1. Causes of malnutrition & Health assessment
Session 5
Causes of malnutrition &
Health assessment

2. The conceptual framework for analysing the causes of malnutrition
People Empowermwnt Advocacy & Communal Harmony (PEACH)

3. Immediate causes of malnutrition
The malnutrition infection cycle
The immediate cause of malnutrition is due to an imbalance between the amount of nutrients absorbed by the body and the amount of nutrients required by the body
This happens as a consequence of consuming too little food or having an infection which either increases the body’s requirements for nutrients or prevents the body from absorbing the food consumed
In practice, malnutrition and infection often occur at the same time because one can lead to another.
A malnourished child, whose resistance to illness is poor, falls ill and becomes more malnourished which reduces his capacity to fight against illness and so on
This is called the infection-malnutrition cycle and is illustrated in figure below
People Empowermwnt Advocacy & Communal Harmony (PEACH)

4. Increased incidence, severity and duration of disease
The infection-malnutrition cycle
Loss of appetite
Malabsorption
Increased nutritional requirements
Increased incidence, severity and duration of disease
Inadequate diet
Weight loss
Growth faltering
Lowered immunity
People Empowermwnt Advocacy & Communal Harmony (PEACH)

5. People Empowermwnt Advocacy & Communal Harmony (PEACH)
Summary of interactions between malnutrition and the major killers in emergencies
Disease
Impact of disease on malnutrition status of individual
Impact of infection on factors which tend to lead to malnutrition
Diarrhoea (e.g. shigellosis)
Increased duration
Increased severity
Increased mortality
Malabsorption
Appetite loss
Loss of nutrients
Acute Respiratory Infection
(lower tract)
Metabolic effects resulting in muscle breakdown
People Empowermwnt Advocacy & Communal Harmony (PEACH)

6. People Empowermwnt Advocacy & Communal Harmony (PEACH)
Summary of interactions between malnutrition and the major killers in emergencies…
Disease
Impact of disease on malnutrition status of individual
Impact of infection on factors which tend to lead to malnutrition
Measles
Increased duration
Increased severity
Increased mortality
Appetite loss
Decreased levels of plasma Vitamin A
Prolonged immune suppression resulting in increased incidence of ARI and diarrhoea
Fever increasing requirements
Metabolic effects resulting in muscle breakdown
Malaria
Some evidence of increased severity in deficiencies of Vitamin A and zinc
Iron deficiency leading to anaemia
Impaired foetal development, low birth weight and growth faltering
People Empowermwnt Advocacy & Communal Harmony (PEACH)

7. Underlying causes of malnutrition
Food
Care
Caring for and supporting vulnerable groups
Child feeding behaviour
Health protection behaviour
Psycho-social behaviour
Caring for and supporting mothers
Health
People Empowermwnt Advocacy & Communal Harmony (PEACH)

8. Underlying causes of malnutrition…
Food
Household food security (HFS)
“Sustainable access to safe food of sufficient quality and quantity to ensure adequate intake and a healthy life for all members of the family”
HFS depends on
Access to food
Food availability and utilisation by the body
HFS applies to foods available in a particular geographical area through local food production systems; agriculture, fisheries, livestock rearing and foods from hunting.
It also includes
Food imported and exported into the region
A consideration of seasonal variations in food availability
Food security does not stop short at the availability, it needs to include food access by different households with different livelihoods (means of making a living) and incomes.
People Empowermwnt Advocacy & Communal Harmony (PEACH)

9. Underlying causes of malnutrition…
Food…
In emergencies the way people obtain food is often disrupted
(Especially if they have to leave their homes due to conflict or sudden flooding or an earthquake)
In disasters
Food stocks are destroyed
(in the home, warehouses and where crops are grown i.e. land, water, forests and grazing ground)
Even abundant of food is available on the market, but families may not be able to afford to buy the food
People Empowermwnt Advocacy & Communal Harmony (PEACH)

10. Underlying causes of malnutrition…
Care
Caring practices
“The way community members, including the vulnerable such as children, the elderly and the sick, are fed, take care of, taught and guided”
It is the responsibility of the entire family and the community
Caring practices can be determined by
Cultural factors
Resources, like income, time and knowledge
Attitudes to modern health services, water supplies and sanitation
The values of the society strongly influence the priority given to the care of children, women and the elderly
People Empowermwnt Advocacy & Communal Harmony (PEACH)

