1.
Understanding
the
complexity
of
under
and
over
nutrition
in
Egypt
Shibani
Ghosh,
Ashish
Pokharel,
Patrick
Webb,
Marwa
Moaz,
Johanna
Andrews-­‐Chavez
Grace
Namirembe,
Elizabeth
Marino-­‐Costello
and
Jeffrey
K.
Griffiths
Report
to
USAID
Mission
in
Egypt
Associative
Cooperative
Agreement
AID-­‐263-­‐LA-­‐14-­‐00004
Reference
Leader
Cooperative
Agreement
AID-­‐OAA-­‐L-­‐10-­‐00006

2. Understanding
the
complexity
of
malnutrition
in
Egypt
2
Introduction
According
to
the
Global
Nutrition
Report
of
2014,
the
coexistence
of
many
forms
of
malnutrition
is
the
“new
normal”
worldwide
(IFPRI
2014).
While
no
country
is
totally
free
of
malnutrition,
most
developing
and
emerging
economies
have
to
contend
with
multiple
manifestations
that
pose
complex
policy
challenges
to
national
governments.
Egypt
faces
this
precise
quandary.
While
undernutrition,
manifested
by
poor
linear
growth
and
micronutrient
deficiencies
in
children
and
anemia
in
women
saps
an
estimated
1.9%
of
Egypt’s
annual
Gross
Domestic
Product
(GDP)
through
productivity
foregone
and
costs
to
the
health
system
-­‐
which
represents
an
economic
hemorrhaging
of
around
US$5.5
billion1
per
year
–
the
prevalence
and
costs
of
rising
overweight
and
obesity
in
adults
and
children,
as
well
as
diet-­‐related
non-­‐
communicable
diseases
(NCDs)
in
adults
are
escalating
fast
(AUC/NEPAD/UNECA/WFP
2014;
Badran
and
Laher
2011).
Egypt
ranks
in
the
top
10
countries
with
the
highest
prevalence
of
diabetes
mellitus
(7.5
million
cases
in
2014),
a
condition
associated
with
12
%
of
all
adult
deaths
in
the
region
–
72,000
adult
deaths
in
Egypt
alone
in
2014
(IDB
2014).
A
review
of
cardio-­‐
metabolic
deaths
in
2010
related
to
poor
nutrition
found
Egypt
ranked
high
(Afshin
et
al,
2015).
The
unusual
difficulty
for
countries
like
Egypt
is
that,
unlike
many
other
countries
in
the
world,
it
faces
the
growing
challenge
of
overweight
and
obesity
at
a
time
when
most
other
forms
of
nutritional
compromise
(wasting,
stunting,
and
some
micronutrient
deficiencies)
have
been
rising
too
(IFPRI
2014).
As
a
result,
Egypt
is
currently
not
on
track
to
meet
any
of
the
six
nutrition
targets
established
by
the
World
Health
Assembly
for
the
year
2025
(IFPRI
2014).
In
terms
of
progress
against
those
targets,
Egypt
ranked
59th
out
of
89
low
and
middle-­‐income
countries
in
2014
–below
Equatorial
Guinea,
Rwanda,
and
Papua
New
Guinea
(Webb
et
al.
2015).
In
other
words,
the
simultaneous
coexistence
of
multiple
nutrition
problems
represents
a
human,
economic
and
policy
challenge
of
the
highest
order
in
Egypt.
This
paper
represents
a
preliminary
review
of
the
literature
and
empirical
data
available
on
these
many
nutrition
conditions
and
challenges
in
Egypt.
The
review
is
a
first
step
towards
mapping
current
nutrition,
health
and
food
system
policies
in
Egypt
against
nutrition
goals
and
conducting
rigorous
analysis
of
secondary
datasets
to
explore
determinants
and
options
for
action.
It
is
anticipated
that
as
secondary
analyses
progress
and
engagement
with
the
scientific
community
in
Egypt
deepens,
more
empirical
evidence
and
less-­‐known
papers
are
likely
to
materialize
which
will
enrich
and
update
this
review.
A
separate
‘mapping’
of
food
and
nutrition
policies
in
relation
to
the
problems
identified
here
is
being
prepared
as
a
companion
to
this
literature
review.
The
review
summarizes
current
evidence
and
knowledge
relating
to
the
five
main
clusters
of
nutrition
and
diet-­‐related
problems
including:
a)
classical
forms
of
undernutrition,
b)
micronutrient
deficiencies,
and
c)
obesity
and
diet-­‐related
chronic
diseases,
d)
co-­‐morbidities
associated
with
the
co-­‐existence
of
two
or
more
of
the
above
nutrition
outcomes,
and
e)
1
Based
on
2013
GDP
of
US$272
billion.
The
level
of
US$5.5
billion
per
year
is
considerably
higher
than
the
estimate
made
in
by
Abegunde
et
al.
(2007)
of
the
cost
of
malnutrition
to
Egypt
of
US$1.5
billion
per
year
by
2015.

3. Understanding
the
complexity
of
malnutrition
in
Egypt
3
environmental
risks
including
both
food-­‐based
contamination
and
water-­‐based
contamination.
A
final
section
highlights
key
areas
where
data
and
analyses
are
lacking.
Major
Facets
of
Undernutrition
in
Egypt
Globally,
undernutrition
is
associated
with
roughly
45
%
of
preventable
deaths
in
children
under
five
years
of
age
(Black
et
al.
2013).
At
least
15
%
of
those
deaths
would
be
resolved
if
just
10
evidence-­‐based
‘classic’
targeted
nutrition
interventions
were
to
be
implemented
at
scale
(90
%
coverage
of
need)
in
the
34
countries
which
together
account
for
most
of
the
world’s
stunting
(Bhutta
et
al.
2013).
Egypt
is
one
of
the
34
‘high
burden’
countries
(UNICEF
2013;
Black
et
al.
2013).
With
a
prevalence
of
over
20
%,
stunting
(defined
as
height
for
age
Z-­‐score
that
is
two
standard
deviations
(SDs)
below
the
mean
of
an
internationally-­‐defined
reference
set
by
the
World
Health
Organization)
in
Egypt
is
a
serious
public
health
concern.
This
level
(while
lower
than
in
2008)
still
reflects
an
8-­‐fold
excess
over
the
expected
rate
for
a
‘normal’
population
(WHO
2015;
MHP/El-­‐Zanaty/Macro
2015).
As
a
result,
the
benefit:cost
ratio
of
scaling
up
the
10
targeted
interventions
to
resolve
stunting
in
Egypt
has
been
estimated
as
US$31
(in
gains)
for
every
US$1
invested
(Hoddinott
et
al.
2013).
Stunting
Despite
progress
in
reducing
stunting
during
the
late
1990s
through
2008,
as
of
2014
Egypt’s
rate
of
21
%
is
still
higher
than
for
other
countries
in
the
region
that
have
the
same
levels
of
GDP
(UNICEF
2013).
While
it
is
closer
to
the
trend
line
for
the
region,
it
remains
much
above
countries
with
a
similar
income
level
such
as
Jordan
and
Tunisia
(comparable
countries
in
terms
of
national
income
per
capita)
(Figure
1).
Figure
1:
Stunting
in
children
0
to
59
months,
by
GDP
per
capita
for
selected
countries.
Source:
El-­‐Kogali
and
Krafft
2015

