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1.2Undernutrition and its consequences

Undernutrition includes a broad range of conditions that arise from a deficit in the energy, protein and/or micronutrients provided by the diet. The deficit may be caused by insufficient intake (and may be described as ‘hunger’) or poor use of those nutrients consumed (associated with illness or ‘morbidity’). See Section 1.4.

1.2.1The consequences at individual level

Undernutrition in children and mothers has devastating consequences in developing countries:

  • Undernutrition causes the death of over three million children every year;9

  • It contributes to 35 % of the illnesses suffered by children under five;

  • It contributes to 11 % of the illnesses suffered globally (adults and children);

  • Undernutrition in childhood increases the risk of chronic illness in adulthood (such as diabetes and obesity), with serious consequences for adult health, productivity and survival;

  • A girl affected by stunting in the early stages of life (from pregnancy to two years of age) is more likely to grow into a shorter woman. This deprivation impairs birth outcomes: her babies are more likely to be small and face a higher risk of undernutrition;

  • Also, the mother is more likely to die in childbirth (iron deficiency anaemia and low height in pregnant mothers are implicated in one in five maternal deaths).

Table 1: The disease burden and deaths associated with undernutrition10


% of deaths in children under 5

Disease burden (1000 DALYs)

% of DALYs in
children under 5 years


1 491 188


54 912



1 509 236


64 566


Low birthweight

337 047


15 536


Vit. A deficiency11

667 771


22 668


Zinc deficiency12

453 207


16 342


Iron deficiency13

20 854


2 156


Iodine deficiency14

3 619


2 614


Note: DALY stands for Disability-Adjusted Life Year.

Undernutrition, in addition to its physical consequences, impairs individuals’ mental capacity:

  • Undernutrition impairs brain development so that children do less well at school. There is evidence that stunted children, compared with non-stunted children, were less likely to be enrolled in school, more likely to enrol late, to attain lower achievement levels or grades for their age, and have poorer cognitive ability or achievement scores.15

  • Studies in 79 countries show that every 10 % increase in stunting is matched by a 7.9 % drop in the proportion of children reaching the final grade of primary school.16

  • Iodine deficiency impairs the mental development of 18 million babies born each year.17

  • Low birth weight may reduce a person’s IQ by 5 percentage points.

The combination of physical and mental impairment plus weaker health leads to fewer income opportunities and lower success in an individual’s working life. The economic costs of undernutrition have been estimated at 10 % of individuals’ lifetime earnings.18 This has a bearing on the development prospects of countries.

1.2.2Consequences at national level

Undernutrition is both a consequence and a cause of poverty. It disproportionately affects poor people. For example, severe stunting is almost three times higher amongst the poorest population groups than the richest ones.19

  • The economic costs of undernutrition have been estimated at 2 % to 8 % of GDP.20 Even a single micronutrient may have an impact on national economies. For instance, iron deficiency anaemia has been shown to be responsible for a 5.2 % drop in GDP in Pakistan and a 7.9 % drop in GDP in Bangladesh, though further research is needed to validate these findings.21

  • Undernutrition puts a strain on over-stretched health systems – immediately, because undernourished individuals are more likely to be sick, and in the long term, as undernutrition in childhood is associated with chronic, costly, diseases later in life.

Improved nutrition can drive economic growth. Equitable economic growth – that benefits the poorest – can significantly help improve nutrition. However, even equitable economic growth will not be sufficient to tackle undernutrition. Countries and development actors need to first create a policy environment geared to addressing undernutrition, and second invest in a coherent package of measures.

Undernutrition is the biggest development challenge facing the world22

1.2.3Consequences at international level

Political interest in nutrition has been fuelled by concerns that the Millennium Development Goals (MDGs) are unlikely to be achieved by the target date of 2015 and a realisation that adequate nutrition is required to achieve three of them (see Table 2).