11. Underlying causes of malnutrition…
Care…
Caring for and supporting vulnerable groups
Children, the disabled, the chronically ill, the elderly and those in hospitals or prisons all deserve special care attention
Different cultural norms and economic situations tell-how these caring practices are carried out?
Both formal and informal systems of care exist through institutional care and family networks
In emergency situations these tend to be disrupted and may leave these groups more vulnerable to developing malnutrition
People Empowermwnt Advocacy & Communal Harmony (PEACH)

12. Underlying causes of malnutrition…
Care…
Child feeding behaviour
Alongwith breastfeeding children must be provided with complementary foods at six months
(to ensure optimal growth and protection from infection)
The foods first introduced
Family’s financial situation and cultural norms
Changing the diets of infants from a diet based on milk to the family plate
Time consuming
Requires extra care
(Around hygiene practices related to preparation and provision of food)
In emergency situations, normal child feeding practices may be disrupted and undermined if care takers are busy with meeting their daily family needs
People Empowermwnt Advocacy & Communal Harmony (PEACH)

13. Underlying causes of malnutrition…
Care…
Health protection behaviour
In order for children to flourish, they require essential health care, especially immunizations
Cultural norms and quality of health information and services available influence the way families seek appropriate and timely health care for their children
In emergencies, this is disrupted and carers may not know who to go to for support
People Empowermwnt Advocacy & Communal Harmony (PEACH)

14. Underlying causes of malnutrition…
Care…
Psycho-social behaviour
Emotional support and cognitive stimulation is required for optimal child development
In emergency situations
It is essential to maintain high levels of stimulation and interaction between carers and their children (to maximise recovery rates among the malnourished)
People Empowermwnt Advocacy & Communal Harmony (PEACH)

15. Underlying causes of malnutrition…
Care…
Caring for and supporting mothers
The unequal division of labour and resources in families and communities that favours men jeopardizes the well-being of both children and women
The elements of care most critical for women during pregnancy and breastfeeding include
Extra quantities of good-quality food
Release from heavy labour
Adequate time for rest.
People Empowermwnt Advocacy & Communal Harmony (PEACH)

16. Underlying causes of malnutrition…
Health
Health refers to
“A range of factors linked to access to health care, safe water and sanitation”
An essential element of good health is access to affordable, good quality health services and a healthy environment
People Empowermwnt Advocacy & Communal Harmony (PEACH)

17. Underlying causes of malnutrition…
Health…
In emergency situations the health environment often deteriorates rapidly
Access to adequate clean water and sanitation may be adversely affected
Displacement may lead to people having to live in camps and overcrowding, encouraging infectious diseases to spread
People Empowermwnt Advocacy & Communal Harmony (PEACH)

18. Underlying causes of malnutrition…
Health…
Access to basic health services determines the extent to which infection can be prevented or treated
Effective treatment should reduce the duration and the severity of infection
Access to health services is determined by physical distance and cost
Costs can include transport costs, medical costs for treatment as well as time costs for the family member having to attend the clinic and leave other tasks undone
In emergencies, there is frequently a complete disruption of health services so reducing access to medicines and qualified staff
People Empowermwnt Advocacy & Communal Harmony (PEACH)

19. Basic causes of malnutrition
Basic causes are
Political
Legal
Cultural factors
These also include
The degree to which the rights of women and girls are protected by law and custom
The political and economic system that determines how income and assets are distributed
The ideologies and policies that govern the social sectors
To address basic causes of malnutrition
Greater and better-targeted resources and better collaboration are needed between sections of national governments and between governments and all development partners, including donors, United Nations agencies, non-governmental organisations and investors. Above all, the poor themselves must be a major part of the process
People Empowermwnt Advocacy & Communal Harmony (PEACH)

20. The role of seasonality
All three clusters of underlying causes are subject to seasonal variation
For example
Access to food typically reduces prior to the harvest when workload is also high (for agricultural producers), or prior to the rains when workload finding water and pasture is high (for pastoralists)
The health environment changes according to the temperature and rainfall
The care environment changes as labour requirements alter according to the agricultural cycle. Often seasonal calendars are drawn to illustrate the seasonal variation of various factors affecting nutritional status
People Empowermwnt Advocacy & Communal Harmony (PEACH)

