Breaking the Poverty/Malnutrition Cycle in Africa and the Middle East

Breaking the poverty/malnutrition cycle in Africa and the Middle East

Tola Atinmo, Parvin Mirmiran, Oyediran E Oyewole, Rekia Belahsen, and Lluís Serra-Majem

The cost to developing countries, for current and future generations, of not eradicating hunger and poverty – in terms of recurrent conﬂicts and emergencies, widening inequalities, depleted resources, ill health, and premature death – is enormous. Although strategies are underway to address certain problems in Africa and the Middle East, much remains to be done. Breaking the poverty cycle in these regions demands both local and international attention. Nutrition transition is a key factor, since many countries in the region also suﬀer the consequences of the excessive and unbalanced diets that are typical of developed countries. This paper reviews the experiences with facing malnutrition in Sub-Saharan and North Africa and the Middle East. © 2009 International Life Sciences Institute

INTRODUCTION rupturing of self-reliance inhibits developing economies and contributes to the devastating downward spiral of In spite of the numerous strategies being implemented at hunger and poverty. the national and international levels in order to break the There is clear evidence that the major damage caused cycle of poverty in Africa and developing nations in the by malnutrition takes place in the womb and during Middle East, the problem continues unabated. It is doubt- the first 2 years of life. This damage is irreversible and ful that any another condition is more damaging to indi- is linked to lower intelligence and reduced physical vidual dignity or causes greater dependence on others capacity, which in turn diminishes productivity, slows than persistent deprivation of food, which, along with economic growth, and perpetuates poverty. Moreover, water, is one of the most essential ingredients for a malnutrition passes from generation to generation healthy and fulfilling life. because stunted mothers are more likely to have underweight children.1 As such, it is clear that to break this cycle, the focus must be on preventing and treating mal- POVERTY AND HUNGER: FOCUS ON AFRICA nutrition in pregnant women and in children aged 0–2 years. School feeding programs – often implemented as Chronic hunger afflicts one in five of the developing nutrition interventions – may help get children into world’s people, assaulting children and individuals in school and keep them there, but such programs do not rural populations in particular. Hunger is both a violation attack the root causes of malnutrition. of dignity and an obstacle to social, political, and eco- Hunger is as much a cause as an effect of poverty. nomic progress; chronic hunger increases one’s suscepti- Failure to address problems of hunger and undernourish- bility to disease, hinders learning ability, and leaves one ment frustrates and retards the achievement of poverty weak and unable to work and meet family needs. This alleviation goals. Sub-Saharan Africa has the highest

Aﬃliations: T Atinmo and OE Oyewole are with the Department of Human Nutrition, University of Ibadan, Nigeria. P Mirmiran is with the Institute of Nutrition, Endocrine Research Center, Shaheed Beheshti University of Medical Sciences, Iran. R Belahsen is with the Training and Research Unit on Food Sciences, Laboratory of Physiology Applied to Nutrition and Feeding, Chouaib Doukkali University, School of Sciences, El Jadida, Morocco. L Serra-Majem is with the NGO Nutrition without Borders, Barcelona and the Department of Clinical Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain. Correspondence: L Serra-Majem, Department of Clinical Sciences, University of Las Palmas de Gran Canaria, PO Box 550, 35080 Las Palmas de Gran Canaria, Spain. E-mail: [email protected], Phone: +34-928-453-477. Key words: Africa, hunger, Middle East, nutrition transition, poverty

