CHAPTER According to (WHO, 2017)In 2014, approximately 462

                                                CHAPTER TWO



chapter of the research project contains the key issues in the study, review of
theories, existing literature and procedures that have contributed to the
existing and expanding science in this field. This is done for the purpose of a
detailed and relevant research and in order to enhance comprehension and
understanding that will promote knowledge.



results from the interaction of our quality diets and poor-quality health and
care environments and behaviours.

is a triple burden of malnutrition in Nigeria. It is divided into:
undernutrition, micronutrient deficiency and over nutrition. Malnutrition is a
wide spread problem.  According to (WHO, 2017)In 2014,
approximately 462 million adults worldwide were under weight, 1.9 billion were
either overweight or obese.

2016, an estimated 155 million children under the age of 5 were suffering from
stunting, while 41 million were obese or overweight.




2.2.2 Forms of

        A. Undernutrition

according to UNICEF (UNICEF) is defined as the
outcome of insufficient food intake and repeated infectious diseases.
Undernutrition includes being underweight for one’s age, too short for one’s
age (stunted), dangerously thin (wasted), and deficient in vitamins and
minerals (micronutrient malnutrition).

to WHO (WHO), there are four
broad sub forms of undernutrition: wasting, stunting, underweight, and
deficiencies in vitamins and minerals

makes children in particular much more vulnerable to disease and death.

 Low weight for height is also known as
wasting. It indicates severe weight loss, because a person has not had enough
food to eat or they have had an infectious disease such as diarrhoea,

weight for age is known as stunting. It is the result of chronic or recurrent
undernutrition, usually associated with poor socioeconomic conditions, poor
maternal health and nutrition, frequent illness and inappropriate infant and
young children feeding and care in early life. Stunting restrains children from
reaching their potential physically and cognitively.

children with low weight for age are also known as underweight. An underweight
child may be stunted or wasted and can even be both.

        B. Micronutrient-related malnutrition

are gotten from the intake of vitamins and minerals. Micronutri²ents are vital
for proper growth and development as they produce enzymes, hormones, and other

public health regards iodine and vitamin A as very important as their
deficiency poses as a great threat to the health and development of population
worldwide. The deficiencies in iodine and vitamin A are commonly found in
children and pregnant women of low-income countries.

most common and wide spread nutrition disorder in the world is iron deficiency.
It is also the nutrient deficiency prevalent in industrialised countries as it
affects more people than any other condition. 


         C. Overweight and obesity

occurs when a person is too heavy for his or her height. Overweight or obesity
is caused by excessive accumulation of fat.

commonly used index of weight for height is the body mass index (BMI). It is
defined as a person’s weight in kilograms divided by the square of his/her
height in metres (kg/m²).

adults, when the BMI is greater than or equal to 25 then it is overweight.

the BMI is greater than or equal to 30 then it is regarded as obesity.

weight and obesity result from an imbalance between energy consumed (too much)
and energy expended (too little). That is when the energy consumed is too much
and the energy expended is too little. Globally, people are consuming foods and
drinks that are more energy dense (that is foods and drinks high in sugars and
fats) and are engaging in less physical activity. (WHO, 2017)

to (WHO, 2017):

In 2016 more than 1.9
billion adults aged 18 years and older were overweight and over 650 million
were obese

In 2016, 39% of adults
aged 18 years and over (39% of men and 40% of women are overweight).

In 2016, about 13% of the
world’s adult population (11% of men and 15% of women) were obese.

The worldwide prevalence
of obesity nearly tripled between 1975 and 2016

the individual level obesity can be reduced through:

The limited energy intake
from total fats and sugars

Increased consumption of
fruits, vegetables, legumes, whole grains and nuts, etc.

Increased participation
in regular physical activity. 60 minutes a day for children and 150 minutes a
day for adults.

food and beverage industry also have a part to play in the promotion of healthy
diets through the following means:

Reduction of the fat,
sugar and salt content of processed food.

