HUMAN DEVELOPMENT NETWORK (hmt) Health, Nutrition, and Population Series 19635 August 1999 Toward a Virtuous Circle A Nutrition Review of the Middle East and North Africa Atsuko Aoyama Health, Nutrition, and Population Series This series is produced by the Hlealth, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. The series aims to provide a vehicle for publishing material on the Bank's work in the HNP sector, to consolidate the various previous publications in the sector, and to improve the standard for quality control, peer review, and dissemination of HNP publications. The series focuses on publications that expand our knowledge of HNP policy and strategy issues through thematic reviews, analytical work, case studies, and examples oJ'best practices. The volumes in the series focus on material of global and regional relevance. The broad strategic themes of the series are proposed by its editor- ial committee, which is coordinated by Alexander S. Prckcr. Thc other members of this committee ate A. Edward Elmendorf, Mariam Claeson, Armin H. Fidler, Charles C. Griffin, Peter E Heywood, Prabhat K. Jha, Jack Langenbrunner, Maureen A. Lewis, Samuel S. Lieberman, Milla Melachlan, Judith Snavely Mcguire, Akiko Maeda, Thomas W Merrick, Philip Musgrove, David H. Peters, Oscar Picazo, George Schieber, and Michael Walton. HUMAN DEVELOPMENT NETWORK Health, Nutrition, and Population Series Toward a Virtuous Circle A Nutrition Review of the Middle East and North Africa Atsuko Aoyama The World Bank Washington, D. C. Copyright ( 1999 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of ALmerica First printing August 1999 The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any meanner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility for any consequence of their use. The boundaries, colors, denominations, and other information shown on any map in this volume do not imply on the part of the World Bank Group any judgment on the legal sl:atus of any territory or the endorsement or acceptance of such boundaries. The material in this publication is copyrighted. The World Bank encourages dissemination of its work and will normally grant permission promptly. 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Library of Congress Cataloging-in-Publication Data Aoyama, Atsuko, 1954- Toward a virtuous circle: a nutrition review of the Middle East and North Africa / Atsuko Aoyama. p. cm. - (Human development network series) Includes bibliographical references. ISBN 0-8213-4557-5 1. Nutrition-Middle East. 2. Nutrition-Africa, North. 3. Malnutrition-Middle East. 4. Malnutrition-Africa, North. I. Title. II. Series. TX360.M628A59 1999 363.8'2'0956-dc2l 99-35061 CIP III 8E - - -- -- '-- -- -- -- -- - ~~~~~AHdVIIOI'liIfl LE3fSSI sAIHOIHa V SV olu11Ifis - KolsWI3NIOD s I t .....................SKOIJV UNIV S3I93LVHS 3'fflIssoO O. -................................. S3lHNf1OJ V fW NI SfISSI MOIIHIfIMN HOfVW O. -.. . . SHIM11NfO3 VN4 NI NOKIIlXiNIONIIAOHdIwAI it .z . ............. S13NINOD (INV S3DNVHJ JIHdVH9OLK3(t zz ......................................... NI AHVIlKI3Wf1 dNO UNIV 9Nl3AUlSVS 3HqI .Z SHMrdOSIU oN0IIIfN AOSINVNINH3IUNIV S33M3Ql)3SNOJ 'S3Sf1VJ T Z a ~~~~~~~~~~~~~~NIZvl 9 1 NIlo~I 91.*-- ----- -------------- ----- - ----- -- ---'--SH3I3aOSI(J 1IN3L111NO I3IW bz . .............................. - ..... .........................i suuINiz as b.UNX UaNVl a MOIIVf1InIS 1N~LW13 - VMILW Nl MOIILIIfN *Z I fls13lJ SfIonILIA V :ss:3H90H 31SN0NI3 UNIV NIOISIINi (1009- NIOIIJ[IoH.LI I1 . .IXsnSNOIIVINIIIIIfl x.S1NI3W9JUTIMNIN3 8 I ~................................................................................ a:)vaw ea .~~~.................................... ............. --mai -M -IIvlLs N ml - -m ] -i --IIJL -------Zoo . llA.3*V- - - SINI3INOJ BOXES Box 1: NUTRITION IMPLICATIONS OF QAT CHEWING IN YEMEN .................................... ................. 1 0 Box 2: NUTRITION IMPACTS OF RAMADAN . ..................... .................................... 13 Box 3: DELIVERfNG NUTRITION MESSAGES TO THE PUBLIC ........................................................... 25 Box 4: DISPLACED POPULATION IN SOUTHERN IRAQ ............................................................... 26 Box 5: INFLUENCE OF BORDER CLOSURES IN GAZA .................................................. ............ 29 TABLES TABLE 1: HEALTH AND NUTRITION INDICATORS IN MENA COU NTRIES .................... .................... 5 TABLE 2: STUNTING PREVALENCE IN CHILDREN UNDER 5 YEARS ............ ..................................... 7 TABLE 3: AVERAGE FOOD CONSUMPTION (1989) ......................... ..................................... 12 TABLE 4: OBESITY PREVALENCE IN SELECTED OECD COUNTRIES ............................... ..................... 1 3 TABLE5: ANEMIA PREVALENCE ............-.................. ..................... 17 TABLE 6: IODINE DEFICIENCY I)ISORDERS (IDD) ...................... ........................................ 1 9 TABLE 7: TOTAL DIETARY ENERGY INTAKE IN IRAQ BEFORE AND AFTER THE GULF WAR ................. 27 TABLE 8: MAJOR NUTRITION ISSUES IN MENA COUNTRIES .............................................................. 3 1 TABLE 9: NUTRITION INTERVENTIONS .............................................................. 34 TABLE 10: COSTS OF MICRONUTRIENT FORTIFICATION PROGRAMS . ................................................... 35 FIGURES FIGURE 1: STUNTING PREVALENCE AND GNP PER CAPITA IN MENA COUNTRIES ............ .................... 2 FIGURE 2: STUNTING PREVALENCE AND GNP PER CAPITA IN TUNISIA ............................ ...................... 3 FIGURE 3: ESTIMATED STUNTINCG PREVALENCE BY REGION .............................................................. 6 FIGURE 4: TREND OF NATIONAL STUNTING PREVALENCE .............................................................. 7 FIGURE 5: STUNTING PREVALENCE HIGHER IN RURAL AREAS .............................................................. 8 FIGURE 6: STUNTING PREVALENCE BY AGE .............................................................. 8 FIGURE 7: COHORT STUDY OF STUNTING PREVALENCE AMONG BEDOUIN CHILDREN ......9.......... 9 FIGURE 8: CHILD MALNUTRITION IN IRAQ .............................................................. I 1 FIGURE 9: SEVERE CHILD MALNUTRITION IN IRAQ (MONTHLY AVERAGE) .................11..................... . I I FIGURE 10: OBESITY PREVALENCE (BMI 2 30) ................ .............................................. 14 FIGURE 1 1: OVERWEIGHT PREVALENCE IN CHILDREN UNDER 5 YEARS ......................... ........................ 14 FIGURE 12: DEATH DUE TO CIRCULATORY SYSTEM DISEASES .............................................................. 15 FIGURE 13: PREVALENCE OF DLABETES MELLITUS ....................... ....................................... 1 5 FIGURE 14: ANEMIA PREVALENCE AMONG WOMEN AND CHILDREN .... . ............................................... 16 FIGURE 15: ANEMIA PREVALENCE IN BAHRAIN ................. ............................................. 17 FIGURE 16: PROPORTION OF TOTAI POPULATION AT RISK OF IODINE DEFICIENCY DISORDERS .............. 1 9 FIGURE 17: ESTIMATED CLINICAL VITAMIN A DEFICIENCY PREVALENCE FOR UNDER 5 YEAR CHILDREN .............................................................. 21 FIGURE 18: EXCLUSIVE BREASTFEEDING UP TO 3 MONTHS .............................................................. 23 FIGURE 19: STUNTING PREVALENCE AND FEMALE SECONDARY SCHOOL ENROLLMENT IN MENA COUNTRIES ................................................................. 25 FIGURE 20: NUTRITION IMPACTS OF INTERNATIONAL SANCTIONS AGAINST IRAQ ............ ..................... 27 FIGURE 2 1: PROTEIN CONSUMPTION AND GNP PER CAPITA IN MENA COUNTRIES ........... ................... 28 FIGURE 22: STUNTING PREVALENCE AND GNP PER CAPITA IN EGYPT ........................ .......................... 30 iv A 8 -. .--.. . . --. . -. . .. . . . .. . . . .. . . . . .. . .-.. . .ol 8 ...OI 8 -.............. -.. -.. -....-....- A3NHtI3Ifls( IN2[flif1NoMHlI bL .*.. . .. 3d03AaI 3)IN0&03a UMNV NOIlIflIN I L .- NOIiVJ.. . .IAIv(wa1 aN NVOIIlIflK OL . IHDI3aA HIIfil MO-1 OL .SSAIVKNV VIV AHVIKTWla1df1S :b XaNNV 89.srSMnINo3 V3N Ni sNolvIN3UNI C)S vI 99 ..............................................................................NOIIVIfIOd INIV HI!v3H .9 SIIHINfoJ VNI3W NI s3f1ssI HYIV'IH UINV OOtA 10 MAAIAaAo : xaKNlv .b9 *... . . .. . - * -- * - *- -- KO193-dVN aW Na SXIOAA Ho01IS NOIIiXIfIN (INV SIYDfOHJ)l INVfl (HXOM INaHnID aHI MI SINIaNOdWO3 NIOIIIIflTK 09 ............................ SMNInOD g HIO NI SI3VWI (NV SISOJ IM"DOHda A0 STIdWVX3 09 ................................................IN dO.I3aA3q 3I IONI03 UNIV 'IVIJOS 09 .*------------------------------------------ .. (Jag) a9mwrvH mo1tAvHaE[ Hoa mouvaInfwwo3 6. ....VH ..I.lif L. ........S3fINojw 9 .A.IanlaS AgIoNa aooA 9. -..