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Nutritional Status Assessment and Analysis
Nutritional Status and Food Security
Learner Notes
This course is funded by the European Union and implemented
by the Food and Agriculture Organization.
© FAO, 2007
Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
Table of contents
Learning objectives............................................................................................2
Introduction ......................................................................................................2
What is malnutrition? .........................................................................................3
Causes of malnutrition .......................................................................................4
Conceptual frameworks .....................................................................................6
Nutritional status, health, mortality and low birth weight .....................................7
Summary ........................................................................................................ 10
If you want to know more ................................................................................ 10
Learner Notes
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
Learning objectives
At the end of this lesson you will be able to:
define the concept of malnutrition;
identify the factors influencing nutritional status; and
be aware of the relationships between nutrition, food security,
health and mortality.
Introduction
The factors affecting an individual’s nutritional status are many and diverse.
Understanding these factors is essential in order to assess malnutrition, to design programmes
which tackle nutrition problems, and to correctly inform programme management and
evaluation.
Understanding malnutrition is also important as it carries heavy costs on individuals and
households, communities and nations. In fact, due to malnutrition, millions of lives are
destroyed by death and disability, both mental and physical.
Besides being morally unacceptable, this implies economic costs, in terms of lost productivity
and income caused by premature death, lower physical capacity, absenteeism and lower
educational and occupational opportunities.
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
What is malnutrition?
Nutritional status is the physiological state of an individual, which results from the
relationship between nutrient intake and requirements and from the body’s ability to digest,
absorb and use these nutrients.
The term malnutrition indicates a bad nutritional status.
Malnutrition refers to all deviations from adequate nutrition, including undernutrition,
overnutrition and specific deficiencies (or excesses) of essential nutrients such as vitamins and
minerals.
The terms malnutrition and undernutrition are often used loosely and interchangeably,
although a distinction needs to be made at all times.
Malnutrition arises either from deficiencies or excesses of specific nutrients, or from
undiversified diets (wrong kinds or proportions of foods). Malnutrition may arise from
imbalance, excesses or deficiency of specific nutrients, for example, iodine, vitamin C, iron and
vitamin A.
Undernutrition is the outcome of insufficient food caused primarily by an inadequate intake of
dietary or food energy. It is defined as a dietary energy intake below the minimum requirement
level to maintain the balance between actual energy intake and acceptable levels of energy
expenditure.
“Malnutrition" and "undernutrition" often both refer to nutritional situations that are typical in
populations belonging to the low-income and poor socio-economic groups of developing
countries. However, in many developing countries, under- and overnutrition are occurring
simultaneously among different population groups. This phenomenon is referred to as the
“double burden” of malnutrition.
Learner Notes
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
Background information
The “double burden” of malnutrition refers to the co-existence of undernutrition, micronutrient
deficiencies, overweight/obesity and other nutrition-related chronic diseases in the same
countries, in the same communities and even in the same households.
This phenomenon is not limited to upper-income developing countries, but is occurring across
the globe in countries with very different cultures and dietary customs.
When poor economic conditions improve, amounts and variety of food consumed tends to rise
and mortality rates of infant and young children tend to fall as communicable diseases are more
successfully put under control. This may be accompanied by rises in obesity and diet related
non-communicable diseases which may co-exist with high levels of child undernutrition.
Causes of malnutrition
Poverty is the root cause of malnutrition. Food security, health and care are the underlying
causes – as we will consider later.
Most micronutrient deficiencies primarily affect poor and disadvantaged households whose
members cannot produce or procure adequate food, who live in marginal or unsanitary
environments without access to clean water and basic services, who lack access to appropriate
education and information, or are otherwise socially disadvantaged. However, overnutrition and
dietary imbalances, which may lead to chronic diseases, cut across many socio-economic
boundaries.
Nutritional status is influenced by multiple and interrelated factors.
The most important factors can be grouped under the broad categories of food, health and
care.
FOOD:
The availability of, access to and consumption of adequate quantities of safe good quality
nutritious food is an important factor influencing nutritional status.
Nutritional well-being is influenced by the nutrient content of food consumed and its absorption
by the body, in relation to other requirements determined by age, sex, level of physical activity
and health status, as well as the efficiency of nutrient utilization by the body.
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
HEALTH:
Health and sanitation are essential for nutrition, yet they are beyond the reach of the majority
of the world's population.
Infectious disease and inadequate diet act together, each aggravating the effects of the other to
produce what is referred to as the "malnutrition and infection cycle".
Nutritional requirements are higher during and following episodes of infection. Chronic or
frequent acute infections make it almost impossible to maintain adequate nutritional status.
CARE:
Care and feeding practices require time, attention and support and are essential to meet the
physical, mental and social needs of individuals.
