The Basic Determinants of Malnutrition: Resources, Structures, Ideas and Power

Document Type : Review Article

Authors

Institute of Development Studies, University of Sussex, Brighton, UK

Abstract

Background
While child undernutrition is improving overall, different population groups are experiencing different outcomes. What sets some groups apart is their experience of the ‘basic determinants’ of malnutrition, that underpin the ‘immediate’ and ‘underlying’ determinants, and that have been much less studied, defined and understood.
 
Methods
We undertook a qualitative narrative review based in two sets of ideas: nutrition’s basic determinants as laid out in the original United Nations Children’s Fund (UNICEF) framework, and critical concepts emerging from development studies. These ideas informed searches in Google Scholar, and resulting papers formed the basis for the review.
 
Results
Based on this literature, we expand and clarify the terminology of ‘basic determinants’ into a new framework, to include (1) resources and (material, human, social and natural) capitals at the basic level; (2) structures including social, market, legal and political systems driven by long-term demographic, economic, and environmental trends; and (3) ideas, beliefs and ideologies prevailing within a given society – crystallising into social norms and institutions – fundamentally shaping how societies are structured around power and marginalisation. We then illustrate with existing literature how these basic factors play out in the food, health and care determinants of malnutrition; and how theories of human rights and collective commons point us towards practical redressal options through improved participation and accountability.
 
Conclusion
We show here that the basic determinants are not a black box of ‘context,’ but can be broken down into comprehensible issues that are amenable to change, and should be considered explicitly in research and action to reduce the global burden of malnutrition.

Keywords


  1. United Nations Children’s Fund (UNICEF). Strategy for Improved Nutrition of Children and Women in Developing Countries.: UNICEF; 1990.
  2. Black RE, Alderman H, Bhutta ZA, et al. Maternal and child nutrition: building momentum for impact. Lancet. 2013;382(9890):372-375. doi:10.1016/s0140-6736(13)60988-5
  3. Popkin BM, Corvalan C, Grummer-Strawn LM. Dynamics of the double burden of malnutrition and the changing nutrition reality. Lancet. 2020;395(10217):65-74. doi:10.1016/s0140-6736(19)32497-3
  4. Scrinis G. Reframing malnutrition in all its forms: a critique of the tripartite classification of malnutrition. Glob Food Sec. 2020;26:100396. doi:10.1016/j.gfs.2020.100396
  5. Wells JC, Sawaya AL, Wibaek R, et al. The double burden of malnutrition: aetiological pathways and consequences for health. Lancet. 2020;395(10217):75-88. doi:10.1016/s0140-6736(19)32472-9
  6. Wells JC. Maternal capital and the metabolic ghetto: an evolutionary perspective on the transgenerational basis of health inequalities. Am J Hum Biol. 2010;22(1):1-17. doi:10.1002/ajhb.20994
  7. Nisbett N. Understanding the nourishment of bodies at the centre of food and health systems-systemic, bodily and new materialist perspectives on nutritional inequity. Soc Sci Med. 2019;228:9-16. doi:10.1016/j.socscimed.2019.02.041
  8. Baethge C, Goldbeck-Wood S, Mertens S. SANRA-a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5. doi:10.1186/s41073-019-0064-8
  9. Longhurst R. Introduction: universal development–research and practice. In: Longhurst R, ed. Has Universal Development Come of Age? IDS Bulletin. 2017;48(1A):1-24.
  10. Friel S, Ford L. Systems, food security and human health. Food Secur. 2015;7(2):437-451. doi:10.1007/s12571-015-0433-1
  11. Lancet. Executive summary of the lancet maternal and child nutrition series. Lancet. 2013;382(9890):1-12.
  12. United Nations Children’s Fund (UNICEF). UNICEF’s Approach to Scaling Up Nutrition for Mothers and Their Children. UNICEF; 2015.