-..-....-.....StSO2 aNV SNILNIa I12NI NOI aNI TIassoJ :zX NV ig.................... SiiUMosMr NOIIIXIfTN 9MIYI9NWS3- S-d3aU1I0(I A-dVJIIU3X3H .SsINar3mNINoHJIW WIHIO IS *-*-.*--------- V NIHILVITA 1 5 *--' .. a~~~~~~~~~~~~~~~~~~~~NIOIc:0 .VI'WINIV 'IVNIOLLNIf1 6b~IV UNIV aS IV s UaIIoUV3 'NII3IOHJ 8b.(Jj4a~1) X3UNII SSV saofl 8b - .--NOII1XIfNI1VN '1V131 LbV.-*-*--*- - ----- -- ---NOIIIXIPNIV 011113 Lb .NIOIIVNIOANII aINIfOH9N3VI - sXaoXOSIcj OISIIfNK :j XaNNV S.X.N.NIV VITAMIN A ............................................................ 84 VITAMIN D ........................................................ 85 ZINC ............................................................ 86 ANNEX 5: MENA NUTRITION DATA TABLES .................................................................. 87 Annex Figures: FIGURE 1: INFANT MORTALITY RATE (IMR) AND Low BIRTH WEIGHT IN MENA COUNTRIES ............ 70 FIGURE 2: STUNTING PREVALENCE AND Low BIRTH WEIGHT IN MENA COUNTRIES ....................... .. 70 FIGURE 3: STUNTING PREVALENCE AND FEMALE SECONDARY SCHOOL ENROLLMENT IN MENA COUNTRIES ......................................................................... 71 FIGURE 4: STUNTING PREVALENiCE AND MALE SECONDARY SCHOOL ENROLLMENT IN MENA COUNTRIES ......................................................................... 72 FIGURE 5: UNDERWEIGHT PREVALENCE AND FEMALE SECONDARY SCHOOL ENROLLMENT IN MENA COUNTRIES ......................................................................... 72 FIGURE 6: WASTING PREVALENC'E AND FEMALE SECONDARY SCHOOL ENROLLMENT IN MENA COUNTRIES ........................................................................ 73 FIGURE 7: Low BIRTH WEIGHT AND FEMALE SECONDARY SCHOOL ENROLLMENT IN MENA COUNTRIES ........................................................................ 73 FIGURE 8: BREASTFEEDING AND FEMALE SECONDARY SCHOOL ENROLLMENT IN MENA COUNTRIES 74 FIGURE 9: DIETARY ENERGY CONSUMPTION AND GNP PER CAPITA IN MENA COUNTRIES ................. 75 FIGURE 10: PROTEIN CONSUMPTION AND GNP PER CAPITA IN MENA COUNTRIES ................................ 75 FIGURE 11: FAT CONSUMPTION AND GNP PER CAPITA IN MENA COUNTRIES ......................................76 FIGURE 12: STUNTING PREVALENCE AND GNP PER CAPITA IN MENA COUNTRIES ............................... 76 FIGURE 13: UNDERWEIGHT PREVALENCE AND GNP PER CAPITA IN MENA COUNTRIES ........................ 77 FIGURE 14: WASTING PREVALENCE AND GNP PER CAPITA IN MENA COUNTRIES ................................ 77 FIGURE 15: Low BIRTH WEIGHT AND GNP PER CAPITA IN MENA COUNTRIES ................................. 78 FIGURE 16: STUNTING PREVALENCE AND GNP PER CAPITA IN EGYPT .... 79 FIGURE 17: STUNTING PREVALENCE IN RURAL AND URBAN AREAS IN EGYPT .... 80 FIGURE 18: STUNTING PREVALENCE AND GNP PER CAPITA IN TUNISIA .... 81 FIGURE 19: STUNTING PREVALENCE IN RURAL AND URBAN AREAS IN TUNISIA .....................................81 FIGURE 20: FOOD SUPPLY AND GNP PER CAPITA IN TUNISIA .... 82 FIGURE 21: STUNTING PREVALENCE AND FOOD SUPPLY IN TUNISIA ......................................................82 Note: Superscript numbers in the text refer to the bibliography starting at the end of the report. vi FOREWORD The countries of the Middle East and North Africa (MENA) region face unprecedented challenges. The pace of change in the global economy has never been faster, prompting the need for new strategies to promote economic and social development. Economic development and rising incomes signal a new prosperity and governments in the region are struggling to sustain the improvements in the quality of life of their citizens, which they have worked hard to bring about. Good nutrition is key to maintain or improve health, and people's ability to secure an adequate diet is fundamental to achieving social and economic advances. Since nutrition is a multi-sectoral issue, development and improvement in other sectors can greatly affect nutritional status. Nutrition disorders in turn impede the economic development of a country through decreasing educational attainment and economic productivity, and increasing health care costs. Therefore, nutritional status is one of the best proxies to measure poverty and social development. In spite of this critical role, nutrition disorders frequently escape notice. Particularly in developing countries, the groups most vulnerable to poor nutrition are women and children, especially if they are rural. This nutrition review of the MENA region is to develop a base of knowledge and a sector strategy, and to help fulfill the World Bank's mandate for poverty reduction. This is the first comprehensive overview of nutritional issues in the region, putting together the problems in an overall economic development context. The review focuses on the health implications of nutritional issues, and supplements a regional study of food subsidy programs and the regional health, nutrition and population sector strategy paper. The findings of this review are sometimes troubling, and often surprising. Although the nutritional status of most people in MENA countries has improved over the last two decades, undernutrition and micronutrient deficiencies remain a serious threat to public health. Even though nutritional deficiencies are strongly linked to poverty, economic progress does not always improve nutritional status. Thus, even in well performing economies, progress has been uneven, leaving pockets of poverty in its wake, especially among rural populations. This also suggests that not only income but the status of women, their educational attainment, cultural factors, food and agriculture policies, and access to various social services including health care and clean water are critical factors affecting nutrition and nutritional disorders. I hope this review will help stimulate country discussions in the context of economic and social development among various stakeholders and result in effective policies and strategies for improving nutrition in the region. (,_;acques Baudouy George Schieber Jarn&Qhristopher Lovelace Director Health Sector Leader Director Human Development Sector Human Development Sector Health, Nutrition, Population vii PREFACE Countries which comprise the World Bank's Middle East and North Africa region (MENA) vary widely in their economic development, politics, geographic and environmental conditions, their health status and other social factors. Until now, World Bank activities in the health, nutrition, and population i'HNP) sector in MENA have focused mainly on health and population, and although the Bank completed some nutrition sector work in Morocco in 1994, and a case study on food subsidy reform in Tunisia in 1996, a comprehensive assessment of nutritional issues in the region has never been done. The World Bank HNP sector board approved this nutrition review in the MENA region to develop a base of knowledge and a sector strategy, and to help fulfill its mandate for regional knowledge management. The review assesses nutritional status, focusing on the health implications of nutritional issues, but the review's scope do not include the assessment of existing nutrition programs. The review proceeds concurrently with a regional study of food subsidy programs, both of which supplement the regional HNP sector strategy paper. The review aims to: * assess the region's nutritional status; * analyze the causes and consequences of nutritional problems and their implications for health; e suggest a strategy to imprcive the nutrition and health of the people in the region; * develop a database from available sources and literature. viii ABSTRACT Good nutrition is key to maintain or improve health, and people's ability to secure an adequate diet is fundamental to achieving social and economic advances. Improving people's nutritional status is linked to economic progress, and economic progress often helps people improve their nutritional status, creating a virtuous circle. This nutrition review in the Middle East and North Africa (MENA) is to develop a base of knowledge and a sector strategy. The review aims to put the problems in an overall economic development context, while focusing on the health implications of nutrition disorders. MENA countries have largely achieved food security and the nutritional status of most people has improved over the last two decades. Despite these achievements, undernutrition and micronutrient deficiencies, such as iron, iodine, and vitamin D, remain a serious threat to public health. In addition, changes in the diet have escalated the incidence of obesity and diet-related non-communicable diseases. Even though nutritional deficiencies are strongly linked to poverty, economic progress does not always improve nutritional status. Improving female