Table 2: Nutrition in the Millennium Development Goals

Goal 1: Eradicate extreme poverty and hunger

Target: Halve the proportion of people who suffer from hunger

Indicators: 1.1 Prevalence of underweight children aged below five years

1.2 Proportion of population below minimum level of dietary energy consumption

Goal 4: Reduce child mortality

Target: Reduce by two-thirds the under-five mortality rate

Indicators: 4.1 Under-five mortality rate

4.2 Infant mortality rate

4.3 Proportion of 1 year-old children immunised against measles

Goal 5: Improve maternal health 

Target: Reduce by three-quarters the maternal mortality ratio

Indicators: 5.1 Maternal mortality ratio

5.2 Proportion of births attended by skilled health personnel

In addition, undernutrition impedes the attainment of three other Goals23:

Goal 2: Achieve universal primary education (undernourished children are less likely to enrol in school, more likely to enrol later and more likely to drop-out of school at an earlier age).

Goal 3: Promote gender equality and empower women (undernourished girls are less likely to stay in school and therefore have diminished chances to control future life choices).

Goal 6: Combat HIV/AIDS, malaria and other diseases (undernutrition hastens the onset of AIDS among HIV-positive persons; babies born to HIV-positive mothers may become nutritionally deprived through early cessation or even absence of exclusive breastfeeding; undernutrition reduces malaria and tuberculosis survival rates and weakens resistance to infections).

Thus, the MDGs and nutrition are interdependent: improved nutrition contributes to achieving the MDGs; and achieving the MDGs underpins an effective response to undernutrition.

1.3The scale of the problem 24

  • Around 195 million, or a third of children below five years in low/middle-income countries, are stunted.

  • About 75 million children (13 %) under five years of age are wasted, 26 million severely so.

  • 19 million babies are born each year with a low birthweight due to poor growth in the womb.

  • Around 33 % (190 million) of preschool age children and 15 % (19 million) of pregnant women lack sufficient vitamin A in their diet and can be classified as vitamin A deficient.

  • Iron deficiency affects about 25 % of the world’s population, especially young children and women.

  • 41 million newborns are not protected against iodine deficiency disorders.25

Although the numbers affected are high, undernutrition is concentrated in relatively few countries.

  • Around 80 % of the world’s stunted children live in 24 countries.

  • Around 80 % of the world’s underweight children live in 10 countries.26

  • The regions worst-affected by undernutrition are south-central Asia and sub-Saharan Africa.

Annex 2 lists the countries with the highest numbers and the highest prevalence rates (proportion) of stunted children. Those bearing the greatest burden are shown in Figure 3.

Figure 3: 90 % of the world’s stunted children live in 36 countries

Source: Black et al, 2008.Lancet series

1.3.1Fragile states

Fragility refers to weak or failing structures and to situations where the social contract is broken due to the State’s incapacity or unwillingness to deal with its basic functions, meet its obligations and responsibilities regarding service delivery, management of resources, rule of law, equitable access to power, security and safety of the populace and protection and promotion of citizens’ rights and freedoms.27

48 countries identified by the OECD as fragile or conflict-affected are home to about a third of the world’s stunted children aged below 5 years. Half of the 36 countries where 90 % of the world’s stunted children live are considered ‘fragile’ according to OECD criteria.28

Nutritional deprivation and hunger can contribute to both the causes and consequences of fragility. Early warning of food insecurity, and/or evidence of nutritional deterioration may be incorporated into analyses of a state’s fragility. The EU and Member States are committed to preventing fragility, addressing its root causes and tackling its consequences. This requires comprehensive engagement with a coordinated application of the various humanitarian, development, diplomacy, law enforcement and security instruments.


  • Progress towards MDG 1 is slow and insufficient. The proportion of underweight children under five years of age declined from 31 % to 26 % between 1990 and 2008, against the 2015 target of 15 % (Figure 4 shows that the proportion fell in all regions).

Figure 4: Regional progress in addressing underweight in children

Source: UNICEF, 2010. Progress for Children. Achieving the MDGs with Equity. No 9, September 2010. Page 16

  • Out of 118 countries, 37 have made insufficient progress and 19 have made none.29 Most of these 19 are in Africa, where the absolute number of underweight children is projected to continue increasing (having risen from 27 million in 1980 to 44 million in 200530).