  13. Development Initiatives. 2018 Global Nutrition Report: Shining a Light to Spur Action on Nutrition. 2018.
  14. Bourdieu P, Nice R. Distinction: A Social Critique of the Judgement of Taste. London: Routledge & Kegan Paul; 1984.
  15. Scoones I. Sustainable Rural Livelihoods: A Framework for Analysis. IDS Working Paper 72. 1998.
  16. McMichael P. A food regime genealogy. J Peasant Stud. 2009;36(1):139-169. doi:10.1080/03066150902820354
  17. Blouin C, Hawkes C, Henson S, Drager N, Dube L. Trade, Health and Dietary Change. In: Hawkes C, Blouin C, Henson S, Drager N, Dube L, eds. Trade, Food, Diet and Health: Perspectives and Policy Options. Chichester: Wiley-Blackwell; 2010.
  18. Berry BJ. The Human Consequences of Urbanisation. London: Macmillan International Higher Education; 2015.
  19. Bettini G. Climate migration as an adaption strategy: de-securitizing climate-induced migration or making the unruly governable? Crit Stud Secur. 2014;2(2):180-195. doi:10.1080/21624887.2014.909225
  20. Foucault M. The Archaeology of Knowledge. Vol 2002. Gallimard; 1969.
  21. Rawls J. A Theory of Justice. Harvard University Press; 2009.
  22. Gaventa J. Power after Lukes: An Overview of Theories of Power Since Lukes and Their Application to Development. Brighton: Participation Group, Institute of Development Studies; 2003.
  23. Sen A. Development as Freedom. Oxford: Oxford University Press; 1999.
  24. Global Nutrition Report. 2018 Global Nutrition Report: Shining a Light to Spur Action on Nutrition. 2018.
  25. Harris J, Huynh P, Nguyen HT, et al. Nobody left behind? Equity and the drivers of stunting reduction in Vietnamese ethnic minority populations. Food Security. Forthcoming.
  26. Headey D, Hoddinott J, Park S. Drivers of nutritional change in four South Asian countries: a dynamic observational analysis. Matern Child Nutr. 2016;12(Suppl 1):210-218. doi:10.1111/mcn.12274
  27. Marphatia AA, Cole TJ, Grijalva-Eternod C, Wells JCK. Associations of gender inequality with child malnutrition and mortality across 96 countries. Glob Health Epidemiol Genom. 2016;1:e6. doi:10.1017/gheg.2016.1
  28. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-1669. doi:10.1016/s0140-6736(08)61690-6
  29. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254-258. doi:10.1136/jech.57.4.254
  30. Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet. 2003;362(9379):233-241. doi:10.1016/s0140-6736(03)13917-7
  31. Wagstaff A, Bustreo F, Bryce J, Claeson M. Child health: reaching the poor. Am J Public Health. 2004;94(5):726-736. doi:10.2105/ajph.94.5.726
  32. Kohli N, Avula R, van den Bold M, et al. Reprint of "what will it take to accelerate improvements in nutrition outcomes in Odisha? learning from the past". Glob Food Sec. 2017;13:38-48. doi:10.1016/j.gfs.2017.04.002
  33. International Institute for Population Studies. National Family Health Survey (NFHS-4). Mumbai: IIPS; 2017.
  34. Rapid Survey on children 2013-2014. Government of India:  Ministry of Women and Child Development; 2016.
  35. Gordon J, Tranchant JP, Casu L, Mitchell B, Nisbett N. APPI/SPREAD Collective Action for Nutrition Social Audit Programme Odisha, India: Final Evaluation Report. Brighton, UK: Institute of Development Studies; 2019.
  36. Marmot M. Achieving health equity: from root causes to fair outcomes. Lancet. 2007;370(9593):1153-1163. doi:10.1016/s0140-6736(07)61385-3
  37. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008;1136:161-171. doi:10.1196/annals.1425.011
  38. Drimie S, Yosef S. Reducing risk, strengthening resilience: social protection and nutrition. In: Gillespie S, Hodge J, Yosef S, Pandya-Lorch R, eds. Nourishing Millions: Stories of Change in Nutrition. International Food Policy Research Institute (IFPRI); 2016:65-72.
