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Module V
Global Nutrition and Nutritional Health
_______________________________________________
Introduction
Nutrition is crucial to both individual and national development.
In this Module we will explore what undernutrition is, common
indicators of undernutrition, disease burden due to nutritional
conditions, and the efforts made in fighting undernutrition.
At the end of this Module you should be able to articulate the
following:
Critical Skills
1. Explain what undernutrition is and its causes.

2. 2. Describe the trend and distribution of undernutrition
globally.
3. Acknowledge the disease burden associated with
nutritional conditions.
4. Explain the link between nutrition/undernutrition and
individual and national development.
5. Describe interventions implemented to address nutritional
conditions.
6. Be familiar with at least two development
organizations/NGOs working in global nutrition efforts.
7. Identify, explain and draw the UNICEF conceptual
framework depicting the immediate, underlying and basic
causes of undernutrition
8. Describe the consequences of acute and chronic
undernutrition
9. Understand the consequences of selected important
micronutrient deficiencies
What is undernutrition?
Undernutrition describes a range of conditions including being
underweight, being short, being thin and being deficient in
vitamins and minerals. It can be understood as an outcome of
insufficient quantity and quality of food.
The most commonly used indicators of undernutrition are:
· Wasting: normally the result of acute or short-term
insufficient food intake often combined with frequent illness.
Results in a child who is dangerously thin (i.e. they have a very
low weight for their height).
· Stunting: normally an indicator of chronic or long-term
insufficient energy or micronutrient intake although it has many
non-nutritional causes such as helminth infestation and frequent
or chronic infection. Results in a child who is very short (i.e.
they have a very short height for their age).
· Underweight: an indicator assessing adequacy of weight for
age with very difficult to explain causes.
· Deficiencies in vitamins and minerals as a result of a poor

3. quality diet. This can also result from frequent illness which
may increase requirement, utilization or loss of nutrients.
· Low birth weight(LBW) - babies with low weight (<2500 g) at
birth a result of premature birth (before 37 weeks gestation) or
babies born at full term who are underweight.
Source:
https://ble.lshtm.ac.uk/pluginfile.php/20037/mod_resource/cont
ent/4/OER/PNO101/sessions/S1S1/PNO101_S1S1_050_030.htm
l
Stunted linear growth has become the main indicator of
childhood undernutrition, because it is highly prevalent in
nearly all low-to-middle income countries (LMICs), and has
important consequences for health and development.
Prevalence of stunting: The prevalence of stunting in children
younger than 5 years in LMICs in 2011 was 26%, a decrease
from 40% in 1990, and 32% in 2005. The number of stunted
children has also decreased globally, from 253 million in 1990,
to 178 million in 2005, to 165 million in 2011. At this rate of
decline, stunting is expected to reduce to 127 million, a 25%
reduction, in 2025. Eastern and western Africa and south-
central Asia have the highest prevalence of stunting; the largest
number of children affected by stunting, 69 million, live in
south-central Asia. In Africa, only small improvements are
anticipated on the basis of present trends, with the number of
affected children increasing from 56 to 61 million, whereas
Asia is projected to show a substantial decrease in stunting
prevalence (Black, et al. 2013).
Prevalence of wasting: The prevalence of wasting was 8%
globally in 2011, affecting 52 million children younger than 5
years, an 11% decrease from an estimated 58 million in 1990.
The prevalence of severe wasting was 2·9%, affecting 19
million children. 70% of the world’s children with wasting live
in Asia, mostly in south-central Asia, where an estimated 15%

4. (28 million) are affected (Black, et al. 2013).
Deficiencies of essential vitamins and minerals: Deficiencies of
vitamin A and zinc adversely affect child health and survival,
and deficiencies of iodine and iron, together with stunting,
contribute to children not reaching their developmental
potential (Black, et al. 2013).
The causes of undernutrition are complicated and often
multisectoral. These range from immediate causes (dietary
intake and disease factors that directly impact on an individual's
nutritional status), underlying causes (comprise household food
security, care for women/children and health
environment/health services and are underpinned by income
poverty), to basic causes (broad set of factors that operate at the
sub-national, national and international levels and range from
structural and natural resources, social and economic
environments to political and cultural contexts). See the
UNICEF conceptual framework depicting the immediate,
underlying and basic causes of undernutrition. See also the one
used by Merson et al (2012)
Figure: Conceptual framework for undernutrition
Source: Adapted from UNICEF 1991
See also the diagram below showing all factors that can
potential affect nutritional status.
Source: Centre image - ACF Mali, courtesy of Samuel
Hauenstein Swan; outside images courtesy of Wikimedia