education and access to other social services also contributes to lowered childhood malnutrition over the long term. Required actions for three types of nutrition disorders among MENA countries and strategic options for the World Bank are suggested. ix ACKNOWLEDGMENTS This review paper was prepared by Atsuko Aoyama, Health Specialist, Human Development Group, Middle East and North Africa Region (MNSHD), as a part of Regional HNP Knowledge Management programs approved by the HNP Sector Board. Takashi Kadowaki and Yoko Nishimura, Consultants, MNSHD, contributed to data research, data management, and cost analyses. Jacques Baudouy, Sector Director, and George Schieber, Sector Leader, MNSIHD, provided overall supervision and guidance. Bonita Brindley provided editorial advice. We appreciate and acknowledge the following specialists and colleagues in the World Bank and other organizations. Peter Heywood, Principal Health Specialist of the World Bank and Donald Bundy, Consultant of the World Bank and Professor of the Welcome Trust Centre for the Epidemiology of Infectious Diseases, Oxford University, generously provided technical advice, critical review, and encouragement throughout the preparation of the paper. Samir Miladi, Regional Food and Nutrition Officer of FAO/ RNE, and Anna Verster, Nutrition Advisor of WHO/EMRO, provided a large amount of essential regional data and information and valuable commrents. Mercedes de Onis, WHO, Bruno de Benoist, WHO, Cathy Needham, UN ACC/SCN, provided essential data and information on global nutrition issues. Mohamed Abu Jahal, Ibrahim Aziza, and Samir Radi, Ministry of Health, Palestinian National Authority, shared experiences of their field nutrition activities in Gaza. Qaed Obadi, Ministry of Public Health, Republic of Yemen, provided updated information on nutrition activities in Yemen. Milla McLachlan, Nutrition Adviser, Judith McGuire, Senior Nutritionist, Dario Berardi, Consultant, Kathy Lindert, Economist, Alan Berg, Consultant, and Laura Tuck, Sector Leader of the World Bank, provided technical advice, valuable comments, data and information. Colleagues of MNSHD, including Setareh Razmara, Bahjat Achikbache, Claire Voltaire, Gail Richardson, Marlaine Lockheed, Eva Jarawan, and Egbe Osifo provided country information and useful comments. x ABBREVIATIONS ACC/SCN United Nations Administrative Committee on Coordination, Sub-Committee on Nutrition BMI Body mass index CAS Country assistance strategy CBC Communication for behavior change EMRO World Health Organization Regional Office for the Eastern Mediterranean ESCWA United Nations Economic and Social Commission for Western Asia FAO Food and Agriculture Organization G6PD Glucose-6-phosphate dehydrogenase GDP Gross domestic product GNP/c Gross national product per capita Hb Hemoglobin HDL High-density lipoproteins HNP Health, nutrition and population IDD Iodine deficiency disorders IMCI Integrated Management of Childhood Illness IMR Infant mortality rate IQ Intelligence quotient IUGR Intrauterine growth retardation LDL Low-density lipoproteins MENA Middle East and North Africa MMR Maternal mortality ratio NCHS National Center for Health Statistics NGOs Non-governmental organizations OECD Organisation for Economic Co-operation and Development 25-OHD 25-hydroxy vitamin D PA Palestinian National Authority RDA Recommended dietary allowance RNE Food and Agriculture Organization Regional Office of the Near East SD Standard deviation T3 Triiodothyronine T4 Thyroxine TFR Total fertility rate TGR Total goiter rate TSH Thyroid stimulating hormone TV Television U5MR Under five year child mortality rate UAE United Arab Emirates UN United Nations UNDP United Nations Development Programme UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children's Fund US United States of America USAID United States Agency for International Development VAD Vitamin A deficiency WFP World Food Programme WBG West Bank and Gaza WHO World Health Organization xi Executive Summary Good Nutrition and Economic Progress: A Virtuous Circle Good health is a crucial element in the quality of life, a prerequisite for better educational attainment and essential to national economic productivity. In all nations, improving people's nutritional status is linked to eco0nomic progress, and economic progress often helps people improve their nutritional status, creating a virtuous circle. Good nutrition is key to maintain or improve health, and people's ability to secure an adequate diet is fundamental to achieving social and economic advances. In spite of the critical role of nutrition in development, malnutrition so frequently escapes notice that it is referred to as "the silent disaster." Globally, the world is producing enough food, but inequitable access and allocation prevents many people from getting an adequate diet and therefore their health is at risk. in 1992, the United Nations Food and Agricultural Organizatb.on (FAO) estimated that about 841 rnillion people or about one fifth of the world's population were food energy deficient. Countries in the Middle EaLst and North Africa (MENA) region have largely achieved national level food security in terms of dietary energy intake, except for Yemen and Iraq. Clinical vitamin A deficiency is largely under control in the region. The nutritional status of most people has improved over the last: two decades. Economic development and rising incomes signal a new prosperity and governments in the region are struggling to sustain the improvements they have worked hard to bring about for their citizens in the quality of life. Despite these achievements, undemutrition and micronutrient deficiencies remain a serious threat to public health. Recently, the prevalence of stunting has increased in several countries-the result of chronic undernutrition. Anemia is widespread among women and children; and there is a high incidence of iodine deficiency disorders and vitamin D deficiency. Changes in the diet brought about in part by new found prosperity have escalated the incidence of obesity and diet-related non-communicable diseases such as heart disease and diabetes mellitus. The numbers are alarming. In MENA countries, it is estimated that over 10 million children suffer from stunted growth, about 90 million people are anemic, and about 85 million people are at risk for iodine deficiency disorders. Even though nutritional deficiencies are strongly linked to poverty, econornic progress does not always improve nutritional status. For instance, in Egypt and Tunisia, the number of stunted children increased despite the rise in GNP per capita. This appears to indicate that even in well performing economies, progress has been uneven, leaving pockets of poverty in its wake, especially among rural populations. The economic costs of nutrition disorders are staggering. Undernourished or anemic adults are less productive and childhood stunting leads to an estimated six to eight percent loss in labor productivity in adulthood. Assuming annual wages of $1,000 per person, stunting of one million children creates a direct income loss of $60 to 80 million per year, plus accompanying health care costs related to the condition. In seven countries in the region, stunting affects over 20 percent of children under five years of age, and in nine countries, wasting is prevalent in over five percent-indicating medium to high levels of childhood malnutrition. This condition is the most serious in Yemen, the poorest country in the region, but also stunting prevalence recently increased in Algeria, Egypt, Oman, and Tunisia. Stunting appears to affect boys and girls equally but rural areas are much worse off than urban, and the gap between rural and urban is widening in Egypt, Morocco, and Tunisia, xii more evidence that childhood undernutrition is not necessarily linked to lower levels of economic development. An improvement in maternal health care could elevate the nutritional status and health of entire nations. hi five MENA countries, low birth weight is a problem for over 10 percent of babies, indicating the poor health and nutritional status of many pregnant women. The increase in the incidence of low birth weight correlates with the increase of infant mortality and stunting. But the problem does not end there-low birth weight babies grow into adults who are likely to be more susceptible to chronic diseases such as hypertension and diabetes mellitus. Countries lose three times over-first because low birth weight babies are more likely to have repeated episodes of illness, or die in infancy; second because those who do survive childhood have a reduced ability to lead productive lives; and third because the expense of treating chronic diseases can cut deeply into the national health budget. Anemia, which is caused mainly by iron deficiency, is