doi:10.1111/j.1753-4887.2009.00158.x S40 Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46 proportion of people living in poverty, with nearly half of resulting in the need for international crisis the population living below the international poverty interventions. level of US$1 a day.2 The world community can drastically reduce hunger Some 300 million people face a daily struggle for over the next five decades if developed and developing survival, with thousands of them – especially children – countries support rural development in poor countries, losing the battle. In the case of Africa, there are many spend more money on research, and reduce barriers in factors that hinder hunger and poverty alleviation efforts, developed countries to importing agricultural products thus disrupting agricultural productivity, sustainable live- from developing countries. lihoods, and effective development initiatives. Such According to studies from the United Nations Con- obstacles to improvement need to be addressed simulta- ference on Trade and Development, trade rules and neously and include the following: restrictions on poor countries, including the poorest in Africa, cost these countries around US$100 billion per Threat to peace. Conflicts across Africa arise from, as well year – twice the amount that the entire developing world as generate, poverty, income inequality, and competition receives in aid. Prevailing and proposed trade policies over resources, while simultaneously playing a role in the cannot address poverty and hunger as they persist in displacement and disruption of sustainable activities for Africa today. Studies demonstrate that even a 1% increase over 15 million people. in world exports from Africa would result in gains in income and livelihoods that could shift 40 million Afri- cans out of poverty and help promote sustainable Lack of job opportunities. Sub-Saharan Africa has the development.4,5 highest proportion of unemployed and underemployed Developed nations must be committed to fair trade people in the world with approximately 300 million and the allocation of resources (encouraged to consist of people living on less than US$1 a day. 0.7% of gross domestic product) that are earmarked for international assistance programs. Developing nations Poor health and the spread of HIV/AIDS. Inadequate must improve and redirect policies that will provide aid nutrition and poor health increase vulnerability to HIV to rural areas. Additionally, the rural poor themselves infection and shorten the HIV incubation period, causing have a central role in seeking sustainable methods of self- people to fall ill sooner. Family spending increases while development that respect equality and education. ability to generate income is reduced.3 It is also envisaged that a focus on integrated approaches to development, transformation of policy Inequitable trade policies and the negative impacts of glo- environments, the advancement of rural infrastructure balization. Subsidies in developed countries, unsustain- (health,education,markets),and improved access to rural able world market prices, and international dumping in livelihood opportunities (agriculture, skills training, developing markets hinder opportunities for African small-business capital) will positively contribute to break- farmers to get out of debt or generate profits. ing the cycle of poverty in Africa.6 In order to achieve food security as a means of breaking the cycle of poverty, the following factors become Unsustainable management of natural resources. Aug- very relevant: supporting rural livelihoods; improving mented deforestation, expansion of arable land, inad- natural resource management; promoting women’s equate soil protection and irrigation methods, overuse of empowerment; training in disaster management and mineral fertilizers, pollution of ground water sources, mitigation; indigenous knowledge and cost-effective and the loss of genetic diversity is affecting weather technology; education targeting female children. patterns and jeopardizing the balance of Africa’s natural ecosystem. NUTRITION TRANSITION

Gender discrimination. Despite studies that demonstrate Malnutrition results from the imbalance of nutrients and the correlation between women’s development and energy provided to the body (too low) relative to its needs household well being, women in many parts of Africa still (too high). More people now die of heart disease, diabe- don’t have access to education, inheritance rights, and tes, and some cancers in developing countries than in the essential resources such as land and investment inputs. developed, and the problem is becoming more serious among the poor.7 Generally consistent associations of Recurrent natural and man-made emergencies. Chronic growth failure in early childhood and the development of drought, ﬂooding, conﬂict, and unreliable food stock overweight in later childhood along with the associated management lead to repeated cycles of food insecurity risk of elevated blood pressure, glucose, and serum lipids

Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46 S41 Table 1 Child malnutrition, underweight, anemia, obesity and iodine deficiency in select North African countries. Nutrition problem Evaluation criteria Country Algeria Egypt Libya Mauritania Morocco Tunisia Child malnutrition: percent Moderate and severe 14.3 11.7 4.7 23.0 9.0 4.0 under 5 y who are Severe 4.3 2.8 0.6 9.2 1.8 0.6 underweight* Prevalence of anemia (%)† Pregnant women 35.2 35.9 5.5 46.2 39.3 30.5 Children under 5 y 37.6 40.3 20.3 73.8 45.0 32.2 Non-pregnant women 31.3 32.7 23.5 42.0 34.0 27.0 Prevalence of obesity in Males 5.3 22.1 11.5 3.7 3.7 7.7 2005 (%)‡ Females 13.5 45.6 22.4 22.7 20.6 30.1 Iodine deficiency (%)§ Total goiter rate 8 >5 0 – 22 0.58 Household iodized salt 68 56 90 1.9* 41 97 * Data from UNICEF.15 † Data from FAO.17 ‡ Data from WHO.18 § Data from Azizi and Mehran (2004).11 in adulthood have been observed.8 Recent studies suggest nationwide survey of goiter in 1989 showed that goiter that certain Middle Eastern and African countries are in existed in schoolchildren in most provinces at rates of the process of nutrition transition.9 between 30% and 80% and it was estimated that 20 Currently developing nutrition transitions are deeply million people were at risk of iodine deficiency. After rooted in the processes of globalization, which is associ- legislation was passed in 1994 for the mandatory iodiza- ated with changing incomes and lifestyles. Globalization tion of all salt produced for household use in Iran, more is having a major impact on food systems around the than 90% of households consumed iodized salt, as shown world that affect availability and access to food through in the 1997 survey. In the last national survey, conducted changes in food production, procurement, and distribu- in 2001, all provinces were iodine sufficient and the total tion. Unfortunately, urbanization and social development goiter rate among school children had decreased to occurring in certain countries are not often accompanied 9.8%.11 In the case of North Africa, the evidence is not as by steady and significant economic growth. Although positive. Iodine deficiency affects about 33 million people food consumption patterns and dietary quality are highly in the region and the prevalence of goiter remains high in income-dependent, dietary choices are also driven by Egypt, Algeria, and Morocco (Table 1). In North Africa, non-economic forces.10 only about half of the households consume iodized salt.11 While the problems of undernutrition still exist, the burden of overweight and obesity and diet-related Iron-deficiency anemia chronic disease is increasing. This can be seen in the case of Iran, which has an endemic area of iodine deficiency Updated data for anemia at the national level is only disorders and where iron-deficiency anemia has been a available for a few countries in the WHO EMRO region. major public health problem. Moreover, riboflavin defi- The prevalence of anemia in women of childbearing age ciency, repeatedly documented in preschool children, still ranged from around 20% in Jordan and parts of Egypt to constitutes a significant problem. Following is a review of more than 30% in countries like Bahrain, Iran, and Oman some of the key malnutrition disorders affecting the (Table 2).12 Iron fortification of commonly consumed WHO Regional Office for the Eastern Mediterranean foods is the most cost-effective option. A consultation (WHO EMRO), consisting primarily of Middle Eastern organized by WHO and UNICEF was held in Tehran, and North African countries, at the beginning of the third Islamic Republic of Iran, in October 1998 to develop millennium: effective strategies for combating iron deficiency. Initia- tives included supplementation with iron, food fortifica- Iodine deficiency disorders tion, and dietary measures such as changing eating behavior, as well as public health measures.13 Following Programs of universal salt iodization have been imple- this meeting, flour fortification was begun in Iran. mented in the WHO EMRO region; Iran, Lebanon, and In North Africa, on the whole, data remain scarce and Syria have the highest percentages of iodized salt con- although improvements have been made in certain coun- sumption, whereas Afghanistan and Pakistan have the tries, notably Tunisia and Morocco, micronutrient defi- lowest. The prevalence of goiter in the Islamic Republic of ciencies are still prevalent. Anemia continues to be a Iran was found to be between 10% and 60% in 1968. A major public health problem in all North African

S42 Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46 countries (Table 1). It affects the population in general, but the groups most affected are preschool children and their mothers.14 With respect to vitamin A deficiency (VAD) in North Africa, VAD is considered to be a subclinical, mild-to- moderate public health problem among preschoolers and their mothers in Algeria, Morocco, and Egypt; in Tunisia it has not been identified as a public health problem. It is prevalent among 40% and 17% of children under the age of 6 years in Morocco and Mauritania, respectively.15