4. Understanding
the
complexity
of
malnutrition
in
Egypt
4
Aitsi-­‐Selmi
A.
(2014),
Kavle
et
al.
(2015)
and
El-­‐Kofali
and
Krafft
(2015)
all
concur
that
stunting
rose
in
Egypt
in
the
late
2000s,
and
that
“the
reason
for
the
increase
in
stunting
prevalence
requires
further
research.”
(Réstrepo-­‐Mendez
et
al.
2014)
(Table
1).
A
review
of
the
trends
clearly
demonstrates
that:
i)
national
level
prevalence
rates
for
stunting
increased
from
2003
to
2008
(from
20
%
to
around
30
%),
and
then
fell
to
about
20
%
as
of
20142
;
ii)
as
in
most
other
countries,
the
majority
of
stunting
in
children
is
already
present
before
the
age
of
24
months;
iii)
the
average
annual
rate
of
reduction
(AARR)
in
stunting
needed
for
Egypt
to
achieve
the
World
Health
Assembly
goal
of
a
40
%
fall
between
2010
and
2025
was
3.7
%
per
annum
based
on
2008
data
(IFPRI
2014).
Now
that
the
trend
has
shifted
positively,
Egypt
will
need
to
focus
on
bringing
the
2014
prevalence
rate
of
about
20
%
down
to
around
11
%
in
the
next
decade
to
meet
the
WHA
goals
(MHP/El-­‐Zanaty/Macro
2015).
Achieving
this
goal
will
require
a
prevalence
rate
decrease
of
1
percentage
point
per
annum,
which
should
be
feasible
if
the
right
actions
are
taken.
Table
1:
DHS
estimates
of
undernutrition
in
Egyptian
children
under
five
years
of
age
DHS
2003
DHS
2005
DHS
2008
DHS
2014
Percentage
of
Stunted
Children
Urban
Governorates
15.03
18.69
22.70
19.0
Lower
Egypt-­‐
Urban
12.89
16.25
38.22
19.3
Lower
Egypt-­‐
Rural
14.34
20.12
32.85
17.6
Upper
Egypt-­‐
Urban
21.47
29.97
23.26
29.8
Upper
Egypt-­‐
Rural
25.05
33.87
26.87
24.8
Frontier
Governorates
-­‐
26.06
28.66
15.1
Total
19.86
26.78
28.63
21.4
Percentage
of
Wasted
Children
Urban
Governorates
3.53
6.44
9.35
8.6
Lower
Egypt-­‐
Urban
3.99
3.10
6.77
8.9
Lower
Egypt-­‐
Rural
4.43
3.98
7.04
8.3
Upper
Egypt-­‐
Urban
6.00
5.92
7.57
9.0
Upper
Egypt-­‐
Rural
4.96
4.75
6.41
8.0
Frontier
Governorates
-­‐
6.68
5.94
14.1
Total
4.7
4.97
7.1
8.4
Percentage
of
Underweight
Children
Urban
Governorates
5.10
4.53
5.93
4.3
Lower
Egypt-­‐
Urban
4.90
3.72
4.76
4.3
Lower
Egypt-­‐
Rural
7.17
4.05
5.64
4.2
Upper
Egypt-­‐
Urban
8.67
6.30
6.31
8.1
Upper
Egypt-­‐
Rural
9.46
6.60
6.47
6.9
Frontier
Governorates
-­‐
5.21
4.03
6.7
Total
7.89
5.48
5.89
5.5
2
A
rate
that
was
foreshadowed
by
the
MICS
of
2014,
which
also
found
just
over
21
%
moderate
stunting
(MHP/UNICEF/El-­‐Zanaty
2014).

5. Understanding
the
complexity
of
malnutrition
in
Egypt
5
The
national
estimates
however
tend
to
mask
sub-­‐national
patterns.
Between
the
2003
and
2008,
there
was
a
2%
increase
in
stunting
in
urban
Upper
Egypt
(21%
to
24%)
compared
to
a
much
greater
(26%)
rise
in
urban
Lower
Egypt
(from
12
%
to
38%)
–
a
huge
increase
over
a
5
year
period
(Kavle
et
al.
2015).
As
of
2014,
urban
Upper
Egypt’s
stunting
prevalence
has
gone
up
further
to
about
29
%,
while
urban
Lower
Egypt’s
rate
had
reverted
to
about
19
%
–
a
major
shift
in
the
right
direction,
albeit
still
higher
than
in
2003
(MHP/El-­‐Zanaty/Macro
2015).
The
very
large
change
in
rural
Lower
Egypt
is
a
large
part
of
the
fall
in
stunting
reported
between
2008
and
2014,
and
that
fall
(15
%
in
5
years,
or
3
%
per
annum)
requires
closer
examination.
The
Urban
Governorates
followed
this
same
pattern,
although
the
relative
swings
were
not
as
large,
running
from
15
%
in
2003
to
22
%
in
2008
and
back
to
19
%
in
2014
(Kavle
et
al.
2014;
MHP/El-­‐Zanaty/Macro
2015).
These
large
swings
in
short
periods
of
time
require
considerable
explanation,
since
policy
conditions/interventions
did
not
change
dramatically
over
this
period.
Interestingly,
the
highest
average
prevalence
rates
for
both
moderate
(<2
SDs
in
height-­‐for-­‐age
Z-­‐score)
and
severe
(<3
SDs
in
height
for
age
Z-­‐score)
stunting
were
in
Lower
Egypt’s
Urban
Governorates
in
2008.
That
was
no
longer
the
case
in
2014,
when
the
highest
rates
of
both
moderate
and
acute
stunting
were
reported
for
urban
Upper
Egypt.
It
has
been
reported
that
poverty
increased
more
dramatically
in
urban
settings
in
the
past
decade
(IFPRI/WFP
2013),
which
may
be
associated
with
such
patterns.
However,
the
gap
between
urban
and
rural
Upper
Egypt
appears
to
be
widening
during
these
last
DHS
rounds.
These
curious
patterns
reinforce
the
need
to
examine
geographic
determinants
and
patterns
at
a
more
granular
level
of
detail.
Importantly,
and
more
positively,
although
stunting
increased
on
average,
this
took
place
in
the
context
of
a
reduction
in
the
inequality
of
stunting
across
wealth
quintiles
–
until
the
2014
DHS
(IFPRI
2014;
MHP/El-­‐Zanaty/Macro
2015).
Egypt
has
shown
improvements
in
both
relative
and
absolute
inequality
in
the
distribution
of
stunting
by
wealth
in
the
1995
to
2008
timeframe
(Restrepo-­‐Méndez
et
al.
2014;
El-­‐Kogali
and
Krafft
2015).
Figure
2
shows
the
changing
distribution
across
wealth
quintile
for
Egypt
compared
with
Jordan
over
5
rounds
of
DHS
(the
first
4
are
as
reported
by
Restrepo-­‐Méndez
et
al.
2014,
while
the
latest
DHS
2014
figures
are
added
as
an
overlay
to
their
graphic
with
DHS
2014
extracted
from
MHP/El-­‐Zanaty/Macro
2015).
Jordan
shows
lower
and
declining
prevalence
rates
over
time,
but
no
decrease
in
the
distribution
of
stunting
across
quintiles.
However,
Egypt
shows
a
decline
in
the
mean
rate
through
2005
followed
by
the
reversal
(increased
stunting),
but
the
trend
over
all
4
rounds
shows
a
decline
in
the
distribution
by
wealth
–
that
is,
the
gap
in
terms
of
risk
of
stunting
fell
steadily
between
rich
and
poor
over
time
and
continued
to
do
so
during
the
recent
increase
in
stunting
(2008
to
2014
change).

6. Understanding
the
complexity
of
malnutrition
in
Egypt
6
Figure
2:
Changes
over
time
in
rate
of
child
stunting
by
wealth
quintile,
Egypt
and
Jordan
Source:
Based
on
Restrepo-­‐Méndez
et
al.
(2014)
–
adapted
by
the
authors
Achieving
greater
equity
in
the
distribution
of
stunting
by
wealth
is
an
important
goal
for
most
governments,
at
least
in
the
context
of
an
overall
decline
in
average
stunting
rates.
For
stunting
inequality
to
be
reduced
while
prevalence
rates
increase
is
not
common,
though
this
is
has
been
observed
for
Nigeria
and
a
few
other
large
economies
during
recent
years
(Black
et
al.
2013).
The
policy
intent
is
usually
to
reduce
stunting
in
the
poorest
income
groups
(catch-­‐up
with
the
mean).
In
contrast,
in
Egypt
the
stunting
distribution
has
been
compressed
as
a
result
of
an
increase
in
stunting
among
wealthier
households.
The
prevalence
of
stunting
in
the
poorest
wealth
quintile
(red
dots,
Figure
2)
barely
changed
from
the
2000
DHS
through
the
2008
DHS.
However,
stunting
in
the
highest
wealth
quintiles
(green
dots)
increased
in
that
same
timeframe
(not
only
since
2004
DHS—reported
in
this
graphic
as
2005).
This
does
change
in
2014,
with
a
stretching
out
of
the
range,
and
an
unexpected
shift
in
relative
positions
among
the
quintiles;
that
is,
the
middle
and
fourth
highest
wealth
quintiles
now
show
the
least
stunting,
while
the
highest
wealth
quintile
has
a
prevalence
rate
that
is
indistinguishable
from
the
poorest
wealth
quintile
-­‐-­‐
23.4
%
versus
24
%
(MHP/El-­‐Zanaty/Macro
2015).
The
policy
challenge
here
is
that
since
stunting
is
found
across
all
household
categories
regardless
of
wealth,
stunting
represents
a
pervasive
public
health
problem
rather
than
one
concentrated
among
certain
vulnerable
population
groups
who
could
potentially
be
targeted
based
on
income.
Egypt 2014

