to elude humanitarian organisations and donors.

For more information, contact: Claire Bader, email:

Show footnotes

1Bader C (2011). Obstacles to treatment of adult undernutrition: A systematic review submitted (June 2011) as part requirement for the MMedSci in Advanced Nursing Studies from Sheffield University. Copies of the full dissertation are available on request.

2Salama, P and Collins, S. (1999). An Ongoing Omission: Adolescent and Adult Malnutrition in Famine Situations. Field Exchange. ENN. (Issue 6). p19. [Online] Available from: [Accessed 30th March, 2010].


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Claire Bader (). A systematic review of obstacles to treatment of adult undernutrition. Field Exchange 44, December 2012. p14.



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