There are many different ways of conceptualizing the relationships between malnutrition and its causes. The approach adopted here is visualized below. The diagram distinguishes among the immediate, underlying, and basic causes of malnutrition.

Figure II-1. Causes of Malnutrition
(Source: UNICEF)

Immediate causes. Malnutrition is caused by inadequate or improper dietary intake and disease. The two are closely linked because bad diets can increase vulnerability to disease, and many diseases result in loss of appetite and reduced absorption. Even with appropriate food intake, malnutrition can result from disease, particularly diarrhea or parasitic diseases. There may be enough good food coming in, but it may in effect run right out, or it might be diverted to the nutrition of parasites. Infection often leads to malnutrition. Disease often increases the body's food requirements. When children die at an early age, usually it is not malnutrition alone but the combination of malnutrition and disease that leads to death. The immediate causes can be understood as the clinical causes of malnutrition.

Underlying causes. The underlying causes of malnutrition are inadequate access to food, inadequate care of children and women, and inadequate access to basic health services, sometimes combined with an unhealthy environment.

Inadequate food supply in the household can be a major factor in causing malnutrition. Often, however, the types of food and the methods of feeding are also important. For example, the supply of food in the household may be adequate but its distribution within the family may be skewed against small children and in favor of the male head-of-household. Of course this is not a significant problem where household food supplies are abundant. Some bulky carbohydrates such as rice or maize have low nutrient density, which means that one must consume large volumes of the food. Small children cannot take in large quantities at one sitting. Thus, children who depend on  such foods must be fed frequently during the day or they will not get enough.

Feeding with breastmilk substitutes clearly illustrates how malnutrition can arise from provision of the wrong kind of food. The promotion of infant formula is especially pernicious in Third World countries where sanitation is poor, literacy levels are low, and people are extremely poor. The result has been that infants fed with formula have had much higher infant mortality rates than breastfed infants. The health effects of formula feeding have been less severe in developed countries, but it is clear that morbidity levels are higher among formula-fed infants even in developed countries. Recent studies have shown that formula-fed infants are more likely to get cancer.

Feeding patterns and the choice of foods used to complement breastmilk are critical. At times children are given inappropriate foods such as tea. Some beliefs regarding appropriate foods and feeding patterns can result in deficient diets for pregnant or lactating women, or children.

Nutrition status is not determined simply by food supply. Rather, nutrition is an outcome of three groups of factors: household food security, good health services (including a healthy environment), and care. People should be well-fed, healthy, and well-cared for. As defined by the United Nations' Administrative Committee on Coordination/Sub-Committee on Nutrition . . .

Care is the provision in the household and the community of time, attention and support to meet the physical, mental and social needs of the growing child and other family members (Gillespie 1990).

The care element is now beginning to be subjected to systematic analysis (Engle 1997; Haddad 1999; Longhurst 1995; UNDP 1999).

Food, health, and care are the three pillars of good nutrition. These are the underlying or household level factors that determine nutrition status.

Basic causes. The basic causes of malnutrition can be divided into three broad categories. First, there may be problems relating to human resources, having to do with inadequate knowledge, inadequate skills, or inadequate time. Second, there may be problems relating to economic resources, referring to inadequate assets in terms of money income, land, or other assets. Third, there may be inadequate organizational resources, such as inadequate schools, health care programs, or water supply systems. The basic causes can be understood as relating to societal causes of malnutrition.

Explanations of malnutrition commonly focus on the clinical and household levels, but an understanding is needed at the societal level as well. The endless marginalization of the poor certainly is one of the basic causes of malnutrition in the world (Kent 1984; Kent 1995; Lappé 1998;  Drèze and Sen 1990; Sen 1981).

Amartya Sen and Jean Drèze argue that hunger is due primarily to a failure of entitlements rather than, say, to inadequate agricultural productivity or excessive population growth. Briefly:

What we can eat depends on what food we are able to acquire.... The set of alternative bundles of commodities over which a person can establish such command will be referred to as this person’s "entitlement". If a group of people fail to establish their entitlement over an adequate amount of food, they have to go hungry (Drèze and Sen 1989,  pp. 9, 22).

Eide explains the importance of this way of thinking:

An entitlement approach to the study of access to food and hunger is required to avoid--in Sen's words--"the simplicity of focusing on the ratio of food to population [that] has persistently played an obscuring role over centuries, and continues to plague policy discussions today much as it has deranged anti-famine policies in the past". This requires, however, a shift in thinking from what exists to who can command what (Eide 1995, p. 95).

Food analysts distinguish between the availability of food, which refers to the overall quantities and types of foods in any particular place, and the accessibility of food, which refers to the ability of individuals to obtain that food. Even when food is available, many people may not have enough money to make a legitimate claim on it. Many famines have occurred in places where overall food supplies have been more than adequate.

It is important to know not only what resources exist, but who has what sorts of control over resources. This in turn leads to questions regarding the way in which the local community and the society as a whole are governed. More democratic societies are likely to be associated with more equitable distribution of resources, and thus with less malnutrition.

It follows from this approach that the remedy to the hunger problem lies in strengthening entitlements. Some analysts implicitly assume that this can be done only through increasing the household’s capacity to produce or purchase food. In the context of food and nutrition rights, however, it is recognized that under some conditions people also should have a claim on the resources (not only food but also care and health services, and other factors essential to an adequate standard of living) of their societies based on their needs. The meaning of entitlements is discussed more fully in Subsection VI-f.

Continue to II-c. Growth Measurement

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Subsection II-b last updated on September 25, 1999