highly prevalent among women and children even in wealthier countries in the region, and is likely linked to the higher rate of maternal mortality and low birth weight. In MENA countries the major source of iron is cereals, but the diet also contains many substances which inhibit iron absorption, leading to widespread anemia. In addition to nutritional education to diversify diets and increase the bioavailability of iron, other control measures could include iron supplementation, iron fortification of staple foods, and public health interventions such as parasitic disease control programs and birth spacing. Iodine deficiency disorders (IDD) are still high in Syria, Iran, Yemen, and a part of Egypt. Although many MENA countries have already started universal salt iodization programs, further technical inputs and multi-sectoral commitment may be required to achieve sufficient coverage of iodized salt. Vitamin D deficiency has been reported among small children and women in Iran, Kuwait, Libya, Morocco, Saudi Arabia, West Bank and Gaza, and Yemen. Infants whose mothers have low vitamin D levels are more likely to develop vitamin D deficiency symptoms. While vitamin D fortification and supplementation programs are required, communication for behavior change (CBC) programs have to be started urgently. One of the most commonly available sources of vitamin D is sunshine-humans can produce vitamin D if their skin is exposed to sunlight but cultural practices-such as women being heavily veiled, and infants being constantly wrapped- prevent it from being synthesized. Nutrition disorders are caused by nutrient deficiencies but also by unbalanced intakes. Economic development has brought a nutrition transition to many MENA countries. People's nutritional intake patterns change from diets based on cereal and vegetables with a relatively low intake of dietary energy, to a diet with an higher dietary energy intake and higher intake of animal fat and protein. As a result, obesity is becoming more common, especially in high income countries and urban areas. Obesity is more prevalent among adult women than men, in part due to cultural prohibitions which restrict women's movements. Obesity and excess fat intakes lead to increase of diet related non-communicable diseases such as coronary heart diseases and diabetes mellitus in 10 to 20 years. Creating the Virtuous Circle: What Can Countries Do? Good nutrition and health create a virtuous circle-bad nutrition and disease create a vicious circle. Nutritional disorders damage health directly by causing disease, but also indirectly by increasing susceptibility to disease. In turn, diseases cause nutritional disorders by creating nutrient loss, reducing the body's ability to absorb nutrients, or increasing the body's nutrient xiii consumption. Children and women are most vulnerable to nutrition disorders because of their higher requirements for nutrients for growth and reproduction, their lower status in society and the family, and other cultural factors. Mothers' health status directly affects that of their children, so the poor nutritional status of women and children also forms an intergenerational vicious circle. Therefore, national improvement in nutritional status should target this critical group-- children aged 6 to 24 months ancd pregnant women. This also suggests that improving female education and other social services contribute to lowered childhood malnutrition over the long term. For example, increased female secondary school enrolment rates in MENA countries correlate with a decrease in the numbers of stunted and underweight children. Many questions remain to be answereds Many national policies, not just those in the social sector, affect nutritional outcomes, but these linkages have been inadequately explored. Food and agricultural policies have a major impact on nutrition, but the nature and extent of these are not yet known because the policies have never been evaluated alongside anthropometric cata and other poverty indicators. Neither have the reasons for the poor correlation between economic development and nutrition status been fully analyzed. Growing income differentials, unequal access to social services and other exclusionary mechanisms might explain some of this polarized development, but it requires proper and in depth analyses. The peri-urban poor are an emerging phenomenon which has not been fully studied. Feasibility studies or sector work is needed to design nutrition interventions such as micronutrient fortification programs. Impacts of existing nutrition programs should be reviewed. Many avenues need to be followed because quantity and quality of data are insufficient to design interventions. Policy makers can select among specif:ic interventions or comprehensive programs, targeted or universal approaches, but institutional and technical capacity building is a prerequisite for sustainable implementation. Some possible interventions are: * Comprehensive public health programs targeting children under two years of age and pregnant and lactating women, particularly among rural population. * Food and micronutrients supplementation including iron, iodine, and vitamin D targeted to pregnant and lactating women, adolescent girls, under five year and school age children. * Micronutrient fortification, such as salt iodization, iron fortification of wheat flour, and vitamin D fortification to edible oil and milk. * CBC programs delivered through health service channels, schools, community organizations, and mass media which aim to prevent nutrition disorders and promote health activities. MENA countries' nutritionL typology. Possible combinations of nutrition interventions for each type are as follows: * Type 1: high malnutrition and micronutrient deficiency; low economic and social indicators; e.g. Yemen, Iraq. Specific nutrition interventions and comprehensive health and social programs are required urgently. Decreasing malnutrition of small children and pregnant women should be the first priority. International support will be essential. * Type 2: relatively large population of undernutrition with large urban/rural gaps and high micronutrient deficiency; relatively well-performing middle income economy with a significant number of poor; e.g. Iran, Tunisia. Specific nutrition interventions and comprehensive health and social programs should be targeted to the rural population, urban xiv poor, women and small children. Food policies should be carefully assessed for their effectiveness and real nutrition impacts on the vulnerable groups. X Type 3: high obesity and micronutrient deficiency; relatively high income with pockets of poverty and social indicators that are low in comparison with similar level economies in other regions; e.g. Saudi Arabia, Bahrain. CBC programs for obesity and micronutrient deficiencies prevention and micronutrient fortification programs, plus nutrition and social programs targeted to the vulnerable groups. International agencies may need to provide technical assistance. To assist MENA countries in improving nutrition, the World Bank may explore strategic options: * Stimulating country discussions. Disseminate this regional nutrition review among stakeholders in the social and economic sectors in each country to stimulate discussions. Organize a regional conference. * Put nutrition back on the policy agenda. Nutritional status is one of the best proxies to measure poverty and social development. Nutritional issues should be included in the country assistance strategy (CAS) and be discussed with the government in the context of economic and social development. * Support specific programs. The Bank's health sector operations may put more emphasis on nutrition improvement. Current national public health programs can be strengthened with more nutrition activities after carefully estimating program costs to prepare feasible and sustainable financing plans. * Partner and facilitate technical assistance. To meet international standards, most MENA countries may need technical support for planning, implementing, and monitoring their nutrition programs. The Bank may facilitate technical assistance in partnership with other organizations such as WHO, UNICEF, FAO, and NGOs. * Coordinate and monitor other sector programs. Poverty reduction programs should use nutrition indicators to assess and adjust the impacts of interventions. Other sector operations including water and sanitation, agriculture, education, and industry, can be designed and monitored to produce positive impacts on nutrition. Improving the nutritional status of people in the MENA countries is a priority-for the well being of citizens, and for continued economic development and growth. Unfortunately, development strategies to date have fallen short of the