5. Commons
It has been estimated that nutrition-specific interventions that
tackle only the direct or immediate causes of undernutrition
such as poor breastfeeding practices or vitamin and mineral
deficiencies can only reduce global levels of chronic
undernutrition by one-third and child mortality by one-quarter
(Black et al, 2008). While these would be extremely significant
actions, it is also clear that without efforts to address the
indirect or underlying causes of undernutrition, the global
problem will not be resolved.
Consider for example the Emerging burden of obesity:
Overweight and obesity prevalence is increasing in children
younger than 5 years globally, especially in developing
countries, and is becoming an increasingly important
contributor to adult obesity, diabetes, and non-communicable
diseases. Although the prevalence of overweight in high-income
countries is more than double that in LMICs, most affected
children (76% of the total number) live in LMICs (Black, et al.
2013)..
Interventions to promote home stimulation and learning
opportunities in addition to good nutrition will be needed to
ensure optimum early development and longer-term gains in
human capital. Most development agencies have revised their
strategies to address undernutrition focused on the 1000 days
during pregnancy and the first 2 years of life, as called for in
the 2008 Series. One of the main drivers of this new
international commitment is the Scaling Up Nutrition (SUN)
movement. National commitment in LMICs is growing, donor
funding is rising, and civil society and the private sector are
increasingly engaged. If trends are not reversed, increasing
rates of childhood overweight and obesity will have vast
implications, not only for future health-care expenditures but
also for the overall development of nations (Black et al, 2008;
Black, et al. 2013).

6. How nutrition relates to development (MDGs)
Each of the MDGs bears a relationship with nutrition.
Remember the MDGs discussed in earlier modules? Take the
following few as examples:
MDG1. One of the three primary targets for MDG1, (1C) aims
at halving, between 1990 and 2015, the proportion of people
who suffer from hunger. The indicators used to measure
progress towards this target are: the prevalence of underweight
children under-five years of age; and the proportion of
population below minimum level of dietary energy
consumption. Thus nutrition is crucial in achieving the goal.
MDG2: The aim of MDG2 is to ensure that, by 2015, children
everywhere, boys and girls alike, will be able to complete a full
course of primary schooling. As we all know
· Undernutrition reduces mental capacity and therefore school
performance. Undernourished children are less likely to attend
school
· Iodine and iron are essential for cognitive development.
Thus nutrition is also crucial in the achievement of MDG2.
MDG3: The objective of MDG3 is to promote gender equality
and empower women. Nutrition relates to gender equality in the
following ways:
· Gender inequality increases the risk of female malnutrition
· Better nourished girls are more likely to stay in school
· Baby-friendly communities with breastfeeding facilities
empower women
MDG 4: Aims to reduce by two thirds, between 1990 and 2015,
the mortality rate of children under 5 years of age. Nutrition
relates to child mortality in the following ways:
· Undernutrition is associated with around 45% of child
mortality
· Undernutrition is the main contributor to the burden of disease
in the low income countries
· Specific micronutrients such as vitamin A are crucial for child
survival
· Exclusive breastfeeding and appropriate complementary

7. feeding are critical for adequate nutrition and development
Key trends on disease burden due to nutritional conditions
· Iron and calcium deficiencies contribute substantially to
maternal deaths
· Maternal iron deficiency is associated with babies with low
weight (<2500 g) at birth
· Maternal and child undernutrition, and unstimulating
household environments, contribute to deficits in children’s
development and health and productivity in adulthood
· Maternal overweight and obesity are associated with maternal
morbidity, preterm birth, and increased infant mortality
· Fetal growth restriction is associated with maternal short
stature and underweight and causes 12% of neonatal deaths
· Stunting prevalence is slowly decreasing globally, but affected
at least 165 million children younger than 5 years in 2011;
wasting affected at least 52 million children
· Suboptimum breastfeeding results in more than 800 000 child
deaths annually
· Undernutrition, including fetal growth restriction, suboptimum
breastfeeding, stunting, wasting, and deficiencies of vitamin A
and zinc, cause 45% of child deaths, resulting in 3·1 million
deaths annually
· Prevalence of overweight and obesity is increasing in children
younger than 5 years globally and is an important contributor to
diabetes and other chronic diseases in adulthood
· Undernutrition during pregnancy, affecting fetal growth, and
the first 2 years of life is a major determinant of both stunting
of linear growth and subsequent obesity and non-communicable
diseases in adulthood
Source: at
http://download.thelancet.com/flatcontentassets/pdfs/nutrition-
eng.pdf
Key messages on enabling environments for nutrition