Ensuring the availability
and affordability of healthy and nutritious food to all consumers


D. Diet related
non-communicable diseases

related non-communicable diseases (NCDs) include diseases such as heart attack,
stroke, high blood pressure, cancer, diabetes and so on. The top risk factors
for these diseases are unhealthy diets and poor nutrition. NCDs are also known
as chronic diseases which tend to last for a long duration of time and are also
as a result of a combination of genetic, physiological, environmental and
behavioural factors.

to (WHO, 2017), it is said that
NCDs kill 40 million people each year, equivalent to 70% of all deaths
globally. Every year, 5 million people die from a NCD between the ages of 30
and 69 years; over 80% of these deaths occur in low income countries and middle
income countries.  (WHO, 2017).

should the government invest in nutrition?

in young children has multiple benefits. Such benefits include:

Boost gross national
product by 11% in Africa and Asia

Improve school attainment
by at least one year.

Break inter-generational
cycle of poverty.

Prevent child deaths by
more than one third per year.

2.2.3 SDG and nutrition

has a central role in achieving sustainable development. About 12 of the 17
SDGs have indicators which relates to nutrition. For there to be progress in
health, education, employment, poverty and inequality nutrition has a role to

to the report published by UNICEF, it shows that 24 low- and middle- income
countries’ government allocate just 2.1 percent of their spending to reduce
undernutrition, whereas they spend a total of more than 30 percent on
agriculture, education, health, and social protection.

Global Nutrition Targets for 2025 are:

Child stunting- cut the
number of stunted children by 40%

Child wasting- reduce and
maintain child wasting to less than 5%

Child overweight- no
increase in child overweight.

Female Anaemia- cut
anaemia in women of reproductive age by 50%

Exclusive breastfeeding-
increase to at least 50%

Low birth weight- cut low
birth weight by 30%

Half the rise in the
prevalence of:

ü  Adult

ü  Adult
diabetes (high blood sugar)

ü  Adult



to NHS there are various condition that can cause malnutrition:


long-term conditions that cause loss of appetite,
feeling sick, vomiting and/or
changes in bowel habit (such as diarrhea) – these
include cancer, disease
and some lung conditions (such as chronic obstructive pulmonary

mental health conditions, such as depression or schizophrenia, which may
affect your mood and desire to eat

conditions that disrupt your ability to digest food or
absorb nutrients, such as Crohn’s disease or ulcerative colitis

dementia, which can
cause the person to neglect their wellbeing and forget to eat

an eating disorder, such
as anorexia



Teeth that are in a poor condition, or dentures that
don’t fit properly, which can make eating difficult or painful 

a physical disability or other impairment that makes
it difficult to move around, cook or shop for food

living alone and being socially isolated

having limited knowledge about nutrition or cooking

alcohol or drug dependency

low income or poverty


lack of appetite

disrupt digestion

increase the body’s demand for energy


if the child is neglected

inappropriate infant feeding


2.2.5 Malnutrition and

with poor health have lower educational attainment, lower social status, worse
adult health outcomes, and a higher likelihood of engaging in risky behaviours
than their healthy. (Eric R. Eide, 2009).

causal relationship from health to education could result from experiences
during childhood, if children in poor health obtain less schooling and they are
also more likely to be unhealthy adults. For example, children that are born
with low or very low birth weight (a health marker at birth) obtain less
schooling that those born with higher weights (even among twins, see Behrman
and Rosenwein, 2004, Black, Devereux and Salvanes 2005). Low birth weight is
also predictive of poor health later in adulthood (Barker, 1995; Roseboom et
al., 2001). Similarly, older children that are sick or malnourished during
childhood are more likely to miss school, less likely to learn while in school,
and ultimately obtain fewer years of schooling (Case, Fertig and Paxson 2005).
And again, sick children are also more likely to 11 become sick adults (Case,
Lubotsky, and Parson 2002).



are various ways in which poor health can reduce learning, so of hem include:
low daily attendance, less learning per day spent in school, fewer years
enrolled. In SSA, school enrolment rate has increased but there is still
available room for improvement. From 1960 to 1970, it increased from 40 percent
to 51 percent, from 1970 to 1980 it increased from 51 percent to 80 percent,
from 1980 to 2000 it increased from 80 percent to 77 percent.

