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Causes of malnutrition Module 5 7/21/2015 1 Learning Objectives • Be able to explain the causal factors of malnutrition that are identified in the conceptual model and the level they act on • Understand the application and limitations of the conceptual framework • Recognise the links between inadequate household food security, inadequate care and inadequate services and an unhealthy environment as inter-related causes in both emergencies and non-emergencies • Understand how basic causes can affect nutritional status, especially in emergencies • Understand how seasonal factors may influence the nutrition situation and how seasonal changes act on the different levels of causality. 7/21/2015 2 7/21/2015 3 The conceptual model for undernutrition Undernutrition Immediate causes Underlying causes Basic causes Inadequate food Disease intake Household food insecurity Poor social and care practices Poor Public Health Formal and informal infrastructure/ political ideology/resources 7/21/2015 4 Immediate causes of undernutrition • Undernutrition occurs when there is – insufficient nutrient intake and/or – an increase of nutrient needs that prevents effective utilization of nutrients (i.e. morbidity) • Nutritional requirements are defined by – Macronutrients: needed in large amounts and include protein, carbohydrate and fat. – Micronutrients: needed in much smaller amounts and include vitamins and minerals 7/21/2015 5 Malnutrition and Infection Cycle Inadequate diet Loss of appetite Malabsorption Increased need for energy and nutrients Weight loss Growth faltering Lowered immunity Increased susceptibility Increased severity and duration of disease 7/21/2015 6 Infection and undernutrition in emergencies •Most mortality in the initial period of an emergency is caused by four infectious diseases: diarrheal diseases, acute respiratory infections, measles and malaria, as well as undernutrition –Malnutrition and infection often occur at the same time. Malnutrition can increase the risk of infection while infection can cause malnutrition leading to a vicious cycle. 7/21/2015 7 Interactions between malnutrition and major diseases Disease Impact of malnutrition on disease Impact of infectious disease on nutritional status Diarrhoea or dysentery •Increased duration •Increased severity •Increased risk of dying •Malabsorption •Appetite loss Acute Respiratory Tract Infections •Increased severity •Increased risk of dying •Appetite loss •Increased metabolic rate resulting in muscle breakdown Measles •Increased duration •Increased severity, especially if deficient in vitamin A •Increased risk of dying •Appetite loss •Decreased levels of plasma vitamin A •Prolonged immune suppression resulting in increased ARI and diarrhoea •Increased metabolic rate resulting in muscle breakdown •Loss of proteins into the gut Malaria •Some evidence of increase severity in deficiencies of vitamin A and zinc •Appetite loss •Increased metabolic rate •Destruction of red blood corpuscles leading to anaemia •Impaired foetal development, 7/21/2015 low birth weight 8 7/21/2015 9 The conceptual model for undernutrition Undernutrition Immediate causes Underlying causes Basic causes Inadequate food Disease intake Household food insecurity Poor social and care practices Poor Public Health Formal and informal infrastructure/ political ideology/resources 7/21/2015 10 Underlying causes of malnutrition: Household food insecurity • Household food security is defined as sustainable access to safe food of sufficient quality and quantity to ensure adequate intake and healthy nutrition for all family members • It depends on access to food as well as its availability and proper utilization by each person • Two examples: – Disasters can destroy food stocks in the home, warehouses and where crops are grown (land, water, forests and grazing ground), as well as incomes – Some of the major famines in the world have been caused by market shocks which have resulted in an inability to buy food due to high food prices 7/21/2015 11 Underlying causes of malnutrition: Poor social and care practices • Caring practices are the way community members, including the vulnerable such as children, the elderly and the sick, are fed, nurtured, taught and guided. Care practices include: – Caring for and supporting vulnerable groups – Optimal infant and young child feeding practices – Health protection behaviour – Psycho-social support – Caring for and supporting mothers • Cultural factors and resources, like income, time and knowledge, determine caring practices Societal values e.g., attitudes towards modern health services, water & sanitation, women’s education, unequal division of labour • 7/21/2015 12 Underlying causes of malnutrition: Poor public health • Health refers to access to affordable, good quality curative and preventative health services and a healthy environment • Access