nutritional goals expected in any caring and equitable society. In the longer term, it is costly and unsustainable to overlook the needs of underprivileged populations, particularly women, children, and rural inhabitants. Targeted interventions are urgent and essential. Policymakers must act immediately to put nutrition on the country's priority agenda. Strong political commitment at the highest level is indispensable to implement and sustain effective nutrition interventions. The World Bank will work together with the governments to achieve the sustainable, equitable, economic, social and human development. xv 1. Introduction - Good Nutrition and Economic Progress: A Virtuous Circle Good health is a crucial element in the quality of life, a prerequisite for better educational attainment and essential to national economic productivity. In all nations, improving people's nutritional status is linked to economic progress, and economic progress often helps people improve their nutritional status, creating a virtuous circle. Good nutrition is key to maintain or improve health, and people's ability to secure an adequate diet is fundamental to achieving social and economic advances. In spite of the critical role of nutrition in development, malnutrition so frequently escapes notice that it is referred to as "the silent disaster.",207' Globally, the world is producing enough food, but inequitable access and allocation prevents many people from getting an adequate diet and therefore their health is at risk. In 1992, the United Nations Food and Agricultural Organization (FAO) estimated that about 841 million people or about one fifth of the world's population were food energy deficient.(70) The Middle East and North Africa region (MENA)' has largely achieved food security, except for Yemen and Iraq. Clinical vitamin A deficiency is, for the most part, under control in the region. People's nutritional status has improved in the last two decades. Despite these achievements, several nutritional deficiency disorders remain serious public health problems which need to be addressed by all of the countries: stunting, anemia among women and children, iodine deficiency disorders (IDD), and vitamin D deficiency. Economic development and rising incomes in the region signal prosperity and have also brought about changes in the diet, but this nutrition transition has been accompanied by an increased incidence of obesity and diet-related non-communicable diseases. And there is worse news. In MENA countries, it is estimated that over 10 million children suffer from stunted growth, about 90 million people are anemic, and about 85 million people are at risk for iodine deficiency disorders. Although nutritional deficiencies are strongly linked to poverty, economic progress does not always improve nutritional status. For example, the number of stunted children increased in Egypt and Tunisia despite the rise in GNP per capita, and in the high-income Gulf states, anemia and vitamin D deficiency are common. The economic costs of nutrition disorders are staggering. Undernourished or anemic adults are less productive (Annex 2) and childhood stunting leads to an estimated six to eight percent loss in labor productivity in adulthood.(1'o) Assuming annual wages of $1,000 per person, stunting of one million children creates a direct income loss of $60 to 80 million per year, plus accompanying health care costs related to the condition. Despite overall economic development, gaps in income levels occur and may grow wider. This appears to indicate that economic progress is uneven, that rural populations have been excluded, and that pockets of poverty are present even in the well performning economies. This polarized economic development is not only socially unjust, but also unsustainable. Even a robust economy can collapse under the pressures arising from an inequitable society-particularly where something as basic as food is concerned. The factors affecting people's ability to secure and maintain adequate nutrition are complex and linked; they include population growth rates, human migration, the state of Countries in the MENA region in this paper indicate: Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates (UAE), West Bank and Gaza (WBG), and Yemen. 1 agriculture, transportation and trade, among others. People's access to health care, education, clean water and sanitation, as well as status of women, affects their nutritional status and their ability to use their food resources wisely. Health problems associated with poor nutrition are widely observed in low income countries but surprisingly are also found among vulnerable populations in middle and high income countries. The issues affecting these groups need to be identified and addressed to achieve adequate nutrition globally. Particularly in developing countries, the groups most vulnerable to poor nutrition are women and children, especially if they are rural. They have lower social and economic status in the family and society, and higher nutritional needs for growth and reproduction. In 1995, the World Health Organization (WHO) estimated that about 200 million or over 30 percent of children under five years old were malnourished.(223) Although many children in developing countries sicken and die from communicable diseases such as diarrhea, respiratory infection, and measles, malnutrition underlies 56 percent of under five year deaths.(256) It not only increases their susceptibility to diseases but also delays their recovery from illness. Furthermore, repear:ed and prolonged illnesses hinder nutritional intake; thus malnutrition and diseases form a vicious circle. Nutrition disorders exist even in high income countries in the MENA region. There is no significant correlation between prevalence of wasting, underweight and low birth weight and GNP/c in MENA countries (Annex 4). Even though malnutrition is generally associated with poverty, economic development has decreased child malnutrition to only a limited extent. The stunting prevalence in MENA countries drops significantly when the GNP/c increases in the range of low and lower-middle income levels, but the correlation is less significant in the range of upper-middle income and higher levels (Figure 1). This indicates that although stunting, the most constant indicator of chronic child malnutrition, is associated with poverty, general economic development alone will not be able to eliminate stunting. Since GNP/c indicates only the average income level, it may conceal the size and status of underprivileged groups where higher prevalence of child malnutrition may be found. Figure 1: Stunting Prevalence and GNPlc in MENA Countries 40 - 30 - Stunting Prevalence 20 - o\ 0 20~~~~~~~~~ 0 1~~~0 -0 10 I I I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 0 5000 10000 15000 20006 US$ GNP/c (Source: 207, 228, 249, 254, 255) 2 Nutritional status in rural areas is much worse than in urban areas in most MENA countries (Table 2, Figure 5, 15; Annex 4). That is because overall economic development may have brought fewer benefits to rural areas, or because investments may not have been well targeted or evenly distributed. When industrialization is concentrated in urban areas it may erode traditional agricultural production by absorbing labor from the rural areas. In addition when rural people produce more market oriented crops it may reduce their own consumption of agricultural products. (58) Unless overall economic development is supplemented with targeted social and rural development, the changes that result may damage the nutritional status of rural people. Tunisia2 exemplifies a country where economic development has not diminished child malnutrition (Figure 2). From 1988 to 1995, GNP/c in Tunisia grew steadily, but the incidence of malnutrition caused stunting prevalence to increase from 17.9 percent to 22.5 percent-as high as 32.6 percent in rural areas, and 14.5 percent in urban areas (Table 2). The gap between urban and rural widened as the national stunting prevalence rose (Figure 5; Annex 4). Figure 2: Stunting Prevalence and GNPlc in Tunisia 45 2500 40- 35- 2000 C) $ 30 1500 e 020 -a 0) ~~~~~~~~~~~~~~~~~~~~~~~1000 D 10o 500 5 =~~~~Stunting (%) e l-GNP/c (US$) Year (Source: 5, 228, 255) Malnutrition commonly refers to a protein-energy deficiency, but another type of nutritional deficiency results from inadequate intake of micronutrients such as iron, iodine, and vitamin A, among others. This type of nutritional deficiency is referred to as "silent hunger" and can occur even when protein-energy intake is sufficient. Micronutrient deficiency impedes physical and mental development, increases morbidity and mortality, and decreases educational attainment and economic productivity. If widespread, it can significantly retard social