At the end of this lesson you will be able to: Learning objectives At the end of this lesson you will be able to: define the concept of malnutrition; identify the factors influencing nutritional status; and be aware of the relationships between nutrition, food security, health and mortality.

What are the factors affecting an individual’s nutritional status? Introduction What are the factors affecting an individual’s nutritional status? Understanding these factors is essential in order to: assess malnutrition, design programmes which tackle nutrition problems, and correctly inform programme management and evaluation. Notes for trainers: Understanding malnutrition is also important as it carries heavy costs on individuals and households, communities and nations. In fact, due to malnutrition, millions of lives are destroyed by death and disability, both mental and physical. Besides being morally unacceptable, this implies economic costs, in terms of lost productivity and income caused by premature death, lower physical capacity, absenteeism and lower educational and occupational opportunities.

The term malnutrition indicates a bad nutritional status. What is malnutrition? The term malnutrition indicates a bad nutritional status. Nutritional status is the physiological state of an individual, which results from: the relationship between nutrient intake and requirements, and the body’s ability to digest, absorb and use these nutrients. Notes for trainers: Malnutrition refers to all deviations from adequate nutrition, including undernutrition, overnutrition and specific deficiencies (or excesses) of essential nutrients such as vitamins and minerals.

Malnutrition Undernutrition What is malnutrition? A distinction must be made between Malnutrition and Undernutrition: It arises either: from deficiencies or excesses of specific nutrients, or from undiversified diets (wrong kinds or proportions of foods). Malnutrition It is the outcome of insufficient food. It is caused primarily by an inadequate intake of dietary or food energy. Notes for trainers: Malnutrition may arise from imbalance, excesses or deficiency of specific nutrients, for example, iodine, vitamin C, iron and vitamin A. Undernutrition is defined as a dietary energy intake below the minimum requirement level to maintain the balance between actual energy intake and acceptable levels of energy expenditure. “Malnutrition" and "undernutrition" are terms generally used interchangeably, and they often both refer to nutritional situations that are typical in populations belonging to the low-income and poor socio-economic groups of developing countries. Undernutrition

This phenomenon is referred to as the “double burden” of malnutrition. What is malnutrition? In many developing countries, under and overnutrition are occurring simultaneously among different population groups. This phenomenon is referred to as the “double burden” of malnutrition. Notes for trainers: The “double burden” of malnutrition The “double burden” of malnutrition refers to the co-existence of undernutrition, micronutrient deficiencies, overweight/obesity and other nutrition-related chronic diseases in the same countries, in the same communities and even in the same households. This phenomenon is not limited to upper-income developing countries, but is occurring across the globe in countries with very different cultures and dietary customs. When poor economic conditions improve, amounts and variety of food consumed tends to rise and mortality rates of infant and young children tend to fall as communicable diseases are more successfully put under control. This may be accompanied by rises in obesity and diet related non-communicable diseases which may co-exist with high levels of child undernutrition.

Poverty is the root cause of malnutrition. Causes of malnutrition Poverty is the root cause of malnutrition. (The underlying causes are food security, health and care). However, overnutrition and dietary imbalances cut across many socio-economic boundaries. Notes for trainers: Most micronutrient deficiencies primarily affect poor and disadvantaged households whose members cannot produce or procure adequate food, who live in marginal or unsanitary environments without access to clean water and basic services, who lack access to appropriate education and information, or are otherwise socially disadvantaged.

Causes of malnutrition Nutritional status is influenced by multiple and interrelated factors. The most important factors can be grouped under these broad categories: FOOD HEALTH CARE Notes for trainers: FOOD: The availability of, access to and consumption of adequate quantities of safe good quality nutritious food is an important factor influencing nutritional status.Nutritional well-being is influenced by the nutrient content of food consumed and its absorption by the body, in relation to other requirements determined by age, sex, level of physical activity and health status, as well as the efficiency of nutrient utilization by the body. HEALTH: Health and sanitation are essential for nutrition, yet they are beyond the reach of the majority of the world's population. Infectious disease and inadequate diet act together, each aggravating the effects of the other to produce what is referred to as the "malnutrition and infection cycle". Nutritional requirements are higher during and following episodes of infection. Chronic or frequent acute infections make it almost impossible to maintain adequate nutritional status. CARE: Care and feeding practices require time, attention and support and are essential to meet the physical, mental and social needs of individuals. The knowledge, attitudes and practices of household members largely determine the nutritional status of the household. An incomplete understanding of the body's nutritional needs and lack of knowledge of how to meet these needs with available foods can lead to malnutrition.