Protein-energy malnutrition

In the case of Iran, the proportion of underweight, wasted, and stunted children, plus the infant and under-5 mortality rates, have fortunately all decreased on the whole over the years. However, the prevalence of stunted children under the age of 5 years is still relatively high, nearing 20%. For children under the age of 6 years, 5.2% arewasted(<2 SD) and 5% are stunted, reﬂecting malnutrition over the past years. Moderate-to-severe degrees of underweight have been reported in 3.7% of children (unpublished data from the Ministry of Health and Medical Education and the United Nations Children’s Fund, Tehran). A rural project aimed at decreasing the incidence of protein-energy malnutrition among children under the age of 5 years was conducted in September 1994. The implementation of nutrition interventions in the primary healthcare system led to a decrease in the incidence of Bahrain Iran Lebanon Oman Saudi Arabia United Arab Emirates malnutrition, dropping from 6.5% to 1.8% in a recent assessment.16 In the case of North Africa, despite the improvements of nutritional status in young children suggested by the latest nationwide nutrition surveys available, data based on anthropometric indicators show that both undernutrition and overweight are prevalent in children under the age of 5 years throughout the entire region. In North African countries, the mean prevalence of undernutrition was 4% from 1992 to 1999–aﬁgurethatrep- resents 39 million children.17 MenWomen 79 56 68 57 53 60 42 41 70 64 40 26 Children 5–14 yearsPregnant womenWomen of child-bearing ageAdult men 37.3 41.6 33.5 33.4 – 20–43 – 20.9 25 – 7.9–9.9 40 – 38 41 18.3 – 15.9 – – 15.8 14 14 – Concerning child malnutrition, as reported by the 15

18 UNICEF Global Database on Child Malnutrition, underweight is prevalent in children under the age of 5 years in all North African countries, with the highest rates

and WHO. seen in Mauritania followed by Algeria, Egypt, and 12 Morocco (Table 1). In adults, underweight has decreased over the last decade in Morocco, Tunisia,and Egypt, but it remains elevated in Mauritania.

Prevalence of anemia and obesity in diﬀerent population groups in select Middle Eastern countries. Overweight and obesity

(%) Alarming increases in the prevalence of obesity and over- Table 2 Nutrition problem Population groupData from Baghchi (2004) Country Prevalence of anemia (%)Prevalence of overweight/obesity Children 6–59 months 48.3weight 15–30are 23 being observed – in the 17.2 Middle Eastern 34 region;

Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46 S43 Bahrain, Iran, Lebanon, and Saudi Arabia all have a high aged 15–60 years,28 indicated that the prevalence of prevalence of obesity in both male and female popula- obesity had doubled among women, to 17.8%, and tions (Table 2).18 showed high rates diabetes (6.6%), hypertension (33.6%), In the case of Iran, the prevalence of overweight and hypercholesterolemia (29%). among urban 15–39 and 40–69 year olds was estimated at In the same way, various surveys in Egypt have con- about 22% and 40%, respectively; corresponding values cluded that the primary nutritional problem for many in rural areas were 16% and 26%, respectively.19 This Egyptian adults is a tendency towards obesity. According demonstrates how Iran is now faced with the need to to the study in 2000, there was an increase in BMI, reach- simultaneously tackle the double burden of over- and ing an average of 30 Ϯ 4 kg/m2, as well as an increase in undernutrition in its population. the prevalence of obesity (BMI Ն 30 kg/m2) in mothers As for North Africa, Table 1 shows that overweight (42%).29 and obesity are prevalent in all countries of the region, Being overweight is associated with a higher risk of reaching a peak in Egypt, where more than 45% of CVDs, type 2 diabetes, ischemic heart disease, hyperten- women are obese. The trend in obesity prevalence in sion, and certain cancers.30 In almost all populations in North Africa is predicted to continue rising in future the North African region, CVD risk factors and metabolic years.20 syndrome have been increasing with age, affect more Changes in the economic, social, and demographic women than men, are higher in urban versus rural areas, determinants of health and the adoption of unhealthy and are associated with obesity,31,32 whichisreaching lifestyles are contributing to the observed transforma- immense proportions, particularly among women. A tions in disease patterns, characterized by a progressive pressing need exists in this region to intensify efforts to and accelerated rise in cardiovascular diseases in the strengthen programs for the prevention and control of North African region. obesity. In Libya, a survey carried out in 1998 and 1999 found Sedentary behavior is one of the main factors that diabetes is emerging as an important public health contributing to increased obesity rates and related car- problem with a prevalence slightly higher in urban than diovascular risk factors. Data demonstrate a sedentary in rural areas (14.5% versus 13.5%).21 In Tunisia, a house- lifestyle is highly prevalent in the North African popu- hold epidemiologic survey of a representative sample of lation. Indeed, a high percentage of the population has the adult urban population of Soussa (n = 957) showed a decreased the amount of physical activity engaged in high prevalence of hypertension (>160/95 mm Hg) in during both work and leisure by spending more hours 18.8% (adjusted rate: 15.6%), a history of diabetes in per week watching TV and by utilizing more vehicles 10.2%, obesity (BMI > 30) in 27.7% (with a higher and activity-saving appliances.33 Results of a survey con- [34.4%] prevalence in women), and android obesity in ducted in 2002 among Moroccan women older than 15 36% of the study sample.22 years on the association between physical inactivity and In Algeria, the first detailed prevalence data for an cardiovascular risk factors indicated that physical inac- Algerian population,23 consisting of a sample of 1457 sub- tivity appears to play a critical role in the development jects aged 30–64 years from Setif Wilaya, showed that the of body fat and may be a risk indicator for features of prevalence of type 2 diabetes and glucose intolerance has metabolic syndrome.34,35 an important socioeconomic impact. Also, a 2003 pilot Although most national public health programs and survey conducted in Setif and Mostaganem demonstrated policies in North Africa focus on undernutrition and its that 27.6% of the population was hypertensive and 6% effects on survival, mortality, and the development of was diabetic.20 mothers and children, more efforts should be made to In Morocco, data on the anthropometric status of decrease other types of malnutrition in this region. children under the age of 5 years show that both under- North African countries, as well as other countries in the nourishment and overweight are prevalent.24,25 In adult Middle East, are undergoing health and nutrition tran- data from the 1984 national household consumption and sition. There is no doubt that if malnutrition and micro- expenditure survey, prevalence rates of 21.4% for over- nutrient deficiencies are not eradicated, there will be an weight (16.9% men and 25.5% women) and 4.1% for increased prevalence of noncommunicable diseases. obesity (1.6% men and 6.4% women) were observed.26 However, noncommunicable diseases are often not rec- More recently, in the year 1998, the prevalence of over- ognized as a high public health priority in the majority weight increased to 27.1% (21.1% men versus 29% of countries in these regions, which are still confronted women) and obesity increased to 11.7% (4.3% men versus with the heavy burden of infectious diseases and poor 16% women). The prevalence of CVD risk factors also maternal and child health. The health and nutrition increased.27 In fact, a more recent national-level survey, transition is happening in the absence of steady and sig- carried out in the year 2000 on 1500 men and women nificant economic growth.