  39. FAO, IFAD, UNICEF, WFP, WHO. The State of Food Security and Nutrition in the World 2017: Building Resilience for Peace and Food Security. FAO; 2017.
  40. UNICEF, WHO, World Bank. Levels and Trends in Child Malnutrition. UNICEF; 2018.
  41. Development Initiatives. Global Nutrition Report 2017: Actions and Accountability to Advance Nutrition and Sustainable Development. Development Initiatives; 2017.
  42. De Schutter O. The right to adequate nutrition. Development. 2014;57(2):147-154. doi:10.1057/dev.2014.64             
  43. Friedman H, McMichael P. Agriculture and the state system: the rise and decline of national agricultures, 1870 to the present. Sociol Ruralis. 1989;29(2):93-117. doi:10.1111/j.1467-9523.1989.tb00360.x
  44. McMichael P. A food regime analysis of the ‘world food crisis.’ Agric Human Values. 2009;26(4):281. doi:10.1007/s10460-009-9218-5
  45. Mooney P. Too Big to Feed: Exploring the Impacts of Mega-Mergers, Consolidation and Concentration of Power in the Agri-Food Sector. IPES; 2017.
  46. Leach M, Nisbett N, Cabral L, Harris J, Hossain N, Thompson J. Food politics and development. World Dev. 2020;134:105024. doi:10.1016/j.worlddev.2020.105024
  47. Margulis ME. Trading out of the global food crisis? the World Trade Organization and the geopolitics of food security. Geopolitics. 2014;19(2):322-350. doi:10.1080/14650045.2014.920233
  48. Howard PH. Concentration and Power in the Food System: Who Controls What We Eat? Vol 3. London: Bloomsbury Academic; 2016.
  49. Thow AM, Jones A, Hawkes C, Ali I, Labonté R. Nutrition labelling is a trade policy issue: lessons from an analysis of specific trade concerns at the World Trade Organization. Health Promot Int. 2018;33(4):561-571. doi:10.1093/heapro/daw109
  50. Baker P, Machado P, Santos T, et al. Ultra-processed foods and the nutrition transition: global, regional and national trends, food systems transformations and political economy drivers. Obes Rev. 2020;21(12):e13126. doi:10.1111/obr.13126
  51. Friel S, Baker P, Thow AM, Gleeson D, Townsend B, Schram A. An exposé of the realpolitik of trade negotiations: implications for population nutrition. Public Health Nutr. 2019;22(16):3083-3091. doi:10.1017/s1368980019001642
  52. Hawkes C, Harris J, Gillespie S. Urbanization and the nutrition transition. In: 2017 Global Food Policy Report. Washington, DC:  International Food Policy Research Institute (IFPRI); 2017:34-41. doi:10.2499/9780896292529_04
  53. Salm L, Nisbett N, Cramer L, Gillespie S, Thornton P. How climate change interacts with inequity to affect nutrition. Wiley Interdiscip Rev Clim Change. 2020;e696. doi:10.1002/wcc.696.
  54. Global Panel on Agriculture and Food Systems for Nutrition. Food systems and diets: Facing the challenges of the 21st century. London, UK: Global Panel on Agriculture and Food Systems for Nutrition; 2016.
  55. Friedmann H. Distance and durability: shaky foundations of the world food economy. Third World Q. 1992;13(2):371-383. doi:10.1080/01436599208420282
  56. Hossain N. Inequality, hunger, and malnutrition: Power matters. In: von Grebmer K, ed. 2017 Global Hunger Index: The Inequalities of Hunger. Washington, DC: International Food Policy Research Institute; 2017:25-29.
  57. IFAD. Bangladesh Haor infrastructure and livelihood improvement project enabling poor people to adapt to climate change project design report. Volume I: Main Report. Vol. Report No.: 2263-BD. IFAD; 2011.
