More than 18 million women in low- and middle-income countries around the world are severely undernourished, according to the first global estimate published in a new study from St. Michael’s Hospital and Harvard T.H. Chan School of Public Health. These women tend to be the poorest and least educated members of society and comprise a “left behind” population of adults with severe undernutrition whose needs have not been met by economic gains and progress and who have been understudied by health researchers.

The study will appear online November 24, 2015 in JAMA.

“What surprised us was the number of women suffering from severe undernutrition despite the fact that the prevalence of being overweight or obese has risen in most of the countries we looked at,” said lead author Fahad Razak, scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Canada, and visiting scientist at the Harvard Center for Population and Development Studies. “What was also striking was that there was no decline in the prevalence of severe adult undernutrition in the past two decades in the majority of countries.”

This was the first broad global study of severe chronic adult undernutrition, which is defined as having a body mass index (BMI) less than 16. Very low BMI has serious adverse health impacts, including decreases in muscle strength and ability to work.

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