Food, health and care are interrelated: Causes of malnutrition Food, health and care are interrelated: actions affecting one area may have significant consequences on another. Development policies usually are not included in the domain of nutrition as such. However, they impact considerably on the nutritional well-being of the population. Notes for trainers: Food, health and care are interrelated, and actions affecting one area may have significant consequences on another. For example: Adoption of sustainable and labour-saving agricultural technologies may influence nutrition not only through improved food supplies and income, but also through their beneficial impact on sanitation and health and on the time available for providing care to household members. The effects of development policies Their effects may be monitored on food, health and care.

Conceptual frameworks This is the most commonly used framework for understanding the causes of malnutrition. (adapted from the UNICEF conceptual framework). Notes for trainers: This framework sets out causes that operate at three levels: immediate, underlying and basic, whereby factors at one level influence other levels. For instance: Diarrhoea. Immediate cause Restrictive land holding policies. Basic cause Malaria. Immediate cause Diets with low vitamin A content. Immediate cause Ethnic bias in government resource allocation. Basic cause Poor breast-feeding practices. Underlying cause.

Another conceptual framework for malnutrition: Conceptual frameworks Another conceptual framework for malnutrition: the Food Insecurity and Vulnerability Mapping System (FIVIMS) framework for food security, livelihoods and nutrition. Socio-economic and political environment Care practices Food consumption Performance of the food economy: availability access stability Nutritional status Notes for trainers: The key difference between the UNICEF and FIVIMS framework is that the latter gives a greater centrality to food availability, access, consumption and utilization and their determinants. However, health and sanitation and care practices still occupy an important place within the framework. Food utilization Health and sanitation

Let’s see these relationships more in detail... Nutritional status, health, mortality and low birth weight It is important to consider the relationships between nutritional status and health status, mortality and low birth weight. NUTRITIONAL STATUS HEALTH STATUS NUTRITIONAL STATUS MORTALITY NUTRITIONAL STATUS LOW BIRTH WEIGHT Notes for trainers: Nutritional and health status: there is a ‘vicious cycle’ in which malnutrition and diseases influence each other. Nutritional status and mortality: mortality increases exponentially with declining nutritional status. Nutritional status and low birth weight: inadequate maternal nutritional status is the most significant cause of low birth weight. Let’s see these relationships more in detail...

Nutrition and health are closely linked: Nutritional and health status Nutrition and health are closely linked: NUTRITIONAL STATUS disease contributes to malnutrition HEALTH STATUS while malnutrition makes an individual more susceptible to disease. This can eventually lead to severe malnutrition and death.

This ‘vicious cycle’ is known as the “malnutrition-infection cycle”: Nutritional and health status This ‘vicious cycle’ is known as the “malnutrition-infection cycle”: INADEQUATE DIETARY INTAKE Weight loss, growth faltering and reduced immunity, which lower the body’s ability to resist infection. leads to this causes this results in Loss of appetite, malabsorption of nutrients, altered metabolism and increased nutrient needs. Longer, more severe and more frequent disease episodes. leads to

Nutritional and health status Certain diseases are particularly frequent causes of poor growth, for example: diarrhoea, respiratory infections, HIV/AIDS and malaria. Notes for trainers: Certain diseases may predispose a person to certain types of malnutrition; vice versa, certain types of malnutrition may predispose a person to certain types of infection. For example, lack of vitamin A can predispose a person to measles. The relationship between nutrition and infection is also affected by the type of caring that takes place for sick individuals.

Nutritional and health status The relationship between nutrition and disease can be observed in the seasonal changes in nutritional status. Many communities experience periods in the year when malnutrition levels are higher. These are influenced by seasonal patterns such as: cropping patterns, food availability, disease, child care, income sources, price of foods, labour demand. Notes for trainers: Seasonal changes in nutritional status are more evident in rural populations, especially when they depend on a single harvest. These expected changes in malnutrition need to be taken into account when interpreting changes in observed rates of malnutrition. However, the seasonal peaks of malnutrition coincide not just with the hungry season, when food may be in most scarce supply, but also when the frequency of certain diseases is highest, particularly diarrhoea and malaria.