7. Understanding
the
complexity
of
malnutrition
in
Egypt
7
There
are
still
significant
knowledge
gaps
with
respect
to
stunting
in
Egyptian
children.
For
instance:
Ø What
explains
the
statistically
significant
rise
and
then
fall
in
mean
stunting
prevalence
over
relatively
short
periods
of
time
in
Egypt?
Ø Why
did
inequality
in
the
distribution
of
stunting
by
wealth
practically
disappear,
and
then
reappear
–
and
in
a
form
where
the
richest
and
poorest
wealth
quintiles
are
similar?
Ø Since
not
all
wealth
quintiles
or
geographic
regions
are
seeing
an
increase
in
stunting,
what
might
explain
relative
changes
over
time
by
income
and
location?
Ø Why
is
severe
stunting
not
increasing
at
the
same
pace
as
moderate?
Ø To
what
extent
does
the
rise
in
stunting
result
from
the
rapid
increase
in
maternal
obesity
(which
is
known
to
be
associated
with
poor
birth
outcomes
and
both
child
stunting
and
the
foetal
and
neonatal
programming
of
adult-­‐onset
chronic
diseases)?
According
to
Aitsi-­‐Selmi
(2014),
the
trends
in
data
from
DHS
since
1992
suggest
the
existence
of
“a
link”
between
maternal
obesity
and
a
rise
in
the
number
of
households
with
concurrent
overweight/obesity
and
stunting,
but
the
nature
of
that
link
has
yet
to
be
found.
Wasting
Despite
the
reversed
trend
in
stunting
prevalence
between
2008
and
2014,
child
wasting
continued
to
increase
to
reach
7
%
nationally
–
up
from
3
%
in
2000
(MHP/El-­‐Zatany/Macro
2015).
In
2003,
the
highest
rates
of
moderate
wasting
(defined
as
weight
for
height
Z-­‐score
that
is
2
SDs
below
the
mean
of
an
internationally-­‐defined
reference
set
by
the
World
Health
Organization)
were
in
the
Urban
Governorates
and
in
the
highest
wealth
quintile.
Moderate
wasting
carries
a
5-­‐fold
increased
risk
of
preventable
child
mortality
from
communicable
diseases.
By
2014,
it
is
the
Frontier
Governorates
that
records
the
highest
prevalence
of
moderate
wasting
(14
%),
along
with
the
fourth
and
middle
wealth
quintiles
which
have
gained
the
most
in
terms
of
stunting
since
2008.
That
being
said,
there
is
no
difference
at
all
between
the
top
and
bottom
quintiles
of
the
wealth
distribution
in
terms
of
wasting
prevalence.
This
contrasts
with
the
small
but
real
gap
for
stunting
in
2014
(Table
1).
A
14
%
prevalence
of
moderate
wasting
(or
Global
Acute
Malnutrition)
represents
a
serious
problem
according
to
the
crisis
classification
of
the
World
Health
Organization.
It
is
on
the
threshold
of
‘critical’
status,
which
at
15
%
typically
triggers
a
large
scale
humanitarian
response
in
the
context
of
emergencies
(WHO
2003).
Severe
wasting,
which
carries
an
immediate
and
imminent
risk
of
mortality
if
not
appropriately
treated,
was
the
highest
in
2005
in
the
poorest
households
of
rural
Upper
Egypt.
By
2014,
this
had
changed
to
mirror
moderate
stunting;
with
higher
rates
observed
in
the
Frontier
Governorates
(followed
by
urban
Upper
Egypt)
and
in
the
highest
3
wealth
quintiles
(not
the
poorest).
Knowledge
Gaps
on
wasting:
Ø What
explains
the
very
high
rates
of
moderate
wasting
in
the
Frontier
Governorates
–
rates
that
are
often
associated
with
humanitarian
crises?

8. Understanding
the
complexity
of
malnutrition
in
Egypt
8
Ø Why
is
there
more
wasting
prevalence
in
the
3
higher
wealth
quintiles
than
in
the
lower
two
(poorer)
quintiles?
What
does
this
suggest
for
targeting
of
interventions
for
treatment
and
for
prevention?
Ø Based
only
on
the
DHS
for
2003,
Khatab
(2010)
found
that
age
of
mother
was
statistically
correlated
with
wasting
outcomes;
that
is,
the
older
the
mother
the
more
likelihood
of
wasting.
Since
age
in
women
is
also
correlated
with
obesity
(the
share
of
women
who
are
obese
more
than
doubles
from
20
%
in
the
20
to
29
year
old
category
to
65
%
in
the
40
to
49
years
old
category),
and
wasting
episodes
can
contribute
to
linear
growth
retardation
(stunting),
the
relationship
between
obesity
and
wasting
deserves
to
be
explored
further
(MHP/El-­‐Zatany/Macro
2015).
Ø Are
locations
and
household
groups
with
high
rates
of
severe
stunting
more
prone
to
acute
wasting?
Ø Are
the
dynamic
patterns
noted
for
stunting
rates
over
time
in
Egypt
mirrored
by
similar,
or
featuring
different,
patterns
for
wasting?
Maternal
low
BMI
This
nutrition
problem
has
not
featured
as
a
concern
for
Egypt
for
good
reason
–
it
is
almost
non-­‐existent.
In
2003,
only
0.5
%
of
adult
women
had
a
body
mass
index
(BMI)
<18.5
reflecting
thinness
or
undernutrition
–
most
of
those
were
in
the
poorest
wealth
quintile
and
in
the
15
to
19
year-­‐old
age
category.
By
2014,
those
two
categories
of
individuals
still
had
most
of
the
problem
of
thinness,
but
its
prevalence
had
dropped
overall
to
only
0.2
%.
It
is
mainly
concentrated
today
in
rural
Upper
Egypt.
Preventive
actions
include
enhancing
the
health
and
nutrition
of
adolescent
girls
and
young
mothers
in
the
context
of
Scaling
up
Nutrition
(SUN)
also
termed
as
the
1,000
day
initiatives.
Micronutrient
Deficiencies
While
there
are
very
limited
data
for
Egypt
on
actual
deficiencies
in
vitamins
and
minerals
(since
most
DHS
and
other
nationally
representative
surveys
do
not
typically
collect
such
data
other
than
anemia
status),
it
has
been
estimated
that
Egypt
loses
more
than
US$814
million
(through
lost
GDP)
to
micronutrient
deficiencies
(World
Bank
2010).
This
is
likely
to
be
a
significant
underestimate,
given
the
scale
of
economic
losses
associated
with
stunting
that
was
noted
above.
The
World
Bank
(2010)
has
estimated
that
12
%
of
preschoolers
and
over
20
%
of
pregnant
women
were
deficient
in
vitamin
A;
that
30
%
of
preschoolers
and
45
%
of
pregnant
women
were
anemic;
and
that
9
%
of
the
population
was
at
risk
for
insufficient
zinc
intake.
These
represent
estimates
rather
than
data
derived
from
nationally
representative
surveys.
One
recent
study
of
zinc
dietary
intake
among
pregnant
women
in
hospital
settings
reported
zinc
deficiency
in
53.5
%
of
the
sample
(Naem
et
al.
2014).
Similarly,
an
assessment
of
vitamin
D
status
among
diabetic
patients
(Egyptian
children
and
adolescents
with
Type
1,
or
insulin-­‐
requiring,
diabetes
mellitus)
found
that
55
%
of
the
diabetics
were
vitamin
D
deficient
(Azab
et
al.
2013).
Importantly,
in
terms
of
intergenerational
impacts
of
such
deficiencies,
El
Koumi
et
al.
(2013)
found
that
pregnant
women
deficient
in
vitamin
D
in
Egypt
bore
infants
with
vitamin
D
deficiency.

