When we began this work, “malnutrition” was something the clinical world thought it already understood. But in practice, I was seeing a very different picture. In clinic after clinic, patient after patient, some people did not fit the conventional definitions of malnutrition — they ate enough (sometimes more than enough), their lab results were not alarming, and yet they were tired, slow to recover, prone to infections, and showing subtle but accelerating functional decline.

The term we eventually proposed — Exposure-Related Malnutrition (ERM) — grew from that gap between observation and definition. It was clear that chronic stress, environmental exposures, and metabolic strain could gradually reallocate the body’s limited energy and nutrient resources toward short-term survival, leaving long-term maintenance and repair underfunded. This wasn’t malnutrition caused by famine — it was malnutrition hidden in plain sight.

The untold journey

This paper represents years of weaving together three threads:

1. Clinical observation from more than 1,000 patient cases.

2. Mechanistic science from fields as diverse as stress physiology, mitochondrial biology, and nutrition.

3. A conceptual need to give this pattern a name, a framework, and a place in the malnutrition landscape.

The biggest challenge?

Explaining a problem that is not yet in the textbooks — one that requires seeing patterns, not just points, in the data. We had to resist the temptation to oversimplify. Instead, we proposed ERM as a phenotype: a distinct but reversible state of maladaptation under bioenergetic constraint, recognizable by its trade-offs across survival, housekeeping, and long-term functions.

Why a publication matters

Publishing in Biogerontology, one of the top journals in aging research, was more than an academic milestone. It was a way to place ERM in front of an audience that understands the importance of early, subtle shifts in physiology — the kind that often precede frailty, immune dysfunction, or sarcopenia by years. The peer review process was rigorous, forcing us to refine the definition, clarify its boundaries, and strengthen its alignment with the hallmarks of aging.

What comes next

This paper is the first peer-reviewed documentation of ERM, but it’s not the end of the story. We are now:

• Conducting a systematic review to map biomarker patterns of ERM across the literature.

• Analyzing retrospective clinical trial data from thousands of cases to validate and stage ERM.

• Exploring how ERM interacts with interventions in chronic disease, aging, and resilience medicine.

We hope that by naming ERM, we open the door to earlier recognition, better prevention, and ultimately, a shift in how clinicians and researchers think about resilience under chronic stress.

If you’ve ever felt that some patients “fall through the cracks” of conventional nutrition and aging models, ERM might be the missing piece. And this paper — while only the beginning — is our first step toward making that piece visible, measurable, and treatable.