Mortality increases exponentially with declining nutritional status. Nutritional status and mortality Mortality increases exponentially with declining nutritional status. NUTRITIONAL STATUS Many factors that impact mortality are often compromised in situations of conflict and displacement. In emergencies there may be varying levels of mortality associated with the same level of malnutrition. MORTALITY Notes for trainers: In fact, the relationship between malnutrition and mortality is not linear but increases exponentially. For example, In 1991 during the northern Iraq refugee crisis, a survey of Kurdish refugees found a prevalence of acute malnutrition among under-fives of only 4.3% (which is low) but a crude mortality rate (CMR) of 3/10,000/day, which is very high. Most deaths were due to diarrhoea and dehydration. Consequently, mortality rates cannot be predicted from prevailing rates of malnutrition.

The most significant cause is poor maternal nutrition. Nutritional status and low birth weight NUTRITIONAL STATUS LOW BIRTH WEIGHT It is estimated that each year 24 million babies are born with low birth weight (LBW)-less than 2.5 kg. Ninety five percent of these events occur in developing countries. The most significant cause is poor maternal nutrition. Notes for trainers: LBW puts infants at greater risk of neonatal death and is a major cause of poor growth and development in later childhood. Undernutrition in utero is also associated with certain chronic diseases in adult life. The most significant cause for LBW is poor maternal nutrition: however, there is also a number of other factors, such as a woman’s small size, uterine infections, smoking and malarial infection.

The cycle of poor nutrition perpetuates itself across generations. Nutritional status and low birth weight The cycle of poor nutrition perpetuates itself across generations. This diagram by the Standing Committee on Nutrition shows the intergenerational cycle of growth failure: Child growth failure Low weight and height in teenagers Low birth weight baby Early pregnancy Small adult woman

Summary Malnutrition refers to all deviations from adequate nutrition, including undernutrition (and overnutrition) resulting from inadequacy (or excess) of food. Malnutrition carries heavy human and economic costs on individuals and households, communities and nations. Malnutrition and undernutrition are often used as synonyms. However, a clear distinction needs to be made at all times. The co-existence of undernutrition, micronutrient deficiencies, overweight/obesity and other nutrition-related chronic diseases occurs in the same countries, in the same communities and even in the same households throughout the world today, posing one of the greatest challenges to national policy makers. This phenomenon is referred to as the “double burden” of malnutrition. Even if poverty is the root cause of undernutrition, malnutrition has multiple and interrelated causes. The direct causes of malnutrition can be grouped under the broad categories of: food, health and care.

If you want to know more... Nutrition and development: a global challenge - adapted from Nutrition and development - a global assessment, written by FAO and WHO for the International Conference on Nutrition, 1992. United Nations Standing Committee on Nutrition/Administrative Committee on Coordination (ACC/SCN) Second report on the World Nutrition Situation: Vol.1: Global and Regional Results, ACC/SCN Geneva, 1992. The double burden of malnutrition – Case studies from six developing countries. FAO Food and Nutrition Paper 84, Rome 2006. http://www.fao.org/docrep/009/a0442e/a0442e00.htm Measurement and Assessment of Food Deprivation and Undernutrition - FIVIMS Proceedings, International Scientific Symposium held in FAO, Rome 26-28 June 2002. FAO 2003. http://www.fao.org/DOCREP/005/Y4249E/Y4249E00.HTM Conducting small-scale nutrition surveys: A field manual. FAO, 1990, 186p, English, Spanish, French ISBN 202851. http://www.fao.org/docrep/009/a0442e/a0442e00.htm#Contents Body mass index - A measure of chronic energy deficiency in adults. FAO Food and Nutrition Paper 56, 1994. http://www.fao.org/docrep/T1970E/T1970E00.htm

If you want to know more... United Nations Standing Committee on Nutrition Issue No. 33 Diet-related Chronic Diseases and the Double Burden of Malnutrition in West Africa, 2006, pages 18-20. http://www.unsystem.org/scn/Publications/SCNNews/scnnews33.pdf. Incorporating Nutrition Considerations into Development Policies and Programmes: Brief for Policy-Makers and Programme Planners in Developing Countries, FAO 2004. http://www.fao.org/docrep/007/y5343e/y5343e00.htm The State of Food Insecurity in the World (SOFI): monitoring progress towards the World Food Summit and Millennium Development Goals (FAO-SOFI, 2004) http://www.fao.org/docrep/007/y5650e/y5650e00.htm