9. Understanding
the
complexity
of
malnutrition
in
Egypt
9
Other
recent
related
studies
include
the
larger
study
on
folate
status
by
Tawfik
et
al.
(2014).
It
identified
folate
deficiency
in
almost
14
%
of
just
under
2,000
households
in
9
Governorates.
The
highest
rates
of
deficiency
were
found
in
Lower
Egypt
(over
23
%),
with
the
coastal
regions
showing
less
than
4
%
deficiency.
Adolescents
showed
a
slightly
lower
than
average
deficiency
of
around
12
%.
Folate
deficiency
leads
to
anemia
and
birth
defects
such
as
spina
bifida,
congenital
heart
defects,
cleft
lip,
and
urinary
tract
abnormalities.
At
a
national
level,
the
2014
DHS
reports
far
fewer
women
in
the
lowest
wealth
quintile
live
in
homes
that
use
iodized
salt
(80
%
compared
with
over
98
%
in
the
top
wealth
quintile).
It
also
reports
that
a
quarter
of
children
in
Egypt
suffer
from
some
degree
of
anemia,
although
most
of
this
is
mild
to
moderate
in
nature.
Roughly
10
%
were
found
to
be
moderately
anemic,
with
the
remainder
classified
as
mildly
anemic.
Children
in
rural
households
are
more
likely
to
be
anemic
than
urban
children
(29
%
and
23
%,
respectively).
Children
in
the
three
Frontier
Governorates
and
in
rural
Upper
Egypt
are
more
likely
than
children
in
other
areas
to
be
anemic
(45%
and
30%,
respectively).
Knowledge
Gaps
on
micronutrient
deficiencies:
Ø What
are
current
rates
of
key
micronutrient
deficiencies,
and
how
are
these
distributed
by
wealth
quintile,
residence,
gender,
etc.?
Ø To
what
extent
are
micronutrient
deficiencies
linked
to
obesity,
stunting
and
wasting
(by
association
and
or
determination)?
Ø What
are
current
coverage
rates
of
supplementation
and
fortification
interventions
in
relation
to
estimates
of
deficiencies,
actual
dietary
patterns,
and
other
forms
of
nutrition
outcomes?
Overweight
and
Obesity
Egypt
has
had
the
biggest
rise
in
overweight
and
obesity
since
1980,
and
is
one
of
10
countries
that
account
for
more
than
half
of
the
world’s
obesity
problem
(in
terms
of
absolute
numbers
affected)
(Ng
et
al.
2014).
Overweight
is
defined
as
having
a
body
mass
index
(BMI)
>
25,
and
obesity
is
defined
as
a
BMI
>
30.
While
overweight
and
obesity
tend
to
cut
across
Egypt’s
regions
and,
to
some
extent,
its
wealth
categories,
the
country
stands
out
as
having
one
of
the
highest
gender
disparities
in
obesity
(IFPRI
2014b).
That
is,
Egypt
ranks
8th
in
the
world
in
terms
of
adult
male
obesity,
but
3rd
in
the
world
in
adult
female
obesity
(Badran
and
Laher
2011).
Table
2
shows
that
there
is
wide
variation
across
selected
countries
of
the
region
in
terms
of
this
male-­‐female
differential,
which
has
yet
to
be
adequately
explored
or
explained.
Adding
in
the
latest
data
for
Egypt
from
the
2014
DHS,
the
difference
is
likely
to
have
increased
–
since
adult
women’s
obesity
prevalence
appears
to
have
risen
to
48
%
(MHP/El-­‐Zatany/Macro
2015)
with
almost
80%
of
women
classified
as
overweight.
While
the
DHS
does
not
typically
report
on
male
obesity,
the
Global
Nutrition
Report
(IFPRI
2014b)
notes
male
obesity
in
Egypt
as
22.5
%
(about
62%
classified
as
overweight):
resulting
in
a
gender
difference
of
25.5
%
(a
much
higher
rate
than
the
17.2
%
rate
noted
in
2010,
Table
1).

10. Understanding
the
complexity
of
malnutrition
in
Egypt
10
Table
2:
Prevalence
of
obesity
(BMI≥30)
among
adults
by
gender,
selected
countries
Country
Age
(Years)
Males
(%)
Females
(%)
Difference
(Female%
-­‐
Male%)
Total
(%)
Egypt
25-­‐64
21.8
39.0
17.2
30.3
Iran
≥25
9.0
20.1
11.1
14.9
Saudi
Arabia
≥
30
36.1
51.8
15.7
43.8
Kuwait
21-­‐77
38.7
40.9
2.2
39.8
Lebanon
≥20
14.3
18.8
4.5
17.0
Morocco
≥20
8.2
21.7
13.5
16.0
Source:
Sibai
et
al.
(2010)
More
recent
estimates
by
WHO
proposed
19
%
of
Egyptian
adult
men
as
obese,
which
represents
a
29
%
different
with
the
2014
DHS
report
of
48
%
adult
women
as
obese
(BMI
>30)
(WHO
2014b;
MHP/El-­‐Zatany/Macro
2015).3
That
compares
with
Jordan’s
21
%
men-­‐36
%
women
ratio,
Saudi
Arabia’s
30
%
men
to
40
%
women,
and
Morocco’s
16
%
men
to
28
%
women
(WHO
2014b).
When
wealth
is
taken
into
account,
an
importantly
differential
appears
in
Egypt’s
distribution
of
malnutrition
in
that
it
has
greater
disparity
for
obesity
by
both
gender
and
wealth
than
for
child
stunting.
Tzioumis
and
Adair
(2014)
conclude
that
wealth
may
explain
variability
across
countries
in
the
relationships
between
stunting
and
overweight,
since
per
capita
income
is
generally
inversely
associated
with
stunting
and
positively
associated
with
obesity.
Yet,
for
Egypt
this
pattern
does
not
hold
true
–
stunting
is
found
more
or
less
equally
across
all
wealth
quintiles,
but
in
contrast
there
is
a
wider
distribution
of
obesity
by
wealth.
Figure
3
adapted
from
the
DHS
2014
shows
that
most
obese
women
reside
in
urban
and
rural
Lower
Egypt
(although
the
Urban
Governorates
are
not
far
behind
Lower
Egypt
Governorates).
Interestingly,
while
the
Frontier
Governorates
and
rural
Upper
Egypt
have
a
relatively
low
obesity
prevalence,
those
locations
are
no
different
from
most
others
in
terms
of
adult
women
who
are
overweight
(>25),
which
suggests
that
obesity
is
likely
to
rise
higher
in
all
geographic
settings
in
coming
years.
Obesity
among
girls
aged
15
to
19,
is
already
high
in
most
parts
of
the
country,
with
little
distinction
between
urban
and
rural
setting.
There
is,
however,
a
wealth
gradient
(even
more
pronounced
among
boys
of
that
age
group),
where
obesity
rises
by
wealth
quintile.
3
Although
Ng
et
al.
(2014)
estimate
Egypt’s
male
obesity
rate
(adults
over
20
years)
at
26.4
%,
which
would
narrow
the
difference
a
little.

11. Understanding
the
complexity
of
malnutrition
in
Egypt
11
Figure
3:
Obese
Women
(Ever-­‐Married,
Aged
15-­‐49,
by
Region
Knowledge
Gaps
on
obesity:
Ø What
explains
the
unusually
high
different
in
obesity
rates
between
men
and
women?
Ø Can
one
predict
(model)
subsequent
rates
of
obesity
from
prior
rates
of
stunting
depending
on
location
and
rate
of
wealth
increase
over
time?
That
is,
is
a
stunted
child
with
access
to
a
nutrient-­‐poor
diet
more
likely
to
become
an
obese
adult
in
certain
settings,
controlling
for
education
of
parents,
setting,
age,
etc.
Ø Why
do
patterns
of
overweight
and
obesity
differ
by
wealth
quintile
depending
on
age?
That
is,
<20
year
olds
do
not
directly
reflect
patterns
and
trends
among
older
women
(for
whom
wealth
is
less
of
a
distinguishing
factor).
Co-­‐Existing
Burdens
Egypt
has
attracted
growing
attention
of
researchers
due
to
the
multiple
forms
of
malnutrition
occurring
across
its
rapidly
increasing
population.
Most
work
indicates
that
despite
the
variable
epidemiological
and
geographic
spread
of
the
different
forms,
one
or
more
form
of
poor
nutrition
(undernutrition
as
manifested
by
stunting
or
wasting,
micronutrient
deficiencies,
overweight
and
obesity,
and
associated
co-­‐morbidities
such
as
diabetes
mellitus)
are
likely
to
be
correlated
at
the
level
of
the
individual
or
the
household.
For
example,
at
the
individual
level
Asfaw
(2007)
reported
that
the
odds
of
being
overweight
or
obese
were
81
%
higher
for
micronutrient
deficient
mothers
in
Egypt
than
for
non-­‐deficient
mothers
(controlling
for
20
25
30
35
40
45
50
55
60
Percentage
of
Women
Urban
Governorates
Lower
Egypt-­‐
Urban
Lower
Egypt-­‐
Rural
Upper
Egypt-­‐
Urban
Upper
Egypt-­‐
Rural
Fronser
Governorates
(excludes
North
&
South
Sinai
governorates)
Source:
Egypt
DHS
2014

