Scaling Up Nutrition in the Arab Republic of Egypt Investing in a Healthy Future Christopher H. Herbst, Amr Elshalakani, Jakub Kakietek, Alia Hafiz, and Oliver Petrovic, Editors INTERNATIONAL DEVELOPMENT IN FOCUS INTERNATIONAL INTERNATIONAL DEVELOPMENT IN FOCUS Scaling Up Nutrition in the Arab Republic of Egypt Investing in a Healthy Future CHRISTOPHER H. HERBST, AMR ELSHALAKANI, JAKUB KAKIETEK, ALIA HAFIZ, AND OLIVER PETROVIC, EDITORS © 2020 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 22 21 20 19 Books in this series are published to communicate the results of Bank research, analysis, and operational experience with the least possible delay. The extent of language editing varies from book to book. This work is a product of the staff of The World Bank with external contributions. 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Contents Foreword by Rekha Menon ix Foreword by Bruno Maes xi Acknowledgments xiii Executive Summary xv Abbreviations xxv Background 1 Study objective and rationale 2 Methods and analytical approach 2 Structure of the report 3 References 3 CHAPTER 1 Undernutrition of Children Under 5 and Women of Reproductive Age in Egypt 5 Jonathan Kweku Akuoku Key messages 5 Introduction 5 Methodology 6 Undernutrition of children 0–59 months of age 8 Conclusions 23 Notes 25 References 26 CHAPTER 2 Overnutrition of Children Under 5 and Women of Reproductive Age in Egypt 29 Frank Hu and Yanping Li Key messages 29 Introduction 29 Childhood overweight and obesity 30 Double burden of stunting and overweight 36 Overweight and obesity in women of reproductive age 40 Conclusions 52 References 53 CHAPTER 3 Undernutrition Interventions in Egypt: Status, Gaps, and Opportunities 57 Fayrouz Sakr-Ashour, Bjorn Ljungqvist, and Matthew Robinson Key messages 57 Introduction 58 iii iv | SCALING UP NUTRITION IN THE ARAB REPUBLIC OF EGYPT Nutrition-specific interventions 59 Nutrition-sensitive interventions 75 Recommendations: Potential high-impact nutrition policy and program options to consider for Egypt 88 Approaches to scaling up the identified interventions 92 Elements critical to scale-up success 94 Notes 95 References 95 CHAPTER 4 Cost-Effectiveness of Potential Scale-Up Scenarios in Egypt 101 Davide de Beni Key messages 101 Introduction 101 Methodology 102 Findings 108 Conclusions 124 Notes 125 References 125 CHAPTER 5 Fiscal Space to Scale Up Nutrition in Egypt 129 Helen C. Connolly Key messages 129 Estimating the current level of spending on nutrition in Egypt 130 Identifying fiscal space for nutrition: The five pillars 135 Summary of fiscal space 141 Notes 143 References 143 APPENDIX A Statistical Methods Applied to Analysis of the Determinants of Malnutrition among Egyptian Children 145 APPENDIX B Distribution of Sample by Key Characteristics and Regression Analysis Results 149 Glossary 155 Boxes 1.1 Evidence of and recommendations on the increased nutritional needs of children 7 3.1 Why 1,000 days? 59 3.2 Common challenges in micronutrient supplementation programs in Egypt 67 Figures 1.1 UNICEF conceptual framework for the determinants of malnutrition 6 1.2 Prevalence of stunting among children under 5: Middle East and North Africa economies, various years 9 1.3 Trends in stunting prevalence among children under 5: Middle East and North Africa economies, 1990–2016 10 1.4 Trends in stunting prevalence across regions: Egypt, 1992–2014 10 1.5 Trends in stunting prevalence across wealth quintiles: Egypt, 1995–2014 11 1.6 Trends in stunting prevalence across urban and rural areas: Egypt, 1992–2014 11 1.7 Trends in stunting prevalence by child’s sex: Egypt, 1992–2014 12 1.8 Breastfeeding practices, complementary feeding practices, and incidence of disease among children 0–23 months of age: Egypt 13 1.9 Adjusted odds ratio for significant determinants of stunting among rural Egyptian children 0–23 months of age 15 Contents | v 1.10 Adjusted odds ratio for significant determinants of stunting among urban Egyptian children 0–23 months of age 16 1.11 Prevalence of wasting among children under 5: Middle East and North Africa economies, various years 17 1.12 Trends in wasting prevalence: Middle East and North Africa economies, 1990–2014 18 1.13 Trends in wasting prevalence across regions: Egypt, 1992–2014 18 1.14 Trends in wasting prevalence across wealth quintiles: Egypt, 1995–2014 19 1.15 Trends in wasting prevalence across urban and rural areas: Egypt, 1992–2014 19 1.16 Trends in wasting prevalence by child’s sex: Egypt, 1992–2014 19 1.17 Trends in anemia among children 6–59 months of age: Egypt, 2000, 2005, 2014 21 2.1 Prevalence of overweight among children under 5: Middle East and North Africa economies, various years 30 2.2 Trends in prevalence of childhood overweight: Middle East and North Africa economies, various years 31 2.3 Prevalence of overweight and obesity among children: Egypt, 2014 31 2.4 Time trend of overweight among infants and children by sex: Egypt, 1992–2014 32 2.5 Time trend of overweight among infants and children across urban and rural areas: Egypt, 1992–2014 32 2.6 Prevalence of overweight children by wealth index and region: Egypt, 2014 33 2.7 Prevalence of overweight children by birthweight, family size, mother’s obesity level, and mother’s education level: Egypt, 2014 34 2.8 Multivariate-adjusted odds ratio for overweight among children under 5: Egypt, 2014 35 2.9 Prevalence of overweight and stunting among children under 5: Egypt, 2014 36 2.10 Prevalence of overweight with and without stunting: Egypt, 1992–2014 37 2.11 Odds ratio for overweight (including obesity) with or without stunting: Egypt, 2014 38 2.12 Prevalence of overweight with and without stunting according to the number of food groups children 6–23 months of age living with their mother were fed in last 24 hours: Egypt, 2014 40 2.13 Trends in overweight and obesity among women of reproductive age: Egypt, 2000–2014 41 2.14 Prevalence of obesity among women in Middle East and North Africa countries, 2014 42 2.15 Prevalence of overweight and obesity across women 15–49 years of age: Egypt, 2014 43 2.16 Overweight and obesity prevalence among women in rural and urban areas: Egypt, 2014 43 2.17 Prevalence of obesity across sociodemographic factors: Egypt, 2014 44 2.18 Multivariate-adjusted odds ratio for obesity among women 15–49 years of age: Egypt, 2014 45 2.19 Interactions between