21. People Empowermwnt Advocacy & Communal Harmony (PEACH)
Conclusion
Identifying the causes of malnutrition is essential in emergencies to guide appropriate response
All nutrition assessments carried out during an emergency should include an assessment of causes
The conceptual framework continues to be used widely to help understand causes, how they relate to one another and the multi-causal nature of malnutrition
People Empowermwnt Advocacy & Communal Harmony (PEACH)

22. People Empowermwnt Advocacy & Communal Harmony (PEACH)
Exercise
Q. Common consequences of malnutrition in emergency situations include
a) Food allergies
b) Growth failure
c) Micronutrient deficiency
d) Reduced ability to work
(a)
Q. Which of these is not made worse by malnutrition in an individual?
a) Increased severity of disease
b) Increased duration of disease
c) Increased resistance to disease
d) Increased incidence of disease
(c)
Q. The main childhood killers include:
a) Iron deficiency anaemia
b) Acute lower respiratory tract infections
c) Malaria
d) Measles
People Empowermwnt Advocacy & Communal Harmony (PEACH)

23. People Empowermwnt Advocacy & Communal Harmony (PEACH)
Exercise…
Q. At which level do the underlying causes of malnutrition have their main effect?
a) individual level
b) household level
c) community level
d) society level
(b&C)
Q. True or false
Household food insecurity affects all members of the household in the same way
(False)
Intra-household differences due to family composition and status affect individuals who have different needs. For example if there is a reduction in food available to the house it is likely to affect children, the elderly and the infirm more quickly than able-bodied adults. However, mothers often decide to forego food in order to be able to feed the rest of the family better, which may mean children are protected but in the long term the health of the mother is compromised which can lead to future children not developing fully during pregnancy, or the mother becoming ill and not being able to perform the many household tasks. Food insecurity affects household members differently at different times.
People Empowermwnt Advocacy & Communal Harmony (PEACH)

24. People Empowermwnt Advocacy & Communal Harmony (PEACH)
Exercise…
True or false
Adequate shelter serves to keep people safe, warm and with a sense of privacy that allows them to protect themselves from disease
(True)
Q. True or false
The values of the society strongly influence the priority given to the care of children, women and the elderly, but all societies prioritise the care of children above all else.
(False)
Whilst child care is essential in all societies, cultural norms will protect different members of society through formal and informal systems with different degrees of success. It is essential to understand the care practices to e able to identify the most vulnerable in emergencies who may not be receiving adequate care.
Q. The elements of care most critical for women during pregnancy and breastfeeding include
Extra quantities of good-quality food
Extra rest time
Extra health care
Extra vaccinations
(a, b, c)
10. Which of these are seasonal factors to consider in nutrition emergencies?
a) market price of foods
b) migration patterns of wild animals
c) tides
d) vaccination campaigns at health centres
(all)
People Empowermwnt Advocacy & Communal Harmony (PEACH)

25. People Empowermwnt Advocacy & Communal Harmony (PEACH)
Key messages
Malnutrition has many inter-related causes which need to be identified in order to be effectively addressed during an emergency
The conceptual framework for malnutrition is a useful tool for understanding the causes of malnutrition. It describes three levels of causality: immediate, underlying and basic
The immediate causes of malnutrition in an individual are inadequate food intake and disease
The cycle of infection and malnutrition describes how infection leads to malnutrition. Most malnourished individuals also suffer from infections
There are three clusters of underlying causes that overlap: food, care and health
Food insecurity is about the availability, access and utilisation of food
Caring practices are the way community members, especially the vulnerable, are fed, nurtured, taught and guided
Health refers to a range of factors linked to access to health care, safe water and sanitation.
The basic causes of malnutrition are related to formal and informal institutions, infrastructure and physical, natural, social and economic resources, and the type of shock that leads to the emergency
All three clusters of underlying causes are subject to seasonal variation which can be magnified in an emergency
People Empowermwnt Advocacy & Communal Harmony (PEACH)