12. Understanding
the
complexity
of
malnutrition
in
Egypt
12
socioeconomic
and
health
variables).4
Asfaw
(2007)
did
not,
however,
untangle
the
direction
of
causality;
that
is,
does
being
micronutrient
deficient
contribute
towards
becoming
obese,
or
does
being
obese
result
in
deficiencies
in
certain
micronutrients?
Conversely,
using
just
the
2000
DHS
data,
Eckhardt
et
al.
(2008)
noted
that
overweight
and
obese
women
had
significantly
lower
odds
of
being
anemic
than
women
who
are
not
overweight;
the
latter
difference
was
statistically
highly
significant,
but
was
not
found
to
hold
for
other
countries
such
as
Mexico
and
Peru.
This
then
raises
questions
about
the
generalizable
assumptions
of
underlying
physiological
mechanisms.
It
has
also
been
shown
that
anemia
and
low
vitamin
A
status
are
more
prevalent
among
stunted
children
in
Egypt
than
among
non-­‐stunted
children
(Khairy
et
al.
2010).
Indeed,
as
shown
in
Table
3,
stunted
children
were
also
likely
to
have
significantly
lower
serum
levels
of
calcium,
magnesium,
zinc,
selenium
and
copper.
Again,
because
of
the
use
of
a
cross-­‐sectional
study
design,
the
authors
were
unable
to
conclude
anything
regarding
the
direction
of
causality.
Table
3:
The
association
between
stunting
and
mineral
deficiencies
in
Egyptian
children
Stunted
(n=100)
Control
(n=100)
P-­‐value
Macro
minerals
Calcium
(mg/dl)
7.55±1.46
8.72±1.35
<0.05*
Phosphorus(
mg/dl)
5.60±0.81
5.50±1.10
>0.05
Magnesium
(mg/dl)
2.26±0.24
2.37±0.23
<0.05*
Micro
minerals
Zinc
(µg/dl)
98.47±30.45
115.02±25.32
<0.05*
Selenium
(µg/dl)
8.53±2.34
11.07±3.18
<0.05*
Copper
(µg/dl)
86.62±19.95
91.41±16.61
>0.05
Source:
Khairy
et
al.
(2010)
At
the
household
level,
the
co-­‐existence
of
stunted
children
and
obese
mothers
in
the
same
household
increased
significantly
from
the
early
1990s
to
the
late
2000s.
Aitsi-­‐Selmi
(2014)
found
that
this
pairing
rose
from
4
%
in
the
1992
and
1995
DHS
rounds,
to
almost
6
%
by
2008.
This
puts
Egypt
in
the
same
realm
as
Bangladesh
which
has
around
4
%
of
households
with
both
obese
mothers
and
underweight
children,
and
Indonesia’s
11
%
of
households
with
such
a
pairing
(Oddo
et
al.
2012).
That
said,
according
to
the
2014
DHS
for
Egypt,
moderately
stunted
children
are
slightly
less
likely
to
be
paired
with
an
overweight
or
obese
mother
(21%)
than
paired
with
a
mother
with
a
normal
BMI
(23.5%).
The
same
is
true
for
severely
stunted
children
and
also
for
wasted
children.
The
one
case
where
the
pairings
lean
towards
the
obese
mother
is
the
15
%
of
4
The
author
concluded
that
the
co-­‐existence
of
these
nutrition
problems
is
important
given
“the
potential
impact
of
the
interaction
between
micronutrient
deficiency
and
chronic
diseases
is
not
well
known.”
(Asfaw
2007)

13. Understanding
the
complexity
of
malnutrition
in
Egypt
13
children
who
are
themselves
overweight
(+2
SDs
of
weight-­‐for-­‐height)
and
have
an
overweight
or
obese
mother.
That
compares
with
13
%
of
overweight
children
who
have
normal
weight
mothers
(MHP/El-­‐Zatany/Macro
2015).
Perhaps
not
surprisingly,
the
largest
share
of
the
27
%
overweight
girls
and
adolescents
(5
to
19
years
of
age)
are
found
in
both
rural
and
urban
Lower
Egypt,
which
is
the
location
of
most
maternal
overweight
and
obesity.
That
pattern
holds
true
for
boys
and
adolescents
(5
to
19
years
of
age),
but
there
is
also
a
high
concentration
of
overweight
and
obesity
among
males
of
this
age
in
urban
Upper
Egypt.
The
existence
of
stunting
and
overweight/obesity
in
the
same
child
has
been
documented
globally
in
Guatemala,
Mexico,
Russia,
China
and
Brazil
(Fernald
and
Neufeld
2007,
Popkin
et
al
1996).
Published
analyses
of
the
2005
Egypt
DHS
data
indicate
an
interaction
of
stunting
and
obesity/overweight
within
the
same
individual/child
(Dodoo
2011).
The
author
noted
that
simultaneous
stunting
and
obesity
is
spread
across
all
social
and
economic
classes
though
the
relationship
is
complex
-­‐
and
recommended
further
study
and
analyses
to
elucidate
factors
that
influence
stunting
and
obesity
in
Egyptian
children.
This
is
particularly
interesting,
as
research
in
Latin
America
has
shown
that
childhood
nutritional
stunting
is
associated
with
impaired
fat
oxidation,
a
factor
that
predicts
obesity
in
at
risk
populations
(Hoffman
et
al
2000).
Furthermore
studies
done
in
Brazil
on
stunted
and
non-­‐stunted
children
have
shown
higher
fat
mass
accumulation
in
stunted
boys
and
less
lean
mass
accumulation,
over
a
3
year
period
of
observation.
Similarly
stunted
girls
also
gained
less
lean
mass
and
had
significantly
higher
values
of
fat
mass
when
compared
to
their
baseline
(Martins
et
al
2004).
This
is
a
significant
public
health
issue
since
co-­‐existence
of
the
double
burden
within
the
same
child
is
related
to
significant
risk
of
metabolic
syndrome
and
later
risk
of
chronic
diseases
such
as
diabetes
mellitus
and
cardiovascular
diseases.
(Popkin
et
al
1996).
Knowledge
Gaps
on
co-­‐morbidities:
Ø Did
the
pairing
of
stunted
child
with
obese
mother
continue
to
increase
in
the
2014
DHS
round?
While
stunting
will
have
declined,
the
prevalence
of
obese
mothers
has
risen
dramatically,
suggesting
that
such
pairs
may
reach
close
to
10
%
of
households.
Ø Which
adverse
anthropometric
conditions
(stunting
or
wasting
versus
obesity)
are
associated
with
each
other
(obesity
and
stunting
can
coexist
at
both
individual
and
household
levels)
or
with
other
nutritional
deficiencies?
Ø What
is
the
prevalence
of
the
co-­‐existence
of
stunting
and
overweight
in
the
same
child?
Are
there
similar
issue
viz-­‐a-­‐viz
fat
mass
versus
lean
mass
accumulation
in
stunted
children?
Ø Does
obesity
(or
stunting)
cause
certain
micronutrient
deficiencies,
or
are
they
joint
outcomes
of
a
common
process?
Ø Can
programs
aimed
at
tackling
micronutrient
status
have
positive
side-­‐effects
in
preventing
stunting
or
obesity
in
the
absence
of
additional
activities?
Ø Do
multiple
bouts
of
wasting
contribute
to
stunting
in
such
a
way
that
later
obesity
is
more
or
less
likely
in
the
individual?

14. Understanding
the
complexity
of
malnutrition
in
Egypt
14
Ø At
a
sub-­‐national
level,
how
do
different
co-­‐morbidities
map
vary
geographically?
Determinants
of
Co-­‐Existing
Burdens
in
Egypt
The
literature
in
this
area
is
large,
but
mainly
focused
on
a
nutrient-­‐by-­‐nutrient
or
individual
nutrition
outcomes
relating
to
defined
policy
interventions.
There
are
few
studies
that
consider
multiple
forms
of
malnutrition
in
Egypt
in
such
a
way
that
co-­‐morbidities
can
be
fully
understood.
The
planned
analysis
of
secondary
data
will
help
in
this
regard,
by
examining
individual,
household,
community
and
regional
correlates
of
co-­‐morbidities,
including
the
role
of
wealth,
health-­‐related
behaviors
and
diets
that
are
considered
briefly
below.
Poverty
determinants
of
co-­‐existing
conditions
In
the
past
decade,
global
food
price
hikes
and
volatility,
political
instability,
economic
and
financial
crises,
and
the
avian
influenza
crisis
of
the
mid-­‐2000s,
all
combined
to
push
many
Egyptians
to
the
edge
of,
or
into,
poverty.
According
to
IFPRI/WFP
(2013),
income
poverty
increased
from
around
15
%
in
1999
to
almost
20
%
in
2004/2005
over
25
%
in
2010/2011.
The
25
%
rate
is
likely
to
have
remained
at
or
above
at
that
level
since.
As
one
would
expect,
different
groups
of
households
were
“affected
differently
by
growth
and
inflation
and
then
by
deceleration
of
the
economy”
during
the
years
since
2000
(Marotta
and
Yemptsov
2010).
The
authors
found
very
high
instability
of
household
incomes,
leading
to
volatility
in
purchasing
power
which
affected
many
expenditure
decisions
across
the
decade.
One
older
study
in
Egypt
reported
a
lower
rate
of
obesity
in
poorer
people
(3
%)
compared
to
those
who
are
more
affluent
(10
%)
(Salazar-­‐Martinez
et
al.
2006).
The
2014
DHS
shows
that
generalized
view
remains
true,
but
that
the
actual
rates
are
significantly
higher
and
the
gap
has
narrowed:
45
%
of
women
in
the
lowest
wealth
quintile
are
now
obese
compared
with
48
%
in
the
top
wealth
quintile.
This
suggests
that
wealth
alone
is
not
either
the
main
or
only
cause
or
contributor
to
obesity
–
there
are
multiple
factors
at
play
in
its
causality,
just
as
with
stunting.
That
said,
the
inability
to
access
and
purchase
a
quality
diet
remains
a
key
facet
in
both
stunting
and
wasting,
coupled
with
the
knowledge
(formal
and
informal
education)
and
desire
to
make
healthy
choices
in
the
procurement
of
food
and
drinks.
A
review
of
the
findings
of
the
Household
Income,
Consumption
and
Expenditure
Survey
(HICES)
from
2012/2013
(published
in
2014),
shows
the
stark
difference
in
percent
expenditure
between
urban
and
rural
areas
on
food
items
and
specifically
within
food
groups
(Table
4).
For
instance
almost
42%
of
total
expenditure
in
the
rural
areas
is
on
food
and
non-­‐alcoholic
beverages,
while
in
urban
areas
the
percent
expenditure
is
34.
More
is
expended
in
rural
areas
on
obtaining
nutritious
foods
such
as
vegetables
and
meat.
Interestingly,
bread
and
cereals
are
also
more
expensive
in
rural
areas
as
noted
by
an
almost
doubling
of
expenditure
on
that
group
from
urban
to
rural
areas
(CAPMAS
2014).