  58. Chowdhury IA, Kamal MM, Haque N, Islam MN, Akter S. Patterns of co-operation in community based fishery management: a sociological study on the people of Hail Haor. Asian Soc Sci. 2012;8(15):222-234. doi:10.5539/ass.v8n15p222
  59. Ahmed I, Deaton BJ, Sarker R, Virani T. Wetland ownership and management in a common property resource setting: a case study of Hakaluki Haor in Bangladesh. Ecol Econ. 2008;68(1-2):429-436. doi:10.1016/j.ecolecon.2008.04.016
  60. Nisbett N, Longhurst R, Barnett I, et al. Impact Evaluation of the DFID Programme to Accelerate Improved Nutrition for the Extreme poor in Bangladesh: Final Report. Brighton: MQSUN; 2016.
  61. Nisbett N, Davis P, Yosef S, Akhtar N. Bangladesh’s story of change in nutrition: strong improvements in basic and underlying determinants with an unfinished agenda for direct community level support. Glob Food Sec. 2017;13:21-29. doi:10.1016/j.gfs.2017.01.005
  62. Weiler AM, Hergesheimer C, Brisbois B, Wittman H, Yassi A, Spiegel JM. Food sovereignty, food security and health equity: a meta-narrative mapping exercise. Health Policy Plan. 2015;30(8):1078-1092. doi:10.1093/heapol/czu109
  63. Gaventa J. Finding the spaces for change: a power analysis. IDS Bull. 2006;37(6):23-33. doi:10.1111/j.1759-5436.2006.tb00320.x
  64. Shelton BA, John D. The division of household labor. Annu Rev Sociol. 1996;22(1):299-322. doi:10.1146/annurev.soc.22.1.299
  65. OECD. Doing Better for Families. OECD; 2011.
  66. Olivetti C, Petrongolo B. The economic consequences of family policies: lessons from a century of legislation in high-income countries. J Econ Perspect. 2017;31(1):205-230. doi:10.1257/jep.31.1.205
  67. International Labour Organization (ILO). World Employment and Social Outlook: Trends for Women 2018. Geneva: ILO; 2018.
  68. Knodel J, Loi VM, Jayakody R, Huy VT. Gender roles in the family: change and stability in Vietnam. Asian Popul Stud. 2005;1(1):69-92. doi:10.1080/17441730500125888
  69. Smith L, Haddad LJ. Explaining Child Malnutrition in Developing Countries: A Cross-Country Analysis. Vol 111. International Food Policy Research Institute (IFPRI); 2000.
  70. Komatsu H, Malapit HJL, Theis S. Does women’s time in domestic work and agriculture affect women’s and children’s dietary diversity? evidence from Bangladesh, Nepal, Cambodia, Ghana, and Mozambique. Food Policy. 2018;79:256-270. doi:10.1016/j.foodpol.2018.07.002
  71. Johnston D, Stevano S, Malapit HJ, Hull E, Kadiyala S. Review: time use as an explanation for the agri-nutrition disconnect: evidence from rural areas in low and middle-income countries. Food Policy. 2018;76:8-18. doi:10.1016/j.foodpol.2017.12.011
  72. Sear R, Mace R. Who keeps children alive? a review of the effects of kin on child survival. Evol Hum Behav. 2008;29(1):1-18. doi:10.1016/j.evolhumbehav.2007.10.001
  73. Clark S, Madhavan S, Cotton C, Beguy D, Kabiru C. Who helps single mothers in Nairobi? the role of kin support. J Marriage Fam. 2017;79(4):1186-1204. doi:10.1111/jomf.12404
  74. Harris J, Frongillo EA, Nguyen PH, Kim SS, Menon P. Changes in the policy environment for infant and young child feeding in Vietnam, Bangladesh, and Ethiopia, and the role of targeted advocacy. BMC Public Health. 2017;17(Suppl 2):492. doi:10.1186/s12889-017-4343-3
  75. Blau DM, Guilkey DK, Popkin BM. Infant health and the labor supply of mothers. J Hum Resour. 1996;31(1):90-139.
  76. Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491-504. doi:10.1016/s0140-6736(15)01044-2
  77. Razavi S. The Political and Social Economy of Care in a Development Context: Conceptual Issues, Research Questions and Policy Options. Geneva: United Nations Research Institute for Social Development; 2007.
