An understanding of the complex and subtle causes of malnutrition is important to appreciate the scale and depth of the problem, the progress achieved to date and the possibilities for further progress that exist.
Malnutrition, clearly, is not a simple problem with a single, simple solution. Multiple and interrelated determinants are involved in why malnutrition develops, and a similarly intricate series of approaches, multifaceted and multisectoral, are needed to deal with it (Fig. 5).
The interplay between the two most significant immediate causes of malnutrition -- inadequate dietary intake and illness -- tends to create a vicious circle: A malnourished child, whose resistance to illness is compromised, falls ill, and malnourishment worsens. Children who enter this malnutrition-infection cycle can quickly fall into a potentially fatal spiral as one condition feeds off the other (Fig. 6).
Malnutrition lowers the body's ability to resist infection by undermining the functioning of the main immune-response mechanisms. This leads to longer, more severe and more frequent episodes of illness.
Infections cause loss of appetite, malabsorption and metabolic and behavioural changes. These, in turn, increase the body's requirements for nutrients, which further affects young children's eating patterns and how they are cared for.
Three clusters of underlying causes lead to inadequate dietary intake and infectious disease: inadequate access to food in a household; insufficient health services and an unhealthful environment; and inadequate care for children and women.
Household food security
This is defined as sustainable access to safe food of sufficient quality and quantity -- including energy, protein and micronutrients -- to ensure adequate intake and a healthy life for all members of the family.
In rural areas, household food security may depend on access to land and other agricultural resources to guar antee sufficient domestic production.
In urban areas, where food is largely bought on the market, a range of foods must be available at accessible prices to ensure food security. Other potential sources of food are by exchange, gifts from friends or family and in extreme circumstances food aid provided by humanitarian agencies.
Household food security depends on access to food -- financial, physical and social -- as distinct from its availability. For instance, there may be abundant food available on the market, but poor families that cannot afford it are not food secure.
For the poor, therefore, household food security is often extremely precarious. Agricultural production varies with the season and longer-term environmental conditions. Families selling crops may find themselves paid fluctuating prices depending on a variety of factors beyond their control, while those who need to buy food may encounter exorbitant prices.
Families living on the edge of survival have few opportunities to build up sufficient stocks of food, or to develop alternatives that would cushion them in times of hardship. So while poor families may have adequate access to food for one month, what is essential is access that is consistent and sustainable.
Women have a special role to play in maintaining household food security. In most societies, they are solely responsible for preparing, cooking, preserving and storing the family's food -- and in many societies they have the primary responsibility of pro ducing and purchasing it. For house hold food security to translate into good nutrition, this often overwhelming burden of work must be redistributed or reduced so that other needs of children, also related to nutrition, can be met.
Health services, safe water and sanitation
An essential element of good health is access to curative and preventive health services that are affordable and of good quality.
Families should have a health centre within a reasonable distance, and the centre's staff should be qualified and equipped to give the advice and care needed. According to the United Nations Development Programme (UNDP), access varies widely, but in as many as 35 of the poorest countries 30 to 50 per cent of the population may have no access to health services at all.24
In Africa, the programme known as the Bamako Initiative was launched in 1987 to address the crisis in health care that came on the heels of budget cuts and economic decline in the 1980s. It is a strategy for improving health services by moving their control, management and even some of their financing out of central jurisdiction and into communities.
Photo: A complex interplay of factors such as household access to food, women's status, caring practices, disease and access to safe water, sanitation and basic health services affect a child's nutrition. A girl stands in the doorway of her home in Lebanon.
Now in place in a number of countries in Africa, the Initiative's principles are being adopted and adapted in other regions as well. The results are promising: The supply of basic drugs in health centres is more consistent, and management committees, composed of village residents, help ensure that people pay reasonable fees for basic services and that the funds generated are well used.
Nevertheless, the fact remains that many people do not have access to health care and may be further deterred from seeking timely and appropriate care by user fees for health care services.
The additional challenge of creating a climate where preventive health and nutritional care components are also integrated into the Bamako model is harder to realize. Because they are less tangible to communities, preventive health and nutrition services are also often less in demand than curative care. Prevention, nonetheless, is vital and cost-effective.
In terms of environmental health, the lack of ready access to a safe water supply and proper sanitation and the unhygienic handling of food as well as the unhygienic conditions in and around homes, which cause most childhood diarrhoea, have significant implications for the spread of infectious diseases.
Moreover, when food is handled under unhygienic conditions and the environment is unhealthful, littered with animal and human wastes, young children are also more prone to infection by intestinal parasites, another cause of poor growth and malnutrition (Panels 5 and 20).
Also, women and children are usually responsible for fetching the water needed for domestic use, a task that drains considerable time and energy. Depending on how much the distance to the water source is shortened, it has been estimated that women could conserve large reserves of energy, as many as 300 to 600 calories a day.25
Progress has been made in improving access to safe water. But more than 1.1 billion people lack this fun da mental requirement of good nutrition.26
As for sanitary waste disposal, the world is actually losing ground, with the rate of coverage falling in both urban and rural areas. Only 18 per cent of rural dwellers had access to adequate sanitation services at the end of 1994,27 and overall some 2.9 billion people lack access to adequate sanitation.28
Figure 5. Causes of Child Malnutrition
This conceptual framework on the causes of malnutrition was developed in 1990 as part of the Unicef nutrition strategy. The framework shows that causes of malnutrition are multisectoral, embracing food, health and caring practices. They are also classified as immediate, underlying, and basic, whereby factors at one level influence other levels. The framework is used, at national, district and local levels, to help plan effective actions to improve nutrition. It serves as a guide in assessing and analysing the causes of the nutrition problem and helps in identifying the most appropriate mixture of actions.
Source: UNICEF 1997 Figure 6. Inadequate dietary intake/disease cycle Inadequate dietary intake and infection in a vicious cycle that accounts for
much of the high morbidity and mortality seen in developiong countries. When children don't eat
enough, their immune system defences are lowered, resulting in greater incidence, severity and
duration of disease. Disease speeds nutrient loss and suppresses appetite -- so sick children tend
not to eat as they should -- and the cycle continues.
Source: UNICEF 1997
Figure 6. Inadequate dietary intake/disease cycle
Inadequate dietary intake and infection in a vicious cycle that accounts for much of the high morbidity and mortality seen in developiong countries. When children don't eat enough, their immune system defences are lowered, resulting in greater incidence, severity and duration of disease. Disease speeds nutrient loss and suppresses appetite -- so sick children tend not to eat as they should -- and the cycle continues.
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