and economic progress. Most developing countries are undergoing a nutrition transition. This transition occurs when people's food intake patterns change from a cereal and vegetable based diet with a 2 Prelimninary results of 1996/98 survey conducted by the National Institute for Nutrition indicated a significant decrease of child undernutrition in Tunisia (stunting prevalence: total 9.5 percent, urban 7.6 percent, rural 11.6 percent; wasting prevalence 1.3 percent). (eld interviews) 3 relatively low intake of dietary energy, to one with a higher dietary energy intake and an increased portion of animal fat and protein. The transition is accompanied by a reduction in energy expenditure because of more sedentary occupations, motorized transport, and availability of amenities. The nutrition transition is common in high-income countries and is also increasingly seen in urban areas and among relatively affluent populations in low and middle income countries. The nutrition transition signals a higher standard of living which is a welcome development, but it also leads to over-consumption of dietary energy, particularly animal fat, which increases the incidence of obesity and the risk for diet-related non-communicable diseases such as cardiovascular disorders and diabetes mellitus. Preventing these diseases through nutritional education is inexpensive but unless immediate action is taken, MENA countries will have to face the high cost of treating these diseases later. A variety of nutrition issues are observed in MENA countries, but to date, the Bank's activities in the health, nutrition, and population (HNP) sector in the region have focused mainly on health and population. Although the Bank completed some nutrition sector work in Morocco in 1994,(243) and a case study on food subsidy reform in Tunisia in 1996,(190) there has not been a comprehensive assessment of nutritional issues in the region. The World Bank HNP sector board approved this nutrition review in the MENA region to develop a base of knowledge and a sector strategy and to help fulfill its mandate for regional knowledge management. The review assesses nutritional status, focusing on the health implications of nutritional issues, but the review's scope do not include assessments of existing nutrition programs and food policiles. The review proceeds concurrently with a regional study of food subsidy programs, 258) both of which supplement the regional HNP sector strategy paper.(253 The review aims to: L assess the region's nutritional status; * analyze the causes and consequences of nutritional problems and their implications for health; * suggest a strategy to improve the nutrition and health of the people in the region; * develop a database from available sources and literature. 2. Nutrition in MENA Countries - Current Situation and Trends Protein-Energy Disorders Undernutrition Child undernutrition is conmmon in many MENA countries (Table 1). The main indicators of child undernutrition are stunting, a condition where attaining normal height for age is hindered by chronic malnutrition, and wasting, below norimal weight for height where the body is emaciated mainly due to acute malnutrition (Annex 1). In seven of the countries in the region, over 20 percent of children under five years old are stunted. In nine of the countries, wasting is observed in more than five percent of the under five year olds. By international standards, this is considered medium to high levels of undernutrition. Additionally, underweight shows a similar distribution pattern although it is generally lower than the figures for stunting. There is no evidence of absolute shortages of food, but despite this, certain children are chronically undernourished. Child malnutrition is the most serious in Yemen, the poorest countries in the region, but overall, child undernutrition is not clearly linked to the level of economic development among the MENA countries. 4 Table 1: Health and Nutrition Indicators in MENA Countries (Most Recent Data between 1980-1997) GNP per Total Population Infant Stunting Wasting Underweight Low Birth Anemia Total capita Population Annual Growth Mortality (Under 5) (Under 5) (Under 5) Weight (Women) Goiter Rate Rate Rate (US$) (million) (%) (per 1000 (%) (%) (%) (%) (%) (%) live births) _ ___ Low Income* Yemen ] 260 J 15.7 [ 3.7 I 93 ] 39 | 13 39 19 5 - 36 [ 32 Lower-middle Income* Egypt 790 63.3 1.8 57 30 5 12 10 17 - 79 5.2 I ragq- 20.6 2.1 161 28 9 25 21 18 7.3 Morocco 1,110 27.0 2.0 64 24 2 9 9 20 - 40 20 Syra 1,120 14.6 2.9 28 27 9 13 11 30 - 52 73 Jordan 1,510 5.6 4.2 21 16 2 9 7 4 - 46 - Algeria 1,600 28.8 2.0 34 18 9 13 9 19 - 42 8.5 Iran 1,780 70.0 2.5 33 19 7 16 9 20 - 50 30 Tunisia 1,820 9.2 1.6 28 23 4 9 8 41 4.3 West Bank and 1,870 2.3 3.7 28 14 6 15 - 23 - 56 - Gaza Lebanon 2,660 3.1 1.9 33 12 3 10 27 - 49 15 Upper-middle Income* _ Oman 4,820 2.3 4.7 15 23 13 23 1 8 15 - 54 10 Libya - 5.6 3.6 50 15 3 5 5 6 6.3 Saudi Arabia 7,040 18.8 3.4 25 14 3 14 7 5 - 57 _ Bahrain 7,840 0.6 3.6 18 10 6 141 40 - 49 High Income* Qatar 11,600 0.6 5.3 17 8 2 6 5 30 l Israel | 15,920 5.7 2.6 8 - - - 7 18 - 61 | Kuwait 17,390 | 1.7 2.7 13 12 3 6 7 31 - 42 United Arab 17,400 2.5 3.1 15 - - - 6 22 - 62 Emirates lI I I I I I l _I * The definitions of income groups are: low income as GNP/c $765 or less; lower-middle income as $766-$3,035; upper-middle income as $3,036-$9,385; and high income as $9,386 or more. (Source: 55, 148,151, 206, 207, 216, 220, 221, 226, 228, 247, 248, 249, 254, 255) Stunting Childhood stunting, or chronic undernutrition, is largely due to inappropriate feeding, repeated bouts of childhood illnesses such as diarrhea that reduce the intake and absorption of nutrients, plus improper care of sick children. Trends in stunting are mixed among children ir. MENA countries. Figure 3 indicates that stunting in the Near East/North Africa region3 has been the second lowest among the six regions in the developing world between 1980 and 1995. However, the decline during that period was only about 0.6 percent per year for the region.(5) Among MENA countries that conducted multiple national surveys on stunting, there is a disturbing trend. Since 1990, stunting has increased in Algeria, Egypt, Oman and Tunisia. (Figure 4) Stunting prevalence can be analyzed by looking at children's gender and place of residence. Table 2 shows that among girls, stunting is equal to or even lower than that among boys, and reports from Tunisia and Morocco indicate that there is no significant difference in the treatment of boys and girls in the duration or intensity of breastfeeding...56) There are significant differences between urban and rural populations. In most MENA countries, children from rural areas are more likely to be stunted than children from urban areas. In fact, rural children in Iran, Morocco, Saudi Arabia, and Tunisia are twice as likely to suffer from stunting. The stunting prevalence in urban/rural areas has been surveyed more than one time in Egypt, Morocco and Tunisia. For the three countries represented, the urban/rural gap is widening, leaving rural children more vulnerable to stunting (Figure 5). Figure 3. Estimated Stunting Prevalence by Region % 70 * Near East / North Africa 02 South America IS Middle America / Caribbean E9 South East Asia E South Asia 1G Sub-Saharan Africa | (ACCISCN Regions) (Sourc;e: 5) 3 Near East/Nort Africa region of ACC/SCN includes Cyprus and Turkey. 6 Figure 4: Trend of National Stunting Prevalence 50 - 45 - 40 - X-- c 35- ~30O ~25 -A F5 20 - +Yemen 15 - -U-Egypt , o AK U) 15 ~~Morocco 10 - -X- Tunisia K-- Algeria --e Oman 0 - 1970 1975 1980 1985 1990 1995 2000 Year (Source: 5, 228) Table 2: Stunting Prevalence in Children Under 5 Years (Most Recent Data between 1980-1997) Total Male Female Urban Rural Low Income Yemen 39.0 41.5 36.1 29.0 44.4 Lower-middle Income Egypt 29.8 31.0 28.4 22.8 34.4 Iraq 27.5 - - - - Morocco 24.2 24.2 24.2 13.2 30.0 Syria 26.6 27.8 25.8 26.0 27.6 Jordan 15.8 16.2 15.5 15.8 27.3 Algeria 18.3 18.3 18.2 18.0 18.5 Iran 18.9 19.5 18.4 12.2 24.8 Tunisia 22.5 22.3 22.6 14.5 32.6 West Bank and Gaza 14.2 13.8 14.6 - - Lebanon 12.2 12.6 11.8 - - Upper-middle Income Oman 23.0 23.1 22.9 21.2 25.6 Libya 15.1 16.4 13.8 13.9 18.1 Saudi Arabia I - - 14.0 41.0 Bahrain 9.9 10.3 9.6 12.1 7.8 High Income Qatar 8.1 8.3 8.4 - - Kuwait 12.2 - - 5.1* 17.3** * High socioeconomic group; ** Low socioeconomic group (Source: 228) - data not available 7 Figure 5: Sturting Prevalence Higher in Rural Areas 20 - 18 - 16 -. A 14- 12 - - Ci 10 _ ( c) - 8 - Jo* w 6 - Nbro o 4 - -+-Turisa 2 - Egypt 0 l I I I I 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 Year (Sr: Z8) In MENA countries, children under five years old are more likely to suffer from stunting than school age children. Figure 6 shows a small decrease in