  • Across developing regions (South Asia, Sub-Saharan Africa and Middle East & North Africa), underweight is more prevalent amongst the poorest children and those living in rural areas.31

  • Improvements in nutrition are not shared equally across all population groups. In India, for example, the prevalence of underweight in the richest 20 % children dropped by about a third from 1990 to 2008, whereas in the poorest 20 % children, there was no significant difference.32

  • Trends in micronutrient deficiencies are less clear, partly because of changes in methodology, inclusion of younger infants and expansion of preventive programmes. Data from 2004 show how micronutrient deficiencies continue to be significant, especially Vitamin A and zinc.33

1.4Causes of undernutrition

There are numerous possible causes of undernutrition. They are usually analysed in terms of three levels - immediate, underlying or basic causes. These levels are based on UNICEF’s conceptual framework developed in the 1990s, which still underpins much of the thinking around the problem internationally (see Figure 5 below).

  • Immediate causes relate to individual level and have two dimensions: dietary intake and health status. This distinction emphasises the limitation of ‘hunger’ to denote undernutrition, for hunger may or may not be a cause of undernutrition.

  • Underlying causes operate at household and community levels. They comprise three categories: household food security, care for children/women and health environment/ health services. Income poverty underpins all three.

  • Basic causes include a range of factors operating at sub-national, national and international levels, ranging from natural resources, social and economic environments to political contexts.

The relative importance of potential causes depends on the specific dynamics of each situation and population group. For this reason, a thorough situation analysis is a critical pre-requisite to any response effort (see Chapter 3).

The various determinants of undernutrition can act in synergy so that one cause influences others. Given this complex interplay, a multi-sectoral approach is required to act on multiple determinants and prevent/address long-term undernutrition. This is also true in humanitarian contexts, although assistance tends to prioritise life-saving interventions focused on immediate and underlying causes.

Figure 5: A model of the causal pathways leading to undernutrition

Short-term consequences:

Mortality, morbidity, disability

Long-term consequences:

Adult size, intellectual ability, economic productivity,
reproductive performance,
metabolic and cardiovascular disease

Maternal and child undernutrition

Source: Based on UNICEF, 1990: Strategy for Improved Nutrition of Children and Women in Developing Countries; and adapted in the Lancet Series (2008).

Undernutrition can develop over short (acute) or long (chronic) periods of time. To tackle undernutrition, two broad approaches can be followed. Firstly, there are strategies and interventions that have a direct impact on nutritional status by tackling the immediate causes of undernutrition – such as feeding programmes, provision of micronutrient supplements or support for infant feeding. Secondly, there are strategies and interventions that have an indirect impact on nutritional status by tackling the underlying and basic causes of undernutrition – by improving health status, sanitary conditions34, access to more/better quality food, or increasing household income. Both approaches are generally necessary. Figure 6 summarises different programming options that can contribute to reducing undernutrition.

Figure 6: Nutrition framework for action

Multi-country evidence on tackling undernutrition

There is evidence from 63 countries on how different investments contribute to reducing underweight amongst children:

Underlying causes:

43 % of the total reduction in undernutrition came from improvements in child care as represented by women’s education (female enrolment at school);

26 % came from increases in per capita food availability;

19 % came from improvements in the health environment (access to safe water); and

12 % came from improvements in women’s status (female to male life expectancy).

Basic causes:

50 % of the reduction in undernutrition came from increased per capita national income

0 % came from overall improvements in democracy, despite the potentially powerful influence that democracy can exert by giving people a voice in how government resources are allocated. Public accountability had generally not improved in the countries studied over the study period.

The study concludes that actions in sectors that are not the traditional focus of nutrition action can make significant achievements in reducing undernutrition. However, this requires more awareness of the roles these basic causes play in reducing undernutrition and political commitment to do so.

The following chapter demonstrates how different sectoral/thematic aspects of aid investment can tackle immediate, underlying or basic causes of undernutrition.

