Session 3: The Causes of Malnutrition

This session describes the causes of malnutrition, using a widely accepted framework.

After completing Session 3, you will:

 Know the immediate, underlying, and basic causes of malnutrition

 Be able to explain these causes in detail

Causal Framework for Malnutrition

The causes of malnutrition are complex and interrelated, and
operate at different levels, from individual to societal. Good
nutrition requires more than just food—care, health, and hygiene also
influence nutrition outcomes.

For more than two decades, nutritionists have used the UNICEF
Causal Framework for Malnutrition to explain the multiple factors and
relationships that lead to malnutrition.

The framework divides the causes of malnutrition into three main

causes:

 Immediate causes, which relate to an individual’s dietary intake and

health status
 Underlying causes, which relate to the practices and services in
households and communities
 Basic causes, which relate to the economic, societal, and
cultural influences that affect nutrition

Immediate Causes of Malnutrition

The immediate cause of undernutrition is inadequate dietary intake or illnesses and other health conditions—or
sometimes both.

Inadequate dietary intake can be a result of consuming too little food overall or a diet that lacks diversity or is
missing key nutrients.

Disease and infection can increase a person’s nutrition requirements, reduce appetite and food intake, and
affect how the body absorbs nutrients, leading to malnutrition. Causes related to nutrient intake and health status
are closely related and affect each other in a number of ways.
 Spotlight on Immediate Causes: Nutrition
and Infection

Nutrition and infectious diseases work in a vicious cycle, often occurring at the same time.

Individuals who are malnourished are more susceptible to illness, and have a reduced ability to fight off infection.
When a malnourished child becomes ill, they are more likely to die of the illness than a well-nourished child.

Illness can also lead to reduced appetite, increased need for nutrients, and reduced absorption of nutrients in the
body.

Good nutrition and care during illness are critical for children under 2 years of age, when infections are most
frequent. These children require additional foods and fluids, both during the illness and for catch-up growth after
the infection has been resolved.

Nutrition and HIV

HIV and nutrition are closely linked. People living with HIV and AIDS are at greater risk of malnutrition for a number of
reasons, including reduced food intake due to:

 Appetite loss or difficulties in eating

 Poor absorption of nutrients due to diarrhea

 Changes in metabolism

 Chronic infections and illness

Adequate nutrition can improve health and quality of life for people with HIV and AIDS.

Did You Know?

A child with severe wasting is 6 times more likely to die of diarrhea than a well-nourished child, and almost 9 times
more likely to die of pneumonia.

Underlying Causes of Malnutrition

The next level in the causal framework describes the underlying causes of malnutrition. These underlying
causes often act at the household or community level to influence whether an individual can achieve a healthy
diet and good health.

These underlying causes of malnutrition can be grouped into three broad categories:

 Food: Availability, access, affordability, and consumption of sufficient, safe, and nutritious foods
 Care: Household practices and care of family members, especially children and pregnant and lactating women
 Health: Availability, access, and use of health services and a safe and hygienic household environment

Key Resource
It is not always easy to determine exactly how, and to what extent, these different underlying causes are responsible
for poor nutrition. Good quality assessments can help determine which underlying causes are likely to be the most
significant in a given context. The Nutrition Program Design Assistant (PDF, 3.8 MB) is a useful tool for understanding
the nutrition situation in a given area, and allows program designers to prioritize different areas for intervention.

Spotlight on Underlying Causes:

Emergencies and Resilience
Malnutrition—especially when it results in wasting—is often associated with emergencies. In an emergency,
access to food and health care is often disrupted, especially if people are displaced. Breastfeeding practices
may be undermined by inappropriate donations of breastmilk substitutes. Crops and food stocks may be
destroyed, and environmental conditions can lead to high rates of illness. Even if food is available in markets,
poor households may be unable to afford it.

Many households become trapped in a cycle of poverty due to recurrent shocks and hazards. These shocks are
not always big emergencies. For a very poor family, small shocks such as a poor harvest, pest infestation, or the
death of a family member can have dramatic and long-lasting economic effects.

Many programs now recognize that long-term improvements in nutrition are not possible if households are
frequently subjected to shocks, and/or are unable to recover after a shock has
occurred. Resilience programming seeks to reduce chronic vulnerability by improving individual and community
ability to mitigate, adapt to, and recover from shocks.

Highlight

USAID defines resilience as the ability of people, households, communities, countries, and systems to mitigate, adapt
to, and recover from shocks and stresses in a manner that reduces chronic vulnerability and facilitates inclusive
growth.

Basic Causes of Malnutrition

The basic causes of malnutrition are the human, structural, and financial resources available for nutrition, and
the political, legal, and cultural factors that determine how these resources are used. For example, basic causes
of malnutrition may include gender norms that leave women at a disadvantage for resources and care;
widespread poverty or income inequality; or a policy environment that is not conducive to making nutritious food
widely available.

Because the pathway from these basic causes to the direct causes of illness and food intake is long and
complicated, it often isn’t possible to directly manipulate the basic causes of malnutrition and see a change in
nutrition outcomes. However, these causes act as a barrier to improved nutrition, and it is unlikely that significant
improvement in nutrition will occur if they are not addressed.
Spotlight on Basic Causes: Poverty
and Nutrition
Poverty and nutrition are closely related. In low-income countries, children are 2.5 times more likely to be
stunted if their household falls within the lowest wealth quintile, compared to children from the highest-quintile
households.

Malnutrition is not just a consequence of poverty: Poor nutrition can also lead to higher levels of poverty in a
population. On average, children who are stunted will earn 20% less as adults, and will achieve 1 year less of
education, leading to reduced overall economic productivity.

Poverty and obesity have a complicated relationship, which depends very much on the cost and availability of
food and health services within the country. For example, in many high-income countries, poor households are
more likely to experience obesity. In low- and middle-income countries, the opposite is true, with wealthier
households more likely to experience obesity.

Trends around the world have shown that, in most countries, as national GDP (gross domestic product)
increases, the rates of overweight and obesity also rise. On the other hand, undernutrition decreases as GDP
rises, but the decline has not been happening as quickly as the rise in obesity, leading to a double burden of
overnutrition and undernutrition in many countries.

Sources: Black et al. 2013; de Onis and Branca 2016

Highlight

Reducing poverty can lead to better nutrition, but it is not a direct relationship: A 10% increase in GDP per person
predicts a 5.9% reduction in stunting (95% confidence interval 4.1–7.6).

Sources: Ruel et al. 2013

Session 3: Knowledge Recap

You got 3 of 4 possible points.

Your score: 75 %

Question Results
Score 0 of 1
Question:

The underlying causes of malnutrition include which of the following? (Select all that apply.)

Response:

a. Availability and access to food

b. Household caring practices

c. Disease

d. Insufficient dietary intake

e. Availability, access and utilization of health services

Score 1 of 1

Question:

During and after illness, children under the age of 2 require which of the following?

Response:

a. More food and fluid than normal

b. The same amount of food and fluid as usual

c. Less food and fluid than normal

d. Only milk and no food

Score 1 of 1

Question:

People living with HIV and AIDS are at greater risk of malnutrition due to which of the following?

Response:

a. Reduced food intake due to appetite loss

b. Poor absorption of nutrients due to diarrhea

c. Changes in metabolism

d. Chronic infections and illness

e. All of the above

Score 1 of 1

Question:

Which of the following statements is FALSE?

Response:

a. In high income countries, poor households are more likely to experience obesity

b. In low and middle income countries, wealthy households are more likely to experience obesity

c. In most countries, as GDP increases, overweight and obesity rates generally decrease

d. In many countries, there is a high prevalence of both overweight and underweight