stunting in three MENA countri,zs by the age of four, while Figure 7 shows the result of cohort studies by the age of ten among Bedouin children in Israel. It is unclear whether these data imply that children can recover growth lost earlier to stunting once they have passed through the years of high susceptibility to childhood illnesses and are old enough to have more control over their own food intake, or whether they mean that severely malnourished and stunted children die during early childhood. Eigure 6: Stunting Prevalence by Aqe 60- 4 0 --- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 30 - - - - - - - - - 052 0, Age (year) (S1rce: 22) 8 Figure 7: Cohort Study of Stunting Prevalence amonq Bedouin Children 35 T Cohort B 30-- 25-- 4) 2 20 Cohort A 1f 10 Cohort A Age (year) 1,~~~Cohort B 0.75 1.5 5 1 0 Age (year) (Source: 84) Low birth weight Low birth weight, the proximity of intrauterine growth retardation (IUGR), is a sign of fetal malnutrition, a condition that is mainly due to the poor health and nutrition of the mother during pregnancy. The incidence of low birth weight is higher if mothers are of short stature, undernourished, or anemic. Infants born with low birth weights die more frequently during infancy, and if they survive, they are more likely to become stunted children (Annex 4). Also, fetal malnutrition increases an individual's susceptibility later in life to chronic diseases such as hypertension and diabetes mellitus. (5 174) Over 10 percent of babies in Egypt, Iraq, Lebanon, Syria, and Yemen are estimated to have low birth weight (Table 1). However, the data on low birth weight may not be robust because weighing newborns is not common practice in many developing countries. Available statistics show that although 86 percent of babies in Jordan are weighed at birth, in Morocco the figure is only 22 percent, and only 6 percent in Yemen. (45 Child malnutrition in several MENA countries Yemen, Iran, and Iraq present unique cases in the study of child malnutrition in MENA countries because there are widespread child nutrition problems which have resulted from the unique political, social, and economic context. Yemen is the lowest income country in the region and has the highest incidence of child malnutrition. Iran has the largest population and although most of its social indicators are comparable to other lower-middle income states in the region, the prevalence of stunting is twice as high in rural areas as it is in the urban areas. In Iraq, war and international sanctions have diminished the health and nutritional status of its citizens. 9 Yemen, the lowest income country In Yemen child health and nutrition problems are more severe than in the region overall. About 20 percent of the population lives below the poverty line,(246) and most social indicators are also poor-life expectancy at birth is 57 years; the female adult literacy rate is only 26 percent; infant mortality rate (IMR) is 93 per 1,000 live births; and the maternal mortality ratio (MMR) is 1,000 per 100,000 live births (Table 1, Annex 3). In 1995, Yemen's rate of immunization coverage was only 49 percent,4 compared with over 80 percent for most MENA countries. Low immunization coverage leads to high child morbidity, one of the major causes of chronic childhood malnutrition. Unpublis.hed Yemeni government data from 1996 show that 45 percent of children were stunted, 16 percent suffered from wasting, and 38 percent were underweight.(210) Nutritional habits and cultural practices in Yemen appear to exacerbate undernutrition caused by poverty and poor health. Breastfeeding is nearly universal in the first three months of life and 80 percent of mothers continue to breastfeed infants up to five months, but only about 40 percent of infants are breastfed exclusively. The majority are given sugar water, boiled water, honey, butter-fat or cow's milk cream in the first few hours after delivery. People also believe that if the mother is fearful, angry or sick, breast milk is unsuitable for feeding. Complementaiy foods such as biscuits and wheat porridge are introduced at the age of three to six months. The Yemeni habit of chewing qat, especially by pregnant women and teenage children, reduces their nutritional intake (Box 1). In this environment, nutritional intervention is essential but as of October 1998, there were only seven trained nutrition specialists in the Ministry of Public Health.(field interviews) They have backgrounds in medicine, agriculture, and some of them have attended a regional training course in nutrition. Box 1: Nutrition Implications olr Qat Chewing in Yemen Most of the adults in Yemen chew the leaves of the qat plant as an afternoon social activity, usually taking place over a three- to five-hour period. This habit is recently spreading among rich and poor, men and women throughout Yemen. Qat contains an amphetamine-like mild stimulant which causes loss of appetite and insomnia. Since the active ingredients of qat are secreted in breast milk, it may interfere with the appetite of breastfeeding infants. The incidence of low birth weight is 20 percent higher among women who chewed qat during pregnancy. Also, poor households spend an estimated 10 to 12 percent of their income on qat, likely displacing some of the resources which could be spend for nutritious food and health care. Although qat is chewed only in Yemen and a limited part of Africa, it provides an interesting example of the nutritional implications of substance abuse, including tobacco, alcohol, and narcotic drugs.(248) Iran, rural people are much worse off The 1995 joint survey by the Iranian government and the United Nations Children's Fund (UNICEF) shows that the incidence of stunting is almost twice as high in rural areas as it is in 4 The Ministry of Public Health reported that the immnunization coverage in Yemen increased up to 68 percent by August, 1998 (Field.nterievS) 10 cities. Between the ages of 12 and 23 months, 34 percent of rural children and 18 percent of urban children were stunted.(37) In the countryside this situation is probably caused by poverty, lack of education and cultural practices. (113, 168) The diet in agricultural areas is based on unleavened bread, and there is little nutritional diversity. There are poor sanitary conditions, high child morbidity including diarrhea and intestinal parasites, lack of knowledge about child feeding, and a high maternal workload. There are also food taboos, for example, cheese is believed to impair intellectual development, and eggs are thought to delay speech and cause stammering. Local habits such as geophagia (eating clay) and using sedative drugs on children are hazards that likely contribute to nutritional problems and poor health. Iraq, trade sanctions increase malnutrition % Figure 8: Child Malnutrition in Iraq 35.- * Stunting 30 - Zl Underweight EO Wasting 25 - IZ Low Birth Weight - 0 I 1991 1995 Year (Souce: 226, 229) Figure 9: Severe Child Malnutrition in Irag (Monthly Average) 2000 18000 1800 16000 1600 14000 2 1400 12000 e .0 1200 10000AE20 o U, l99 ioooo 192 193E9 . 1000 80 Year 60000 oj600 - /-Z 0 a z 400 -U- Kwashiorkor 4000 200 --- Marasmus 2000 0- 1990 1991 1992 1993 1994 Year (Somce: 226) The state of health and nutrition in Iraq continues to deteriorate since, the United Nations (UN) imposed trade sanctions in August 1990; children are affected most.(71 226) Figure 8 shows that childhood malnutrition increased dramatically between 1991 and 1995. The incidence of stunting and low birth weight doubled; underweight and wasting quadrupled. Severe formns of child malnutrition, marasmus and kwashiorkor, rarely observed before 1990, are increasing rapidly (Figure 9). Obesity and Diet Related Diseases Higher incomes increase average food consumption Table 3: Average Food Consumption (1989] | Energy Protein T Fat (kcal/day/capita) (g/day/capita) I(/day/capita) Low Income Yemen J 2,142 60.0 I 33.5 Lower-middle Income Egypt 3,336 83.5 78.4 Iraq 2,887 71.8 75.3 Morocco 3,020 81.3 55.6 Syria 3,003 78.6 82.7 Jordan 2,634 71.4 62.0 Algeria 2,866 76.6 61.2 Iran 3,181 84.1 62.2 Tunisia 3,119 83.3 85.7 Lebanon 3,274 86.2 97.1 Upper-middle Income Libya I 3,324 80.5 I 108.3 Saudi Arabia Emirates 2,874 86.5 82.5 High Income Kuwait r 3,195 T 95.3 I 104.9 United Arab Emirates 3,309 101.6 111.5 (Source: 150) Obesity is increasing throughout the world, and the MENA region is no exception to this trend. Obesity and diet-related non-communicable diseases are a public health issue in most MENA countries. Table 3 shows average per capita intake of dietary energy, protein and fat. Average intakes5 of dietary energy and protein in most MENA countries are higher than the Recommended Dietary Allowance (RDA) (Annex 1). In high income countries, average dietary energy consumption exceeds 3,000 kcal/day and consumption of animal products is also increasing. Sugar consumption is increasing in most MENA countries.5(7 76) People eat more sugar and fat even during the month of fasting, Ramadan (Box 2). Average intakes of total population do not necessarily reflect the presence of undernourished group of population or the size of the undernourished or ovemourished group of population. 