Sources of further information

DANIDA, 2009. Addressing the Underlying and Basic Causes of Child Undernutrition in Developing Countries: What Works And Why? Evaluation Study 2009/2. http://www.um.dk/NR/rdonlyres/8A1655B7-736C-4403-AE6A-9F7AAF3942F1/0/200902Nutritionfinaltilwww.pdf

UNICEF The State of the World’s Children statistics /rightsite/sowc/statistics.php

FAO nutrition country profiles /ag/agn/nutrition/profiles_by_country_en.stm#africa

World Bank Health, Nutrition and Population (HNP) Statistics /WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTDATASTATISTICSHNP/EXTHNPSTATS/0,,print:Y~isCURL:Y~contentMDK:21187239~menuPK:3342157~pagePK:64168445~piPK:64168309~theSitePK:3237118,00.html

World Bank World Development Indicator Database /ext/ddpreports/ViewSharedReport?&CF=&REPORT_ID=1336&REQUEST_TYPE=VIEWADVANCED

Tracking Progress on Child and Maternal Nutrition: A survival and development priority, UNICEF, 2009 /publications/index_51656.html

DHS survey results: /countries/start.cfm

MICS survey results: /statistics/index_countrystats.html

WHO’s Vitamin and Mineral Nutrition Information System includes country information.
Iodine deficiency disorders: t/vmnis/iodine/data/en/index.html

Anaemia: t/vmnis/anaemia/data/en/index.html

Vitamin A deficiency: t/vmnis/vitamina/data/en/index.html

World Health Statistic 2009, Table 2 cause-specific mortality and morbidity t/whosis/whostat/


Source: Héloïse Troc

As discussed in the previous chapter, the causes of undernutrition are multi-sectoral and multi-layered (see Figure 5). Therefore undernutrition will only be tackled effectively if action is taken in all relevant sectors to address those causes that they can influence. Doing so would also result in several other benefits:

  • improved relevance, efficiency and effectiveness,

  • increased sustainability, equity and impact of poverty-reduction efforts;

  • mitigated risks of social crises caused by nutrition-related stress (riots resulting from rising prices, hunger or displacement);

  • less need for emergency aid, and lower social, economic and financial costs of crises, through preventive action; and

  • stimulus to empower all citizens through capacity building for better nutrition integration. The benefits will be especially felt by poor people, women and indigenous groups, through fostering a culture of shared democracy, participation and rights awareness.

These expected benefits will only be realised if they are planned for and included in several thematic areas and sectors. In order to provide guidance that resonates with, and is practicable for, each of the 27 Member States in the European Union, as well as the European Commission, this chapter has been structured to reflect the aspects of assistance areas under the European Consensus on Development35 and the European Consensus on Humanitarian Aid.36

Whichever thematic area or sector used, it is important to measure their contribution to combating undernutrition. There are a great many possible indicators, too many to list in this Reference document. Box 1 presents the main indicators with an impact on nutrition, which may be valuable for a range of sectoral approaches. Annex 3 provides additional options of indicators linked to inputs, outputs and outcomes. All indicators used in this reference document are derived from current internationally accepted standards.37

The boxes at the end of each section below contain only those indicators that bring specific added value to nutrition. They are intended to complement the core/usual indicators for each sector/thematic area. Some indicators and contributions are valid for several sectors and are therefore repeated.

Box 1: Impact indicators potentially relevant to all aspects of external assistance

(see Annex 3 for further details)

  • Prevalence of stunting in children aged <5 years

  • Prevalence of underweight in children aged <5 years

  • Prevalence of wasting in children aged < 5 years

  • Prevalence of severe acute malnutrition (including oedema) in children < 5 years

  • Prevalence of low MUAC (6-59 months)

  • Low Birth Weight rate (LBW)

  • Prevalence of low Body Mass Index in women of reproductive age

  • Prevalence of overweight amongst women of reproductive age

  • Prevalence of iodine deficiency disorders (IODD)

  • Prevalence of children (2-5 years) suffering from vitamin A deficiency

  • Prevalence of pregnant or lactating women suffering from vitamin A deficiency

  • Prevalence of anaemia in children aged 6 – 59 months

  • Prevalence of anaemia amongst pregnant women

  • Maternal mortality ratio (per 100 000 live births)

  • Infant mortality rate

  • Under five mortality rate

2.1 Improving nutrition through health

The health sector plays an essential role for nutrition. The World Health Assembly adopted several resolutions38 on infant and young child nutrition including the Resolution39 adopted in May 2010. The health sector contributes to nutrition by taking action to support child and maternal health and through a package of nutrition-specific actions such as breastfeeding promotion (see Annex 4), management of severe acute malnutrition and vitamin A supplementation.