The knowledge, attitudes and practices of household members largely determine the nutritional
status of the household.
An incomplete understanding of the body's nutritional needs and lack of knowledge of how to
meet these needs with available foods can lead to malnutrition.
Food, health and care are interrelated, and actions affecting one area may have significant
consequences on another. For example, adoption of sustainable and labour-saving agricultural
technologies may influence nutrition not only through improved food supplies and income, but
also through their beneficial impact on sanitation and health and on the time available for
providing care to household members.
Development policies, which affect the economy and the society as a whole, usually are not
included in the domain of nutrition as such. However, they impact considerably on the
nutritional well-being of the population, and their effects may be monitored on food, health
and care.
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
Conceptual frameworks
The most commonly used
framework for
understanding the causes of
malnutrition is adapted from
the UNICEF conceptual
framework.
This framework sets out
causes that operate at three
levels: immediate,
underlying and basic,
whereby factors at one level
influence other levels.
There are other conceptual frameworks for malnutrition, such as the Food Insecurity and
Vulnerability Mapping System (FIVIMS) framework for food security, livelihoods and
nutrition.
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
The key difference between the UNICEF and FIVIMS framework is that the latter gives a greater
centrality to food availability, access, consumption and utilization and their determinants.
However, health and sanitation and care practices still occupy an important place within the
framework.
Nutritional status, health, mortality and low birth weight
To better understand the concept of malnutrition and its implications, let’s consider the
relationships between nutritional status and health status, mortality and low birth weight.
Nutritional status and Health status.
Nutrition and health are closely linked, as disease contributes to malnutrition, while
malnutrition makes an individual more susceptible to disease.
There is a ‘vicious cycle’ in which malnutrition and diseases influence each other.
This ‘vicious cycle’ in which one exacerbates the other is known as the “malnutritioninfection cycle” and can eventually lead to severe malnutrition and death.
Malnutrition-infection cycle
A.
Inadequate dietary intake leads to weight loss, growth faltering and
reduced immunity, which lower the body’s ability to resist infection.
B.
This causes longer, more severe and more frequent disease episodes.
C.
This leads to loss of appetite, malabsorption of nutrients, altered
metabolism and increased nutrient needs.
D.
This results in inadequate dietary intake.
Certain diseases are particularly frequent causes of poor growth. Among these are
diarrhoea, respiratory infections, HIV/AIDS and malaria. Moreover, certain diseases may
predispose a person to certain types of malnutrition; vice versa, certain types of malnutrition
may predispose a person to certain types of infection. For example, lack of vitamin A can
predispose a person to measles.
The relationship between nutrition and infection is also affected by the type of caring that
takes place for sick individuals.
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
The relationship between nutrition and disease can be observed in the seasonal changes in
nutritional status.
Seasonal changes in nutritional status1 are more evident in rural populations, especially
when they depend on a single harvest. However, the seasonal peaks of malnutrition coincide
not just with the hungry season, when food may be in most scarce supply, but also when
the frequency of certain diseases is highest, particularly diarrhoea and malaria.
Nutritional status and mortality.
It is often assumed that as malnutrition increases so does mortality, but the reality is more
complex. In fact, the relationship between malnutrition and mortality is not linear but
increases exponentially.
In other words, mortality increases exponentially with declining nutritional status.
Many factors impact mortality, especially the health environment and caring capacity, which
are often compromised in situations of conflict and displacement.
In emergencies, where exposure to disease varies, there may therefore be varying levels of
mortality associated with the same level of malnutrition.
Consequently, mortality rates cannot be predicted from prevailing rates of malnutrition.
Example: Northern Iraq refugees
In 1991 during the northern Iraq refugee crisis, a survey of Kurdish refugees found a
prevalence of acute malnutrition among under-fives of only 4.3% (which is low) but a crude
mortality rate (CMR) of 3/10,000/day, which is very high.
Most deaths were due to diarrhoea and dehydration.
1
Many communities, especially in the rural areas, experience periods in the year when malnutrition levels are higher. Changes in
the levels of malnutrition are influenced by seasonal patterns such as: cropping patterns, food availability, disease, child care,
income sources, price of foods, labour demand.
These expected changes in malnutrition need to be taken into account when interpreting changes in observed rates of malnutrition.
Learner Notes
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
Nutritional status and low birth weight.
It is estimated that each year 24 million babies are born with low birth weight (LBW), which
means less than 2.5 kg. Ninety five percent of these events occur in developing countries.
LBW puts infants at greater risk of neonatal death and is a major cause of poor growth and
development in later childhood.
Undernutrition in utero is also associated with certain chronic diseases in adult life.
Although LBW can be due to a number of factors, such as a woman’s small size, uterine
infections, smoking and malarial infection, the most significant cause is poor maternal
nutrition.
The cycle of poor nutrition perpetuates itself across generations.
The following diagram by the Standing Committee on Nutrition shows the intergenerational
cycle of growth failure:
Young girls who grow poorly become stunted women and are more likely to give birth to LBW
infants. If those infants are girls, they are likely to continue the cycle by being stunted in
adulthood, if something is not done to break the cycle.
Adolescent pregnancy heightens the risk of LBW and the difficulty of breaking the cycle.
Learner Notes
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security
Summary