15. Understanding
the
complexity
of
malnutrition
in
Egypt
15
Table
4:
The
urban/rural
expenditure
pattern
on
food
and
non-­‐alcoholic
beverages
(HICES
2012/2013)
Food
Group
Percentage
Expenditure
Total
Egypt
Urban
Rural
Food
and
Non-­‐Alcoholic
Beverages
37
34
41.4
Bread
and
cereals
5
3.9
6.2
Meat
11
10
12.1
Fish
and
seafood
2.5
2.5
2.5
Milk,
cheese
and
eggs
4.9
5.1
4.8
Oils
and
fats
2.5
2.1
2.9
Fruit
2.6
2.4
2.8
Vegetables
5.5
4.6
6.4
Sugar,
Jam,
honey,
Chocolate
and
Confectionery
1.4
1.3
1.5
Other
food
products
0.7
0.6
0.7
Non-­‐Alcoholic
Beverages
1.4
1.3
1.4
Source:
Extracted
from
CAPMAS
2014
An
interesting
analyses
of
the
prior
five
survey
year
periods
(1990/91,
1994/95,
1999/2000,
2004/2005
and
2009/2010)
shows
that
similar
to
the
findings
in
the
current
survey
(Table
4),
rural
expenditure
on
food
is
higher
than
urban
expenditure
of
food.
Expenditure
on
food
in
rural
areas
was
as
high
as
60%
in
1990/91
going
down
to
50%
in
2009/2010.
On
the
other
hand,
food
expenditure
in
urban
areas
has
gone
down
from
almost
50%
to
40%
from
1990/91
to
2009/2010.
Furthermore,
an
estimation
of
expenditure
elasticities
finds
a
decrease
in
elasticities
as
the
survey
years
go
with
commodities
such
as
fish,
milk-­‐eggs
and
fruits
being
considered
as
luxury
goods
in
the
early
survey
periods
(1990/91)
but
moving
up
to
being
necessity
commodities
in
2009/2010.
That
being
said,
expenditure
elasticity
was
found
to
be
quite
different
between
rural
and
urban
areas
with
elasticities
being
higher
in
the
rural
areas.
There
was
an
inverse
relationship
between
income
level
and
expenditure
elasticity
with
higher
income
groups
showing
lower
elasticities
(Dawoud
S.D.Z,
2014).
Dietary
Factors
Aitsi-­‐Selmi
(2014)
argues
“the
body
of
literature
on
the
nutrition
transition
and
the
double
burden
of
malnutrition
points
to
a
role
of
changing
diets.”
That
author,
along
with
most
other
commentators
on
the
double
burden
of
malnutrition
(or
nutrition
transition),
argue
that
diets
in
Egypt
commonly
lack
diversity
and
lack
nutrient
density;
are
lacking
in
key
foods
such
as
fruits
and
vegetables,
pulses,
and
animal
source
foods
(for
certain
categories
of
consumers);
and
are
exposed
to
an
over-­‐abundance
of
processed
foods,
sugar-­‐sweetened
soft
drinks,
added
sugars
in
the
diet,
and
fats
and
oils
(Aitsi-­‐Selmi
2014;
Ng
et
al.
2014;
Popkin
et
al.
2012).

16. Understanding
the
complexity
of
malnutrition
in
Egypt
16
Figure
4
shows
the
UN
World
Food
Programme’s
food
consumption
analysis
for
Egypt
which
highlights
the
poor
status
of
food
consumption
in
Upper
Egypt,
but
especially
in
Rural
Upper
Egypt.
Of
note
is
the
low
%
recording
a
‘poor’
score
in
the
Frontier
Governorate.
Figure
4:
Food
Consumption
Scores
by
Region
in
Egypt
(2011)
Source:
WFP
2013
WFP’s
food
score
is
one
approach
to
assessing
dietary
adequacy.
Others,
like
the
DHS,
focus
on
the
absence
or
presence
of
specific
foods
or
food
groups,
particularly
those
considered
to
be
nutrient
dense
and
contributors
to
a
‘healthy
diet’.
Table
5
puts
Egypt’s
dietary
risk
factors
for
cardiovascular
disease
in
a
comparative
context.
While
not
very
different
in
terms
of
total
number
of
days
of
fruit
consumption,
Egypt
falls
short
of
the
ideal
compared
with
Jordan
in
terms
of
days
of
vegetables
consumed,
and
especially
in
terms
share
of
households
consuming
fewer
than
the
widely
recommended
5
daily
servings
of
fruits
and
vegetables.
Table
5:
Diet-­‐Related
Risk
Factors
for
Chronic
Diseases,
selected
countries
Both
Sexes
Egypt
(2011-­‐12)
Jordan
(2007)
Qatar
(2011)
No.
of
Days
Fruits
Consumed
(Per
Week)
3.5
4.1
3.4
No.
of
Days
Vegetables
Eaten
(Per
Week)
4.6
6.2
5.5
%
Eating
<
5
Servings
of
F&V
(Per
Day)
95.6
14.2
91.1
Source:
WHO
STEPS
survey
data
(WHO
Qatar
2014;
Egypt
2013;
Jordan
2009)
Figure
5,
based
on
national
data
from
FAOSTAT
shows
that
Egypt’s
overall
consumption
is
still
heavily
dominated
by
grains,
and
contains
a
relatively
low
share
of
protein
from
animal
sources.
Animal
source
protein
is
of
high
quality,
which
is
considered
to
be
critical
to
child
growth
and
the
prevention
of
stunting.
The
heavy
reliance
on
(subsidized)
grain
for
total
energy
in
the
diet

17. Understanding
the
complexity
of
malnutrition
in
Egypt
17
has
been
remarked
on
many
times,
but
trends
in
supply
of
animal
source
foods,
and
fruits
and
vegetables,
deserve
more
attention.
Figure
5:
Percent
of
Dietary
Energy
Supply
by
Food
Groups,
Selected
Countries
Other
Behavioral
Risk
Factors
Linked
to
Obesity
In
Egypt,
reported
deaths
from
cardiovascular
disease
(CVD)
have
risen
from
5
%
in
the
1960s
to
almost
50
%
by
the
2000s
(Sibai
et
al.
2010).
The
proposed
drivers
of
Egypt’s
rise
in
CVDs
include
urbanization,
sedentary
lifestyle,
smoking,
and
unhealthy
dietary
changes.
Table
6
shows
that
these
kinds
of
risk
factors
vary
across
countries,
but
Egypt
has
high
levels
of
both
physical
inactivity
and
tobacco
use.
Indeed,
when
disaggregated
by
gender,
interesting
patterns
emerge.
While
in
Egypt
there
are
few
differences
in
dietary
risk
factors
between
adult
men
and
women,
physical
inactivity
among
men
is
reported
as
23
%
compared
with
42
%
among
women.
In
Jordan,
slightly
more
men
are
inactive
than
women,
but
the
rates
are
still
so
low
that
neither
make
the
kind
of
contribution
that
one
sees
in
Egypt
(and
Qatar).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Egypt
Saudi
Arabia
Lebanon
Percentage
Countries
Others
Fruits
&
Vegetables
Milk
Meat,
Animal
Fats,
Eggs,Fish
&
Seafood
Vegetable
Oils
Sugar
Cereal
Products
Source:
Food
Balance
Sheet
2011,
FAOSTAT