to quality health services is essential and is determined by physical distance, cost, transport, poor quality, as well as cost in time – A complete disruption of health services is frequent in emergencies • Health environment Clean water and sanitation facilities, shelter, cold and overcrowding – In emergency situations the environment often deteriorates rapidly and leads to ill-health 7/21/2015 13 Basic causes • • • • Political, legal and cultural factors may defeat the best efforts of households to attain good nutrition, depending on how: – the rights of women and girls are protected by law and custom – control that women have over resources – political and economic systems that determine how income and assets are distributed – ideologies and policies that govern social sectors. Political discrimination due to religion, ethnic and clan can lead to systematic marginalization from food and other relief services and add on top of economic marginalization that is the basic cause of malnutrition in many emergencies – In emergencies, the injustices of the overall system are often exacerbated and can lead to the nutritional status of minority groups deteriorating rapidly Volatile food prices impact on the poorest means difficult decisions have to be made – eating less food, missing a meal and eating less diverse diet – which have detrimental impact on nutritional status. High food prices result in nutritional emergencies Climate change chronic emergencies often occur in places with challenging physical environment – frequent droughts, floods, intense heat. Climate change negatively impacts on food and nutrition security, quality of crops, access to safe water and for agricultural purposes, health. 7/21/2015 14 The conceptual model for undernutrition Undernutrition Immediate causes Underlying causes Basic causes Inadequate food Disease intake Household food insecurity Poor social and care practices Poor Public Health Formal and informal infrastructure/ political ideology/resources 7/21/2015 15 Limitations of the Conceptual Framework • Understandably the conceptual framework focuses on causes of undernutrition and does not take into consideration other forms of malnutrition – overweight and obesity – Definition of malnutrition encompasses stunting, wasting, micronutrients deficiencies and obesity (overnutrition) • The conceptual model does not take into account individual factors (e.g., genetic) that may affect nutritional status • It does not take into account how the different factors that impact on nutrition may be affected by seasonality 7/21/2015 16 Role of seasonality • Underlying causes are subject to seasonal variation: – access to food is typically reduced prior to harvest, food stocks are low and food prices inflated – “hunger season” – quality of child care is compromised when farmers are busy (harvest, etc) – diarrhoeal diseases are more common in the rainy season, while malaria, dengue and yellow fevers tend to be common after the rains – during the rainy season, drinking water is more likely to be collected from nearby contaminated water pools – In emergencies , the impact of these seasonal changes may become more pronounced and have greater effect on the poorest people and malnutrition prevalence may increase Seasonal calendars can be drawn to illustrate the seasonal variation of various factors affecting nutritional status. 7/21/2015 17 Seasonal calendar: Afghanistan 2009 – 2010 7/21/2015 18 Causes of stunting 8.1 cm •Poor living conditions - low parental education, poor maternal nutrition during pregnancy, etc •Poverty Age: 2 years 9 months 2 years 6 months 11.6 kg. Weight: 10.7 kg. 86.4 cm Height: 78.3 cm •Consequences include: •Higher morbidity and mortality •Lower educational achievement •Reduced productivity in adulthood. 7/21/2015 19 Causes of Obesity in Children •Inadequate pre-natal care •Suboptimal infant and young child nutrition •Poor diet •Low levels of physical activity •Consequences: •Obesity in adulthood •Disability in adulthood •Cardiovascular disease •Diabetes •Premature death 7/21/2015 20 Key Messages • Conceptual model is a useful tool to help understand the many factors that impact on nutrition status – The immediate causes of malnutrition are inadequate diet and disease, both of which can make each other worse; this is referred to as the infection-malnutrition cycle – There are 3 main underlying causes: inadequate household food security, inadequate care and inadequate health services and an unhealthy household environment – The basic causes of malnutrition are related to potential resources and the social, political, ideological and economic context • Immediate and underlying causes should be effectively addressed during emergencies • The conceptual model can be used to create a check list to identify and prioritize short and long term needs of vulnerable groups and the general population during an emergency 7/21/2015 21