Possible contributions to this aspect of undernutrition include:

  • Health policies – addressing disparities in access to comprehensive packages of nutrition interventions for women and young children;

  • Health information systems – incorporating nutrition indices in routine reports from health facilities and supervision/evaluation procedures. Community health diagnosis, national surveys (e.g. Demographic Household Survey (DHS), Multiple Indicator Cluster Surveys (MICS)) and surveillance – to include an analysis of the nutrition situation (nature, levels, distribution, trends, causes);

  • Primary health care – for early diagnosis and treatment of diseases and hence prevention of nutritional deterioration; community-based management of acute undernutrition (see case study Malawi - Scaling Up the Management of Acute Malnutrition in separate file and India – The Dular Strategy in Chapter 2) screening for nutritional problems; and nutrition campaigns, especially for pregnant and lactating women and children (e.g. iron-folate and vitamin A supplementation; hygiene promotion; de-worming; zinc to manage diarrhoea and Behaviour Change Communication (BCC) concerning breastfeeding or complementary feeding). See Zimbabwe Case Study on breastfeeding promotion in separate file;

  • Tertiary health care (district and reference health facilities) – for treating cases of severe acute undernutrition and severe micronutrient deficiencies (e.g. severe anaemia with medical complications). Nutrition supplementation for main prevalent diseases (HIV/AIDS, tuberculosis, diabetes, post-measles, endemic parasitic diseases) (see Zimbabwe case study on HIV in separate file);

  • Vaccination campaigns and other special health events – to distribute vitamin A and/or other micronutrients; to screen and refer moderate and/or severe cases of undernutrition; to promote appropriate infant and young child feeding; to discuss constraints that impact on care practices and identify solutions;

  • Capacity development – raising awareness of undernutrition and building relevant skills amongst health staff at all levels; including nutrition modules in medical, nurse or health assistant training; creating capacity for community-based management of acute undernutrition; (see Burundi case study on capacity building in separate file);

  • Supply chain – includes delivery and supply of nutritional products and materials; support local production of ready-to-use food products (see Malawi case study on the Management of Acute Malnutrition again, in separate file);

  • Increasing collaboration with other sectors and exploiting synergies (e.g. establishing links with social protection services). See the Peru case study in Chapter 4;

  • Promoting local production of specialised products that meet quality standards;

  • Advocacy and policy support - to incorporate nutrition into national strategies and plans, including emergency preparedness plans and poverty-reduction strategies.

Annex 5 contains a list of health interventions that have proved effective in improving nutrition. This list will need to be revised and expanded as further evidence becomes available. According to the 2008 Lancet40 Series on Maternal and Child Undernutrition, universal coverage with the full package of effective interventions ‘could prevent about one quarter of child deaths under 36 months of age and reduce the prevalence of stunting at 36 months by about one third41’ in the 36 countries with 90 % of stunted children. Scaling up these interventions to achieve a high and equitable coverage, and sustain it, remains a challenge in many countries. This is often due to insufficient human and financial resources and the low strategic priority given to nutrition.

The authors of the 2008 Lancet Series on Maternal and Child Undernutrition also stress the need to ‘exclude ineffective actions to avoid dilution of focus and the waste of human and financial resources’. ‘Ineffective actions in this context refer to those that are unlikely to improve nutritional status or any of its underlying determinants.’ Three interventions commonly implemented have been ‘found to be ineffective as direct contributors to reducing undernutrition in mothers or young children: growth monitoring (unless linked to adequate nutrition counselling and referrals); preschool feeding programmes targeting children over 24 months; and school feeding programmes targeting children older than 5 years of age’.

The box below lists only those indicators with specific added value to nutrition. They are intended to complement health indicators essential to nutrition such as vaccination coverage and antenatal care.

Box 2: Key indicators of nutrition benefits through health

(see also impact indicators in Box 1 and more information on indicators in Annex 3)

  • Early initiation of breastfeeding

  • Exclusive breastfeeding under 6 months

  • Coverage of child vitamin A supplementation

  • Post partum vitamin A supplementation

  • Coverage of iron/folate supplementation during pregnancy

  • Coverage of the treatment of severe acute malnutrition

  • Adequate introduction of complementary food

  • Minimum dietary diversity (6-23 months)

  • Minimum acceptable diet (6-23 months)

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