18. Understanding
the
complexity
of
malnutrition
in
Egypt
18
Table
6:
Risk
Factors
for
Chronic
Diseases,
selected
countries
Both
Sexes
Egypt
(2011-­‐12)
Jordan
(2007)
Qatar
(2011)
%
with
Low
Physical
Activity
32.1
5.2
45.9
%
who
Currently
Smoke
Tobacco
24.4
29.0
16.4
Source:
WHO
STEPS
survey
data
(WHO
Qatar
2014;
Egypt
2013;
Jordan
2009)
Linked
to
Undernutrition
Although
breastfeeding
is
reported
to
be
almost
universal
in
Egypt
by
the
2014
DHS,
sub-­‐
optimal
practices
are
common
(i.e.
exclusive
breastfeeding
is
not
so
common),
and
appropriate
infant
and
young
child
feeding
practices
are
seen
to
have
fallen
quite
dramatically
in
the
last
two
DHS
rounds.
Table
7
shows
that
this
has
happened
across
all
wealth
quintiles
in
relation
to
the
provision
of
breast
milk
and/or
milk
products
to
infants
and
young
children.
Milk
contains
protein,
calcium,
and
many
other
critical
nutrients.
Table
7:
Breast
milk/milk
product
consumption
among
young
children
Wealth
DHS
2008
DHS
2014
Lowest
97.4
80.9
Second
96.5
78.8
Middle
96.9
79.3
Fourth
95.2
77.4
Highest
98.2
83.3
Total
96.8
79.7
Source:
DHS
2008
and
2014
The
same
is
true
of
appropriate
complementary
feeding
practices
for
infants
and
young
children,
focused
on
providing
3+
food
groups
daily
(to
infants)
and
4+
(to
young
children)
(Table
8).
The
2014
DHS
reports
that
less
than
one-­‐quarter
of
children
age
6-­‐23
months
are
being
fed
according
to
minimum
Infant
and
Young
Child
Feeding
(IYCF)
standards
for
diet
diversity
and
meal
frequency,
although
breastfed
children
are
more
likely
than
non-­‐breastfed
children
to
have
a
minimum
acceptable
diet.

19. Understanding
the
complexity
of
malnutrition
in
Egypt
19
Table
8:
IYCF
practice:
3+
or
4+
food
groups
among
young
children
Wealth
Quintile
DHS
2008
DHS
2014
Lowest
63.7
43.9
Second
66.5
40.3
Middle
70.0
43.2
Fourth
67.1
43.7
Highest
75.0
45.0
Total
68.5
43.2
Source:
DHS
2008
and
2014
Furthermore,
it
has
long
been
known
that
children
of
poor
households
are
less
able
to
accumulate
human
capital,
including
nutrition,
health,
and
cognitive
development.
Kirksey
et
al.
(1994)
showed
two
decades
ago
that
there
were
differences
in
children’s
motor
development
in
Egypt
according
to
household
socioeconomic
status.
Today,
Egypt
still
has
a
twenty
percentage
point
gap
between
urban
and
rural
children
attending
institutionalized
early
childhood
care
and
education
(ECCE)
facilities
or
activities
(El-­‐Kofadi
and
Krafft
2015).
This
impacts
their
ability
to
develop
appropriate
cognitive
facilities
as
well
as
to
socialize,
both
of
which
play
a
role
in
their
subsequent
health
and
nutrition
outcomes.
Environmental
Risk
Factors
Two
major
considerations
within
the
context
of
environmental
risk
factors
associated
with
over
and
under
nutrition
in
Egypt
include
food-­‐based
contamination
and
water
based
contamination.
Food
based
contamination
can
include
mycotoxins,
such
as
aflatoxin,
as
well
as
contaminants
such
as
lead
or
pathogenic
bacteria.
Water
based
contamination
can
include
pathogenic
organisms
and
can
lead
to
environmental
enteropathy.
Aflatoxins
are
mycotoxins,
secondary
metabolites
produced
by
fungi
that
are
capable
of
causing
both
disease
and
death
in
both
humans
and
other
animals.
Aflatoxins
are
common
contaminants
in
staple
foods,
such
as
corn
and
peanuts,
in
developing
countries
(Bhutta
et
al
2013,
Ruel
et
al
2013).
They
are
proven
carcinogens,
immunotoxins,
and
growth
retardants
(Raisuddin
et
al
1993,
Williams
et
al
2004).
Fusarium
mycotoxins,
such
as
fumonisins
and
Deoxynivalenol
(DON),
have
also
been
linked
to
impaired
growth
(D’Mello
et
al
1999,
Kimanya
et
al
2010).
DON,
known
as
“vomitoxin”,
has
been
shown
to
impair
food
intake
and
weight
gain
in
experimental
animals
while
fumonisins
have
also
been
shown
to
reduce
growth
(D’Mello
et
al
1999,
Pestka
2008,
Swamy
et
al
2003,
Rotter
et
al
1996).
Both
hepatitis
C
and
aflatoxins
cause
liver
(hepatocellular)
cancer.
Both
are
prevalent
in
Egypt
and
synergistically
contribute
to
the
high
burden
of
liver
cancer
in
Egypt
(Abdel-­‐Wahab
et
al
2008;
Anwar
et
al,
2008).

20. Understanding
the
complexity
of
malnutrition
in
Egypt
20
A
study
on
breast
milk
aflatoxin
levels
conducted
in
Qalyubiyah
Governorate
in
Egypt
found
that
36%
of
breast
milk
samples
(n=388)
had
detectable
aflatoxin.
Furthermore,
maternal
obesity,
(p<0.011
for
BMI),
consumption
of
corn
oil
(RR
2.21,
p<
0.002),
and
“non-­‐working”
(stay
at
home)
employment
status
(RR
2.87,
p=0.018)
were
the
strongest
predictors
of
finding
aflatoxin
in
breast
milk.
Obese
women
(BMI
>
30)
were
3
times
more
likely
than
normal
BMI
(BMI
20-­‐25)
women
to
have
aflatoxin
in
breast
milk
(Polychronaki
2006,
2007a).
Maternal
aflatoxin
exposure
has
been
shown
to
be
associated
with
poor
birth
outcomes
and
subsequent
poor
linear
growth
of
their
children
(Shuaib
et
al
2010,
Gong
et
al
2002,
Gong
et
al
2003,
Turner
2013,
Turner
et
al
2007,
Turner
et
al
2012,
Leroy
2013).
High
levels
of
aflatoxin
have
been
documented
in
Egyptian
adults,
pregnant
women,
breast
milk
and
young
children
(Abdel-­‐
Wahab
et
al
2008;
Turner
et
al
2007,
Piekkola
et
al,
2012.,
Polychronaki
2006,
2007b,
Hatem
et
al
2005,
Hassan
et
al
2006;
Polychronaki
2007c).
Aflatoxin
contamination
has
been
found
in
several
Egyptian
foods
(Aziz
&
Youssef
1991;
Selim
et
al
1996;
Hifnawy
et
al
2004)
including
foods
fed
to
infants
and
children
(Neel
MZ
et
al
1999).
Hatem
et
al’s
2005
study
found
aflatoxins
present
in
Egyptian
malnourished
children
but
not
in
any
control,
normal
children.
Environmental
enteropathy
(EE)
is
a
condition
where
the
intestinal
gut
is
chronically
inflamed
and
permeable,
or
“leaky”
in
colloquial
terms.
Children
with
this
condition
require
~
15%
more
protein
and
~
5%
more
carbohydrates
to
maintain
the
same
growth
as
children
without
EE
(Prendergast
and
Kelly,
2012).
Children
fail
to
grow
normally
when
they
are
recurrently
exposed
to
human
or
animal
infectious
pathogens
through
living
in
an
unsanitary,
un-­‐hygienic
environment
(Solomons
NW
2003).
The
normal
intestine
“is
a
large
efficient
absorptive
surface
with
a
powerful
barrier
(gut
barrier
function
=
intestinal
permeability)
to
permeation
of
potential
food
antigens
and
bacteria
invading
the
body.
The
indigenous
intestinal
microflora
are
a
stable
and
tightly
regulated
ecosystem
and
play
a
major
role
in
maintaining
the
gut
barrier.”
(Mohammad
et
al
2007).
Children
with
EE
are
colonized
by
an
abnormal
spectrum
of
gut
bacteria
(the
gut
microbiota),
which,
acting
in
consort
as
the
gut
microbiome,
actively
causes
malnutrition
and
blocks
important
metabolic
pathways
(Smith
et
al,
2013).
Lunn
et
al
in
(1991)
have
shown
that
43%
of
stunting
in
young
children
can
be
by
their
abnormal
gut
permeability.
This
circumstance
can
be
changed
by
improving
the
sanitary
environment,
and
by
shifting
the
spectrum
of
gut
bacteria
back
into
a
healthy
profile
as
a
recent
World
Bank
study
(Spears
2013)
shows
that
the
lack
of
strong
sanitation
–
the
proximate
cause
of
EE
-­‐
accounts
for
more
than
56%
of
the
variation
in
height
(stunting)
internationally.
There
may
be
overlapping
causes
of
environmental
enteropathy,
in
that
the
mycotoxin
DON
has
been
found
to
increase
intestinal
permeability.
Thus
ingesting
food
with
mycotoxins
such
as
DON,
and
food
or
water
with
pathogenic
organisms,
could
impair
the
gut
barrier
function.
In
an
important
paper,
Piekkola
et
al
(2012)
found
that
both
aflatoxins
and
DON
were
found
in
pregnant
women
in
Egypt.
Aflatoxins
were
found
in
34
of
98
blood
samples,
while
44
of
93
urine
samples
had
aflatoxin
and
63
of
the
93
had
DON.
In
41
%
of
the
98
pregnant
women,
both
aflatoxins
and
DON
were
found
simultaneously.
Researchers
in
Egypt
have
evaluated
EE
in
children
in
a
pilot
study
(Mohammad
et
al
2007).
EE
was
present
in
96%
of
the
children
sampled,
and
found
to
improve
with
a
simple
set
of

