Definitions & the spectrum of malnutrition (including the double burden)
Why malnutrition matters
Magnitude: global and India (NFHS-6)
Why does it happen? Multifactorial causation (UNICEF framework)
Bridge to Lecture 2: clinical forms, assessment, and management
Learning Objectives
By the end of this session, you should be able to:
Define malnutrition and describe its full spectrum, including the double burden
State the current magnitude of malnutrition in India (NFHS-6) and globally
Explain the multifactorial causation of malnutrition using the UNICEF conceptual framework
Justify why a multifactorial problem requires a multisectoral response (bridge to Lecture 2)
What Is Malnutrition?
WHO definition: deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients.
Malnutrition has two broad arms: undernutrition and overnutrition
WHO’s 2023 clinical framing groups wasting and nutritional oedema together as “acute malnutrition”; the terminology has shifted from purely descriptive (“PEM”) toward this functional grouping
The Spectrum of Malnutrition
Three overlapping domains, each of which can occur alone or together:
Children, all aged 8 years; stunting is chronic and cumulative (field photograph)
The Double Burden of Malnutrition
Definition: the coexistence of undernutrition and overnutrition, at the population, household, or individual level.
A country can have stunted children and obese adults at the same time
A single household can have an underweight grandmother and an overweight child
NFHS-6 shows this pattern emerging in India: adult BMI is worsening at both ends of the distribution at once
This is a hallmark of countries undergoing nutrition transition.
Why Malnutrition Matters
Mortality: undernutrition is an underlying factor in a large share of under-5 deaths globally
Development: impaired cognition, poorer school performance, reduced adult productivity
Intergenerational cycle: an undernourished girl is more likely to become an undernourished mother of an undernourished child
Economic cost: lost productivity and higher healthcare costs at the national level
Magnitude
Section 1 · How big is the problem?
Global Burden (2022 estimates)
Per the UNICEF/WHO/World Bank Joint Malnutrition Estimates (2023 edition):
~45 million children under 5 were wasted (~6.8%)
~13.7 million were severely wasted
Global targets: wasting <5% by 2025, <3% by 2030
Current trajectory: off track for both targets
India: Child Undernutrition (NFHS-6, 2023–24)
Indicator
NFHS-5 (2019–21)
NFHS-6 (2023–24)
Change
Stunting
35.5%
29.3%
↓ ~17% relative
Wasting
19.3%
19.0%
Essentially unchanged
Severe wasting
7.7%
5.2%
↓ ~32% relative
Underweight
32.1%
31.8%
Marginal
India: Feeding Practices & the Anaemia Gap
Only 15.3% of children aged 6–23 months receive an adequate diet
Exclusive breastfeeding fell from 63.7% (NFHS-5) to 55.8% (NFHS-6), a concerning reversal rather than an improvement
Anaemia (still reported from NFHS-5, since NFHS-6 dropped haemoglobin testing):
Children 6–59 months: ~67%
Women 15–49 years: ~57%
Pregnant women: ~52%
The Inequity Gradient
Malnutrition is not evenly distributed. It is consistently higher among:
The lowest wealth quintile
Rural populations
SC/ST and tribal communities
There is also wide state-level variation hidden behind the national averages shown above.
Question for you: if you’re posted to a tribal PHC after internship, what would you expect to find?
Why Does Malnutrition Happen?
Section 2 · Multifactorial causation
The UNICEF Conceptual Framework
Malnutrition is never caused by food alone. It results from a hierarchy of interacting causes: immediate (child level), underlying (household level), and basic or root (societal level). Originally developed in 1990; revised in 2020 to add ecosystems, climate change, and humanitarian or fragile-context shocks.
Breaking this cycle requires addressing both sides at once: nutritional support alone, or infection control alone, is insufficient.
Determinants in Tribal & Underserved Settings
Applying the framework to the field settings many of you will work in:
Geographic access: terrain, distance to the nearest functional facility
Food security shaped by seasonality: forest and agriculture dependence, lean seasons
ICDS/Anganwadi reach and functionality: coverage gaps, last-mile worker availability
Cultural feeding practices and health-seeking behaviour
From the Field
Photo Courtesy: Reuters.
Why This Framework Matters
It explains why single-sector interventions often fail: food supplementation alone, without attention to care practices or WASH, has limited impact
Malnutrition is multifactorial, so the response must be multisectoral
Bridge to Lecture 2: we will see how India’s nutrition programmes are structured around these three causal tiers
Key Takeaways
Malnutrition is a spectrum — undernutrition, micronutrient deficiency, and overnutrition — not simply “not enough food”; the double burden is increasingly the Indian reality
NFHS-6: real progress on stunting and severe wasting, but wasting has plateaued, exclusive breastfeeding is falling, and diet quality remains poor
Causation is multifactorial — immediate, underlying, and basic causes interact — so the response must be multisectoral
The malnutrition–infection cycle means feeding and infection control must be tackled together
Formative Questions
Name the three overlapping domains of the malnutrition spectrum.
Which NFHS-6 child indicator has essentially plateaued, and why is that concerning?
Name the three tiers of the UNICEF conceptual framework of causation.
Up Next — Lecture 2
Clinical forms, assessment & management
Forms of undernutrition (PEM): marasmus, kwashiorkor, and the classification systems
Micronutrient deficiencies and “hidden hunger”
Nutritional assessment: the ABCD framework
Management of SAM and India’s nutrition programmes (POSHAN 2.0)