  78. Jonsson U. The rise and fall of paradigms in world food and nutrition policy. World Nutr. 2010;1(3):128-158.
  79. Eide A. Human Rights Requirement to Social and Economic Development: The Case of the Right to Food and Nutrition Rights. Accessed Norwegian Institute of Human Rights, University of Oslo, Grensen 18, Oslo, Norway.
  80. Chapman AR. Globalization, human rights, and the social determinants of health. Bioethics. 2009;23(2):97-111. doi:10.1111/j.1467-8519.2008.00716.x
  81. Krishnaraj M. Food security, agrarian crisis and rural livelihoods: implications for women. Econ Polit Wkly. 2006;41(52):5376-5388.
  82. Damman S, Eide WB, Kuhnlein HV. Indigenous peoples’ nutrition transition in a right to food perspective. Food Policy. 2008;33(2):135-155. doi:10.1016/j.foodpol.2007.08.002
  83. Eide WB, Kracht U. Towards a definition of the right to food and nutrition: reflections on General Comment No. 12. SCN News. 1999(18):39-40. 
  84. De Schutter O. From Charity to Entitlement: Implementing the Right to Food in Southern and Eastern Africa. United Nations; 2012.
  85. Food and Agriculture Organization of the United Nations (FAO). Guidance Note: Integrating the Right to Adequate Food into Food and Nutrition Security Programmes. FAO; 2012.
  86. Jurkovich M. Feeding the Hungry: Advocacy and Blame in the Global Fight against Hunger. Cornell University Press; 2020.
  87. Harris J, Gibbons S, Kaaba OB, Hrynick T, Stirton R. A ‘right to nutrition’ in its social, legal and political context: Zambia’s experience in a global system. Forthcoming;
  88. Ignatieff M. The attack on human rights. Foreign Aff. 2001;80(6):102-116. doi:10.2307/20050331
  89. Vivero-Pol JL, Ferrando T, De Schutter O, Mattei U. Routledge Handbook of Food as a Commons. Routledge; 2018.
  90. Vivero-Pol JL. The idea of food as commons or commodity in academia. A systematic review of English scholarly texts. J Rural Stud. 2017;53:182-201. doi:10.1016/j.jrurstud.2017.05.015
  91. Smith-Nonini S. Conceiving the health commons: operationalizing a 'right' to health. Soc Anal. 2006;50(3):233-245. doi:10.2307/23182122
  92. Holt-Giménez E, Altieri MA. Agroecology, food sovereignty, and the new green revolution. Agroecol Sustain Food Syst. 2013;37(1):90-102. doi:10.1080/10440046.2012.716388
  93. Pimbert MP. Food Sovereignty, Agroecology and Biocultural Diversity: Constructing and Contesting Knowledge. Routledge; 2017.
  94. Duncan J. Global Food Security Governance: Civil Society Engagement in the Reformed Committee on World Food Security. Routledge; 2015:296.
  95. Kumanyika SK, Obarzanek E, Stettler N, et al. Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science). Circulation. 2008;118(4):428-464. doi:10.1161/circulationaha.108.189702
  96. Allender S, Nichols M, Foulkes C, et al. The development of a network for community-based obesity prevention: the CO-OPS Collaboration. BMC Public Health. 2011;11:132. doi:10.1186/1471-2458-11-132
  97. Bleich SN, Segal J, Wu Y, Wilson R, Wang Y. Systematic review of community-based childhood obesity prevention studies. Pediatrics. 2013;132(1):e201-210. doi:10.1542/peds.2013-0886
  98. King L, Gill T, Allender S, Swinburn B. Best practice principles for community-based obesity prevention: development, content and application. Obes Rev. 2011;12(5):329-338. doi:10.1111/j.1467-789X.2010.00798.x
  99. Gillespie S, Hodge J. On the front line: community nutrition programming. In: Gillespie S, Hodge J, Yosef S, Pandya-Lorch R, eds. Nourishing Millions: Stories of Change in Nutrition. IFPRI; 2016.