21. Understanding
the
complexity
of
malnutrition
in
Egypt
21
nutritional
supplements.
The
supplements
consisted
of
probiotic
yogurt
(containing
Lactobacillus
bacteria)
with
honey.
This
builds
on
important
research
by
Egyptian
researchers
that
both
aflatoxins
and
Fusarium
toxins,
such
as
DON,
are
removed
by
Lactobacillus
bacteria
(El-­‐Nezami
et
al
2002;
Turner
et
al
2008).
Malnourished
children
who
undergo
nutritional
rehabilitation
have
their
gut
permeability
return
to
normal
(Hossain
et
al,
2010)
as
the
enteropathy
is
cured.
Such
data
however
are
sparse
in
Egypt.
This
is
particularly
important
while
reviewing
the
DHS
2014
findings
around
water,
hygiene
and
sanitation.
Egypt
has
high
rates
of
coverage
with
improved
water
supply
(over
90%)
and
access
to
improved
latrines
(over
90%).
Improved
water
sources
are
not
synonymous
with
safe
water
however,
as
the
definition
for
improved
water
(e.g.
piping)
does
not
account
for
microbial
quality,
and
“overestimates
the
population
with
access
to
safe
drinking
water”
(Baum
et
al,
2014).
Indeed,
less
than
15%
of
households
treat
their
drinking
water
supply
and
about
30-­‐40%
of
households
dispose
waste
(especially
in
the
rural
areas)
in
the
street,
in
empty
lots,
canals
and
in
local
drainage
pits.
Sewage
management
is
particularly
an
issue
in
the
rural
areas,
which
houses
half
of
Egypt’s
population.
It
is
noted
by
Hopkins
and
Mehanna
(2003)
that
90%
of
rural
population
have
no
access
to
sewage
systems
or
waste
water
treatment
facilities
with
the
use
of
unlined
latrines
being
the
prevalent
mode
of
sanitation
(Hopkins
and
Mehanna,
2003;
Marei
et
al
2014).
This
is
further
compounded
by
the
issue
that
the
central
waste
water
management
in
rural
areas
does
not
adequate
handle
the
waste
water
thereby
leading
to
a
dumping
of
unclean
water
into
the
River
Nile.
This
leads
to
a
wider
scale
issue
of
pollution
and
deterioration
of
water
quality
and
increased
risk
of
pathogenic
infections
that
is
population
wide
(Marei
et
al
2014)..
Rates
of
diarrheal
disease
in
children
remain
high
in
Egypt
(Fischer
Walker
et
al,
2012)
suggesting
substantive
gaps
related
to
safe
drinking
water
and
sanitation
and
clearly
the
improper
management
of
sewage
and
waste
water
treatment
are
key
issues
linked
to
access
to
safe
water
and
lowered
risk
of
pathogenic
infections.
Pathogenic
infections
include
diarrheal
diseases
in
infants
and
young
children,
typhoid,
infectious
hepatitis
all
leading
to
the
long
term
issue
of
lowered
gut
integrity
and
environmental
enteropathy.
In
summary,
a
review
of
the
literature
in
Egypt
implicates
both
environmental
risk
factors
(mycotoxins,
and
water
and
sanitation)
being
associated
with
the
nutrition
problems
in
Egypt.
Given
the
pervasive
nature
of
environmental
contamination
that
transcends
geography
and
socio-­‐economic
strata,
there
is
clearly
a
need
to
examine
these
issues
within
the
context
of
the
spread
of
stunting
across
regions
and
wealth
quintiles.
Knowledge
Gaps
on
Determinants
of
Nutrition
Problems
in
Egypt:
Ø Are
the
declines
in
provision
of
milk
to
infants
and
food
groups
to
young
children
associated
with
price
dynamics,
location,
and
education?
Ø To
what
extent
are
risk
factors
for
non-­‐communicable
diseases
linked
to
the
drivers
of
stunting
and
micronutrient
deficiencies,
controlling
for
wealth?
Ø Actual
consumption
patterns
are
poorly
understood,
separate
from
food
group
consumption
or
derived
energy
by
food
group
in
the
national
food
supply.
Ø A
greater
focus
on
‘positive
deviants’
is
warranted,
in
terms
of
relatively
good
outcomes
on
various
nutrition
outcomes
in
locations,
quintiles
or
other
categories
that
would
have

22. Understanding
the
complexity
of
malnutrition
in
Egypt
22
suggested
otherwise;
in
other
words,
where
are
the
counter-­‐factual
cases
from
which
lessons
might
be
learned?
Ø Is
there
a
relationship
between
aflatoxin
exposure
and
growth
patterns?
How
is
this
relationship
modulated
by
the
co-­‐existence
of
overweight
and
obesity
in
mothers?
How
does
this
relate
to
differences
in
stunting/height
for
age
adjusting
for
geographic
location
and
wealth
quintile?
Ø Is
there
a
relationship
between
EE
and
growth
pattern
in
Egyptian
children?
How
does
this
relate
to
differences
in
stunting/height
for
age
adjusting
for
geographic
location
and
wealth
quintile?
Conclusions
This
review
examined
the
complexity
of
the
malnutrition
in
Egypt.
There
are
several
different
emerging
considerations
from
this
review,
which
encompass
the
different
nutritional
conditions
of
stunting,
wasting,
underweight,
overweight/obesity
in
relation
to
poverty,
geographic
location,
wealth
and
education.
There
is
need
to
understand
why
there
is
a
statistically
significant
rise
and
then
fall
in
stunting
prevalence
within
a
very
short
period
of
time.
Furthermore,
there
is
need
to
understand
why
inequality
in
stunting
by
wealth
disappeared
and
re-­‐appeared
such
that
the
richest
and
poorest
wealth
quintiles
are
similar.
As
not
all
wealth
quintiles
or
geographic
regions
are
seeing
an
increase
in
stunting,
what
might
explain
relative
changes
over
time
by
income
and
location?
To
what
extent
does
the
rise
in
stunting
result
from
the
rapid
increase
in
maternal
obesity
(which
is
known
to
be
associated
with
poor
birth
outcomes
and
both
child
stunting
and
the
foetal
and
neonatal
programming
of
adult-­‐onset
chronic
diseases)?
According
to
Aitsi-­‐Selmi
(2014),
the
trends
in
data
from
DHS
since
1992
suggest
the
existence
of
“a
link”
between
maternal
obesity
and
a
rise
in
the
number
of
households
with
concurrent
overweight/obesity
and
stunting,
but
the
nature
of
that
link
has
yet
to
be
found.
With
respect
to
wasting,
the
high
rates
of
moderate
wasting
in
the
Frontier
Governorates,
are
concerning
given
that
these
are
rates
that
are
normally
associated
with
humanitarian
crises.
The
other
notable
point
is
that
the
wasting
prevalence
was
higher
in
the
3
higher
wealth
quintiles
than
in
the
two
lower
quintiles.
Based
only
on
the
DHS
for
2003,
Khatab
(2010)
found
that
age
of
mother
was
statistically
correlated
with
wasting
outcomes;
that
is,
the
older
the
mother
the
more
likelihood
of
wasting.
Since
age
in
women
is
also
correlated
with
obesity
(the
share
of
women
who
are
obese
more
than
doubles
from
20
%
in
the
20
to
29
year
old
category
to
65
%
in
the
40
to
49
years
old
category),
and
wasting
episodes
can
contribute
to
linear
growth
retardation
(stunting),
the
relationship
between
obesity
and
wasting
deserves
to
be
explored
further
(MHP/El-­‐Zatany/Macro
2015).
Other
questions
that
need
to
be
examined
include:
Are
locations
and
household
groups
with
high
rates
of
severe
stunting
more
prone
to
acute
wasting;
and
are
the
dynamic
patterns
noted
for
stunting
rates
over
time
in
Egypt
mirrored
by
similar,
or
featuring
different,
patterns
for
wasting?