8. · Emerging country experiences show that rates of
undernutrition reduction can be accelerated with deliberate
action.
· Politicians and policymakers who want to promote broad-
based growth and prevent human suffering should prioritize
investment in scale-up of nutrition-specific interventions, and
should maximize the nutrition sensitivity of national
development processes
· Findings from studies of nutrition governance and policy
processes broadly concur on three factors that shape enabling
environments: knowledge and evidence, politics and
governance, and capacity and resources
· Framing of undernutrition reduction as an apolitical issue is
myopic and self-defeating. Political calculations are at the basis
of effective coordination between sectors, national and
subnational levels, private sector engagement, resource
mobilization, and state accountability to its citizens
· Political commitment can be developed in a short time, but
commitment must not be squandered—conversion to results
needs a different set of strategies and skills
· Leadership for nutrition, at all levels, and from a variety of
perspectives, is fundamentally important for creating and
sustaining momentum and for conversion of that momentum into
results on the ground.
· Acceleration and sustaining of progress in nutrition will not be
possible without national and global support to a long-term
process of strengthening systemic and organizational capacities
· The private sector has substantial potential to contribute to
acceleration of improvements in nutrition, but efforts to realize
this have to date been hindered by a scarcity of credible
evidence and trust. Both these issues need substantial attention
if the positive potential is to be realized
· Operational research of delivery, implementation, and scale-up
of interventions, and contextual analyses about how to shape
and sustain enabling environments, is essential as the focus

9. shifts toward action
Source: at
http://download.thelancet.com/flatcontentassets/pdfs/nutrition-
eng.pdf
Sources used
Black RE, Allen LH, Bhutta ZA, et al, for the Maternal and
Child Undernutrition Study Group. Maternal and child
undernutrition: global and regional exposures and health
consequences. Lancet 2008; 371: 243–60.
Black RE, Victora CG, Walker SP, and the Maternal and Child
Nutrition Study Group. Maternal and child undernutrition and
overweight in low-income and middle-income countries. Lancet
2013; published online June 6. http://
dx.doi.org/10.1016/S0140-6736(13)60937-X.
Maternal and Child Nutrition: Executive Summary of The
Lancet Maternal and Child Nutrition Series. Accessed at
http://download.thelancet.com/flatcontentassets/pdfs/nutrition-
eng.pdf
Schedule and Assignments for Module V
Assignments
Due Date (by mid-night)
1. Study all required readings.
Chapter reflection
Post Bb Discussion and respond
Sunday Nov. 1.
Friday Oct 30.
Ongoing but preferably by Monday Nov. 2

10. 2. Take Module V Quiz.
Sunday Nov. 1: Test questions cover material from all
required/assigned readings.
3. Watch Group 3 Case presentation and submit questions in Bb.
Nov. 8
Required reading:
a) Chapter 11 Jacobsen (2014)
b) Cases 8 and 12
c) Module V Notes
d) Module V PPTs
e)
http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673
613610867.pdf
f)
http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673
613610843.pdf
g)
http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673
613609885.pdf
h) http://ije.oxfordjournals.org/content/35/1/24.full.pdf+html
Recommended reading:
Merson et al (2012) Global Health: Diseases, Programs,
Systems, and Policies. Chapter 6.
Pages: 243-271 and one micronutrient of your choice (Vitamin
A, Iron, Zinc etc) from pages 271-301.
1
Please write a three paragraph summary due next week
regarding either the documentary "Inside Job" or "Capitalism: A
Love Story." Discuss the financial crisis and how the current
state of capitalism impacted average Americans. Further, do you
believe that there still is a middle class in the U.S.? Be sure to

11. consider the difference between positive and normative
economics; that is what is versus what should be with respect to
the differences between the films.