Malnutrition refers to all deviations from adequate nutrition, including undernutrition
(and overnutrition) resulting from inadequacy (or excess) of food.

Malnutrition carries heavy human and economic costs on individuals and households,
communities and nations. Malnutrition and undernutrition are often used as synonyms.
However, a clear distinction needs to be made at all times.

The co-existence of undernutrition, micronutrient deficiencies, overweight/obesity and
other nutrition-related chronic diseases occurs in the same countries, in the same
communities and even in the same households throughout the world today, posing one
of the greatest challenges to national policy makers. This phenomenon is referred to as
the “double burden” of malnutrition.

Even if poverty is the root cause of undernutrition, malnutrition has multiple and
interrelated causes. The direct causes of malnutrition can be grouped under the broad
categories of: food, health and care.
If you want to know more

The double burden of malnutrition – Case studies from six developing countries.
FAO Food and Nutrition Paper 84, Rome 2006.
http://www.fao.org/docrep/009/a0442e/a0442e00.htm

Measurement and Assessment of Food Deprivation and Undernutrition FIVIMS Proceedings, International Scientific Symposium held in FAO, Rome 26-28 June
2002. FAO 2003. http://www.fao.org/DOCREP/005/Y4249E/Y4249E00.HTM

Conducting small-scale nutrition surveys: A field manual. FAO, 1990, 186p,
English, Spanish, French ISBN 202851.
http://www.fao.org/docrep/009/a0442e/a0442e00.htm#Contents

Body mass index - A measure of chronic energy deficiency in adults. FAO Food
and Nutrition Paper 56, 1994. http://www.fao.org/docrep/T1970E/T1970E00.htm

United Nations Standing Committee on Nutrition Issue No. 33 Diet-related
Chronic Diseases and the Double Burden of Malnutrition in West Africa, 2006, pages 1820.http://www.unsystem.org/scn/Publications/SCNNews/scnnews33.pdf.
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Nutritional Status Assessment and Analysis
Lesson: Nutritional Status and Food Security

Incorporating Nutrition Considerations into Development Policies and
Programmes: Brief for Policy-Makers and Programme Planners in Developing
Countries, FAO 2004. http://www.fao.org/docrep/007/y5343e/y5343e00.htm

The State of Food Insecurity in the World (SOFI): monitoring progress towards the
World Food Summit and Millennium Development Goals (FAO-SOFI, 2004)
http://www.fao.org/docrep/007/y5650e/y5650e00.htm
Additional Reading:

Nutrition and development: a global challenge - adapted from Nutrition and
development - a global assessment, written by FAO and WHO for the International
Conference on Nutrition, 1992.

United Nations Standing Committee on Nutrition/Administrative Committee
on Coordination (ACC/SCN) Second report on the World Nutrition Situation: Vol.1:
Global and Regional Results, ACC/SCN Geneva, 1992.

Conducting small-scale nutrition surveys: A field manual. FAO, 1990, 186p,
English, Spanish, French ISBN 202851.
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