  100. Joshi A, Houtzager PP. Widgets or watchdogs? conceptual explorations in social accountability. Public Manag Rev. 2012;14(2):145-162. doi:10.1080/14719037.2012.657837
  101. Cornwall A, Eade D. Deconstructing Development Discourse: Buzzwords and Fuzzwords. Oxfam; 2010.
  102. Fox JA. Social accountability: what does the evidence really say? World Dev. 2015;72:346-361. doi:10.1016/j.worlddev.2015.03.011
  103. Nelson E, Bloom G, Shankland A. Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage. Brighton: IDS; 2018.
  104. Gaventa J, Martorano B. Inequality, Power and Participation–Revisiting the Links. Brighton: IDS; 2016.
  105. Nisbett N, Ahmed N, Deshpande S, Feruglio F. Social Accountabilty Initatives in Health and Nutrition: Lessons from India, Pakistan and Bangladesh. Brighton: IDS; 2017.
  106. Khera R. Democratic Politics and Legal Rights: Employment Guarantee and Food Security in India. Institute of Economic Growth, University of Delhi; 2013.
  107. Manandhar DS, Osrin D, Shrestha BP, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet. 2004;364(9438):970-979. doi:10.1016/s0140-6736(04)17021-9
  108. Prost A, Colbourn T, Seward N, et al. Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet. 2013;381(9879):1736-1746. doi:10.1016/s0140-6736(13)60685-6
  109. Ward B, Goulden J. Accountability for nutrition: A Think Piece publication of the Scaling Up Nutrition Movement. http://scalingupnutrition.org/wp-content/uploads/2016/02/Accountability-Think-Piece.pdf. Published 2015.
  110. Acosta AM, Haddad L. The politics of success in the fight against malnutrition in Peru. Food Policy. 2014;44:26-35. doi:10.1016/j.foodpol.2013.10.009
  111. Nisbett N, Barnett I. Explaining the reduction in child undernutrition in the Indian state of Maharashtra between 2006 and 2012: an analysis of the policy processes. Food Policy. 2017;70:27-39. doi:10.1016/j.foodpol.2017.05.006
  112. Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N. The politics of reducing malnutrition: building commitment and accelerating progress. Lancet. 2013;382(9891):552-569. doi:10.1016/s0140-6736(13)60842-9
  113. Shiffman J. Generating political priority for maternal mortality reduction in 5 developing countries. Am J Public Health. 2007;97(5):796-803. doi:10.2105/ajph.2006.095455
  114. Pelletier D, Haider R, Hajeebhoy N, Mangasaryan N, Mwadime R, Sarkar S. The principles and practices of nutrition advocacy: evidence, experience and the way forward for stunting reduction. Matern Child Nutr. 2013;9(Suppl 2):83-100. doi:10.1111/mcn.12081
  115. te Lintelo DJ. Developing Subnational Scorecards for Nutrition Accountability in Tanzania. IDS Working Paper 530. Brighton: IDS; 2019.
  116. Harris J, Nisbett N. Equity in social and development-studies research: Insights for nutrition. SCN News. 2018;43:57-63.
  117. Krieger N. A glossary for social epidemiology. J Epidemiol Community Health. 2001;55(10):693-700. doi:10.1136/jech.55.10.693
  118. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-1669. doi:10.1016/s0140-6736(08)61690-6
  119. Harris J, Tan W, Mitchell B, Zayed D. Equity in agriculture-nutrition-health research: A scoping review. Nutr Rev. 2021; Forthcoming.
  120. Ruckert A, Labonté R. The global financial crisis and health equity: toward a conceptual framework. Crit Public Health. 2012;22(3):267-279.