 In 1960, primary school gross enrolment rate
was 65% in low-income countries, 83% in middle-income countries, and over 100%
in high-income countries

both low- and middle-income countries the secondary gross enrolment rate
increased by about 150% from 1960 to 1980, while the increase from 1980 to 2000
was 59% in low-income countries and about 51% in middle-income countries.
Another way to see this is to note that from 1970 to 1980 middle-income
countries increased their secondary enrolment ratio from 33 to 51% in only one
decade, while low-income countries took 20 years (1980 to 2000) to increase
from 34 to 54%. Middle-income countries’ progress slowed down sharply in the
1980s, increasing by only eight percentage points (51 to 59%) in that decade,
although the increase was stronger in the 1990s (from 59 to 77%).

health and malnutrition may prevent children from attending school and from
learning while there. The equivalent of more than 200 million school years are
lost each year in low income countries as a result of ill health, and the
impact on learning and cognition is equivalent to a deficit of more than 630
million IQ points.  

United Nations estimates that one third of preschool age children in less
developed countries – a total of 180 million children under age 5–experience
growth stunting relative to international norms

the extent that poor health and nutrition among children has a negative impact
on their education, programs or policies that increase children’s health status
will also improve their education outcomes. Given the importance of education
for economic development (World Bank, 2001)




Global commitment to




the past 57 years of Nigeria like every other country or nations, its heath
sector has experienced some turbulent times. However, some factors are said to
be responsible for this. The World Health
Organization ranked Nigeria 187 out of 191 countries in its ranking of the
world’s health systems. This means that Nigeria’s health system is only better
than that of three countries.

The health care system in Nigeria is divided into three-
primary, secondary and tertiary health care which is then divided among the
three tiers of government – federal, state and local.

The federal government is responsible for providing policy
guidance, planning, and technical assistance, coordinating state-level
implementation of the National Health Policy and establishing health management
information systems.

 In addition, the Federal government is responsible for
disease surveillance, drug regulation, vaccine management and training health
professionals. The Federal Government is also responsible for the management of
teaching, psychiatric and orthopaedic hospitals and also runs some medical

state government.

of these factors as listed by Dr. Osahon Enabuele (Enabuele, 2013):

Poor governance at most
levels of government

Political instability

Monumental corruption and
infrastructural decay

Poor constitutional and
legal framework for health in Nigeria, particularly the absence of a National
Health Act that clearly makes the health rights of the people justiciable.

 Poor funding and budgetary provisions for
health, far less than the stipulated 15% of the National budget as prescribed
by the World Health Organization and affirmed by the 2001 Abuja declaration of
African Heads of State

Weak private health sector coupled with inefficient
utilization of healthcare resources;

Poor co-ordination, integration and implementation of
health policies, programs, projects and donor support;

Inadequate involvement of health professional
associations and communities in the planning, implementation, monitoring and
evaluation of health policies, programs and projects; as well as in budget

Worsening poverty and low
level of Health Coverage for all Nigerians

Weak Primary and
Secondary levels of care with a weak Referral System, attributable to evident
lack of commitment to the development of the primary and secondary healthcare
systems by most local and state governments.




2.2.7.   concept of productivity

are many ways productivity can be defined. Productivity represents the amount
of output pe unit of inut. According to OECD, productivity is defined as a
ratio between the output volume and the volume of inputs. It measures how
efficiently production inputs, such as labour and capital are being used in an
economy to produce a given level of output (Mr. A.A. Attar,
Gupta, & Desai). 

is considered a key source of economic growth. According to Paul Krugman in the
Age of Diminshing Expectations (1994), he said ” productivity isn’t everything,
but in the long run it is almost everything. A country’s ability to improve its
standard of living over time depends almost entirely on its ability to raise
its output per worker.

is always taken to assume labour producy=rivity.

Productivity =


are five widely used concepts of productivity (Mr. A.A. Attar, Gupta, & Desai). They are:

A.    Labour
productivity, based on gross output. It measures labour productivity as labour
requirement per unit of output.

B.     Labour
productivity, based on value-added. Value added based labour productivity is
useful for the analysis of micro-macro links, such as an individual industry’s
contribution to economy wide labour productivity.

C.     Capital-labour
MFP, based on value-added. This productivity measurement is useful for the
analysis of micro-macro links, such as the industry contribution to
economy-wide MFP growth and living standards, as well as, for analysis of
structural change.

D.    Capital
productivity, based on value-added. Changes in capital productivity denote the
degree to which output growth can be achieved with lower welfare costs in the
form of foregone consumption.

E.     KLEMS
Multi-factor productivity. KLEMS-MFP is used in the analysis of industry-level
and sectoral technical change.