S44 Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46 Studies show that the shift of dietary habits from a 10. Hawkes C. Uneven dietary development: linking the policies traditional diet to industrial food could explain, in part, and processes of globalization with the nutrition transition, the nutritional and metabolic disorders reported in these obesity and diet related chronic diseases. Global Health. 2006;2:4–20. population groups. Unhealthy dietary practices include 11. Azizi F, Mehran L. Experiences in the prevention, control and the high consumption of saturated fats and refined car- elimination of iodine deficiency disorders: a regional per- bohydrates, low consumption of fiber, and increasingly spective. East Mediterr Health J. 2004;10:761–770. sedentary behavior. Growing urbanization has also been 12. Baghchi K. Iron deficiency anaemia – an old enemy. East accompanied by a progressive increase in cardiovascular Mediterr Health J. 2004;10:754–760. 13. World Health Organization. Fortification of Flour to Control risk factors such as obesity, hypertension, diabetes, and Iron Deficiencies in the Middle East and North Africa. Report of hypercholesterolemia. a joint WHO/UNICEF/MI/ILSI workshop. Beirut, Lebanon 13–16 June 1998. Alexandria, Egypt: WHO Regional Office for the Eastern Mediterranean; 1999. CONCLUSION 14. Mason JB, Lofti M, Dalmiya N, et al. The Micronutrient Report. Current Progress and Trends in the Control of Vitamin A, Iodine, Poverty, hunger, malnutrition, nutrition transition, and and Iron Deficiencies. Ottawa: Micronutrient Initiative/ obesity and noncommunicable diseases are coexisting in International Development Research Centre; 2001. Available Africa and parts of the Middle East, creating inequalities at: http://www.tulane.edu/~internut/Trial/MN.htm. Ac- that need to be addressed politically. Countries in these cessed 1 April 2007. 15. UNICEF. Global Database on Child Malnutrition. 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