Risk factors for Malnutrition

3.2.1 Poverty and ignorance

Worldwide, about one billion people are hungry and about 2.6 billion people are poor.¹⁹⁵ Studies in Bangladesh, Nepal and Pakistan observed that the situation is worsening; for example, in Bangladesh, there was an increasing trend in the number of hungry people from 20.3 millon in 1970 to 33.3 million in 1990, 43.1 million in 2001/03, 44.0 million in 2004/06 and as at 2007/08,estimated number of hungry people was 65.3 million .¹⁹⁵ Seeing as the price of staple foods is increasing and economic growth is poor, there is little evidence to show that other countries are doing better.¹⁹⁵

54 A consequence of poverty that has been recognized for so long is malnutrition since most of the world’s malnourished children live in the developing nations of Asia, Africa and Latin America where those mostly affected are from low income families.¹⁹⁶ Most of the resources of these developing countries are spent servicing external debts at the expense of health and other social welfare services and also corruption by political leaders leading to heavy depletion of public funds as well as the ravaging effects of wars and strife result in economic instability and low purchasing power of the currencies, thus translating to low standard of living of the people.¹⁹⁷It is also viewed that the problem today is not lack of enough food at least, compared to the relative recent past but that food is neither produced nor distributed equitably. The poor in fertile developing countries are mostly deprived of food as ample harvest and bumper crops are exported for hard cash.¹⁹⁸

At the household level, when income decreases, the quality and quantity of food also decrease.

Evidence shows that when there are unemployment and low wages in families, cheaper food remains the option and because these foods are less nutritious, resultant effects are weight loss and malnutrition.¹⁹⁵ Because food products derived from animals are usually more expensive, children’s intake of proteins and nutrients from these groups decreases with poverty and when the food ingested does not meet the high protein and energy needs of the child, malnutrition develops.^199,200 Ignorance is directly associated with poor infant and child rearing practices, misconceptions about food, inadequate feeding during illness (especially infectious diseases and diarrhoea) and improper food distribution among family members.²⁰¹

3.2.2 Infections

Infections result in increased needs and a high energy expenditure, lower appetite, nutrient losses due to vomiting, diarrhoea, poor digestion, mal-absorption and the utilization of nutrients and disruption of metabolic equilibrium, so playing a major role in the aetiology of

55 malnutrition.^{202, 203} Repeated illnesses contribute to ill health and compromised nutritional status.²⁰⁴ Although it is understood that parasites may lead to malnutrition, the extent to which malnutrition itself causes increased parasite infestation is not clearly known. Nonetheless, the conditions so frequently coexist that they need to be considered together ²⁰⁵, and the high prevalence of bacterial and parasitic diseases in developing countries have been found to greatly contribute to malnutrition there.^14-18

3.2.3 Maternal factors

Childcare practices also include protecting the children’s food and drinks from contamination to reduce the risk of infections. A caregiver’s unwashed hands can cause infections such as diarrhoea.²⁰⁶ In a study in Eldoret, Kenya, it was found that the social risk factors for PEM included being a single mother and a young mother aged 15- 25 years.²⁰⁷Other social problems include child abuse and maternal deprivation.^{201, 208} In Southern Africa there is a decrease in caring capabilities of caregivers the moment poverty and food insecurity increases.²⁰⁹

When the household income decreases, it is usually the women who try earning extra wages.

This causes the mother to have less time for childcare and ensuring the children eat healthy food. If the female children are also sent out to look for work, this results in poor school attendance, which influences education, leading to poor knowledge and caring practices for her own family.^{194, 195}

3.2.4 Inadequate health services and environment

Accessibility to health services is lacking in the developing countries and even the ones available are not being made use of by the patients, thereby making malnutrition rate to still be very high in the developing countries as reported in studies.^{210, 211}

In a prospective study at the Moi teaching and referral hospital, Eldoret in Kenya, it was found that incomplete immunizations were a risk factor for the development of malnutrition ²⁰⁷, and

56 incomplete BCG vaccination against TB has been found to increase the risk for the development of severe PEM in Bangladesh in another study among under five children in three villages. ²¹²

3.2.5 Overcrowding and unhealthy environment

Unhealthy environments, overcrowding, lack of water and unclean water and poor sanitation, directly lead to malnutrition through infections and they also increase the risk of repeated infections according to the WHO.²¹³

Overcrowding and poor environmental sanitation are closely linked to poverty and often cause illness in children, especially in developing countries^{201, 204} and households where there was child waste inside the house had a 7.5 times greater chance of experiencing malnutrition than those that had a clean environment within the house or ten metres from the home as reported by a study in south india.²¹⁴

3.2.6 Information and Education

Formal education can lead directly to a higher knowledge of mothers; literacy acquired in school makes it possible for mothers to identify health problems in children and when mothers have attended school, they are more aware of modern diseases and where to get help and information.¹⁹⁹The school education that mothers receive, though might not include nutrition education can still help with caring for children and the household. Both female and male education can have a positive effect on the child’s nutritional status. Knowledge can lead to a higher household income and better nutritional status when the education is linked with strategies to improve both.¹⁹⁹

Several studies have found association between the above factors and malnutrition. In Pakistan amongst school children, malnutrition was present in 49% of families in the lowest bracket (<

Rs 3000) compared to 33% in the Rs 3000 – 6000 bracket and 29% in the >Rs 6000 bracket.²¹⁵ A few longitudinal studies of children have clearly shown that repeated episodes of respiratory

57 and intestinal infections, including worms, are associated with undernutrition and growth failure like the prospective studies in Santa Mara Cauqué and Peruvian children.^216,217 However, most of the evidence comes from cross sectional studies because prospective studies are uncommon and associated with a lot of ethical issues. These cross sectional studies are difficult to interpret because they suffer from reverse causality bias: did infection cause undernutrition or did undernutrition increase the risk of infection, as undernutrition is both an outcome and a risk factor. For example, if a wasted child is heavily infected with worms, did the worms cause the undernutrition or did the undernutrition predispose the child to heavy infection. A study in Nepal, SEAR reported that more than 68% of mothers of malnourished children were illiterate compared to 56% of normal children. The percentage of mothers of undernourished children in the low income category was more than double that of normal children. Literacy, occupation, monthly per capita income and diet knowledge of mother were found to have highly significant association (p<0.005) with malnutrition among children.¹⁸⁸ Those children whose families had a monthly income of less than 200 ETB (Ethiopian birr) were highly affected by malnutrition (P < 0.05) in a survey in Ethiopia.²¹⁸

In Nigeria, overcrowding, low maternal income and the use of infant formula feeds in children who have attained the age of 6 months and above were associated with a higher prevalence of wasting (P = 0.029, P = 0.031 and P = 0.005 respectively) in a survey in Osun State.¹⁹²Also, a study among school children and adolescents in Abeokuta, South-West Nigeria identified that the risk factors associated with stunting were attendance of public schools (p<0.001), polygamous family setting (p=0.001), low maternal education (p=0.001), and low social class (p=0.034) and following multivariate analysis with logistic regression, low maternal education (odds ratio=2.4; 95% confidence interval 1.20-4.9; p=0.015) was found to be the major contributory factor to stunting.²¹⁹

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