12 Box 2: Nutrition Impacts of Ramadan Ramadan is one of the five pillars of Islam. Throughout the ninth lunar month, Ramadan, all healthy adult Muslims are obliged to fast from dawn to sunset. Although children, people in ill-health or traveling, women who are pregnant, lactating or menstruating are permitted to break their fast, it is known that children as young as nine years old or pregnant women often opt for fasting. Instead of the usual three meals a day, Muslims eat at home with family members-one large meal after sunset, and if they need it, a second meal before dawn. People eat more sugar and fat during Ramadan, plus they work fewer hours and decrease their physical activities. Some studies showed significant weight gain during Ramadan, while other studies showed decreased dietary energy intake for about 500 kcal/day and decreased body weight. Body weight loss could also be largely attributable to negative fluid balance. Most studies indicated increased blood LDL-cholesterol levels, decreased blood HDL-cholesterol levels, decreased blood triglycerides levels, significant increase in blood glucose levels, and significant increase in blood uric acid levels during Ramadan. Ramadan fasting does not harm well-nourished healthy people, and it has positive psychological effects. There can be minor complications such as headache and dyspepsia, and a few serious renal or gastrointestinal complications are reported. Several studies showed that pregnant women's Ramadan fasting had no effect on the mean birth weight. However, it will be necessary to evaluate and monitor the fasting and the food consumption at night on the middle aged and elderly more carefully, since the blood biochemical change increases risks of developing or worsening chronic non-communicable diseases. Women usually cannot decrease household workload during daytime, therefore, the effects of fasting on women, pregnant or non- pregnant, need to be evaluated further. Children and adolescents also need careful evaluation.(79 85. 93, 105, 142, 155) Obesity incidence is on the rise While the problems of undernutrition are well known in MENA countries, health problems associated with being overweight are increasing as parts of these countries become more affluent and urbanized. Obesity is more commonly associated with life in wealthier, developed countries, but is also found in areas where there has been a nutrition transition-that is, when a cereal-based diet is replaced by a diet high in calories and animal fat and low in fiber-combined with a sedentary lifestyle. Obesity is more prevalent among women than men (Figure 10). A comparison of Table 4 and Figure 10 shows that the incidence of obesity is higher in high income MENA countries than it is in OECD countries. Around 44 percent of the women in Kuwait and 3 8 percent in United Arab Emirates are obese, compared to 25 percent of women in United States and less than three percent in Japan. Also, Figure 11 shows an increase in the incidence of overweight among young children in Egypt and Morocco, which may indicate a trend that also exists in other countries in the region. Table 4: Obesity Prevalence in Selected OECD Countries (Most Recent Data between 1993-1996) Obesity Prevalence (%) |___ __ _Male Female U.S. 19.7 24.7 England 15.0 16.5 Netherlands 8.4 8.3 lJapan 1.8 2.6 (Source: 230) 13 Fiqure 10: Obesity Prevalence %0 (BMI > 30) 50T 45 7IMale 40 - ' E Female 35 30 25 Kuwait UAE Bharain Saudi Arabia Iran (Source: 230) Figure 11: Overweight Prevalence in Children Under 5 Years % Q6l~J~ eightIHeight +2SD) 12 |-+-Egypt1 1D0 | i Morocco 2 4 / 2- 5 i 1975 1980 1985 1990 1995 2000 Year (Souse: 228) 14 Faulty diet causes many health problems MENA countries are likely to face much higher health care costs in the decades to come because of diet-related non-communicable diseases. Among women, obesity increases the risk of complications in pregnancy and delivery. Obesity, high intake of animal fat, and low intake of dietary fiber are risk factors for chronic non-communicable diseases such as coronary heart diseases, diabetes mellitus, colon and breast cancer.(82) Figure 12 shows that circulatory system diseases are already a major cause of adult deaths in most MENA countries. The prevalence of diabetes mellitus is high in several MENA countries (Figure 13). It takes 15 to 20 years before the increase in body weight is followed by the onset of diabetes, and another 5 to 15 years before diabetes causes more serious complications such as renal failure, blindness and amputations.(46) This means that MENA countries are likely to face much higher costs of health care in 10 to 20 years, unless nutrition interventions to prevent diet- related non-communicable diseases are begun immediately. In the United States where the incidence of obesity has doubled since 1980, the direct and indirect health care costs associated with the disease are estimated to be more than $70 billion annually.(186' 238) Figure 12: Death Due to Circulatory System Diseases (% of Total Death) Egypt Jordan Kuwait =-77'tt:t W Qatar .- Bahrain Iran - Iraq WBG . UAE i i X Oman X 7-7 > 7-; Syria I I I I I 0 10 20 30 40 50 % (Source: 138,149,150, 249) Figure 13: Prevalence of Diabetes Mellitus Kuw ait Saudi Arabia Bahrain 0 5 10 15 20 % (Source: 149) 15 Micronutrient Disorders Iron Nutritional Anemia Nutritional anemia is usually due to iron deficiency and is a common problem throughout the world, particularly among children and women of reproductive age. Anemia is most critical in children under 24 months of age, because they are at the greatest risk of being deficient and most likely to suffer damage. Compared to other regions, anemia in MENA countries is less prevalent among school-age children, but relatively more widespread among younger children and women6 (Figure 14). Anemia. is common among women and children throughout the MENA region regardless of income level; the incidence in Kuwait is similar to that in Egypt and West Bank and Gaza (Table 5). There are significant gaps between urban and rural and between males and females in children's anemia in Bahrain (Figure 15). Anemia is more prevalent in preschool boys, but decreases considerably when they reach secondary school. The number of anemic girls increases in intermnediate school and, for rural girls, continues to increase into secondary school. Adolescent girls become more susceptible to anemia following menarche, but the number of urban girls with anemia decreases in secondary school revealing that anemia was prevented for some. Fig ure 14: Anemia Prevalence am on Women and Children 80 - 70 - - - | 7 0 - (0-- ---------------W---(-------W---(1 -5-y m0 - t M - ------------- O - No -lndustrialized -------- I0 - ------------ WestPacific OSouth ------ I .a, 40 - l 6 Mhe Eastern Mediterranean Reino Oicue fgha onistn,dypustrDibuiPastnSoalized Americasn but does not include Algeria and Israel. 16 Table 5: Anemia Prevalence (Data from Varous Subnational Surveys between 1980-1996) Children Women Men Under 5 Years School Age Pregnant Reproductive Age (%)_ I (%) (%) I (%)( Low Income Yemen | 17-66 | - I | 5-36 l Lower-middle Income Egypt 23-90 22-45 21-79 17-71 Iraq - - - 18 Morocco 27-47 - 20-40 - Syria 53 - 49-52 30 Jordan 34 - 25-46 4-23 Algeria - - 42 19-42 Iran >30 - 20-50 - Tunisia 30 - 41 - West Bank and Gaza 58-76 40-67 23-56 28-44 Lebanon - - 49 27 Upper-middle Income Oman 40-67 31-78 49-54 15-48 3-24 Libya - - 1 - 6 j Saudi Arabia 36-37 26-55 5-57 - 30-56 Bahrain 30-39 21-42 - 40-49 20 High Income Qatar 26 - J 30 - Israel 44-71 - 10-32 18-61 Kuwait - 13-26 40 42 34 United Arab Emirates 28-76 8-95 22-62 - (Source: 114,148,151,216,220) a/0 Figure 15: Anemia Prevalence in Bahrain 80 - 1D Urban Male 70 - - Rurl Male @ Urban Female 60 -- 0 Rural Female 50-- 40 - - 30-- 20 10 Preschool Primary school Intermediate Secondary school school (Source: 151) 17 Anemia riskfactors The major dietary source of iron in MENA countries is cereals. Unlike heme iron in animal products, the bioavailability of nonheme iron in cereals is low. Absorption of iron is further reduced by the consumption of tannin, phytate, and dietary fiber. People in the region drink a lot of tea, which contains tannin, and eat unleavened bread, or bread baked with high extraction rate flour which is high in phytate and dietary fiber. Vitamin C in fruits and vegetables can increase absorption of nonherme iron, but the amount of fruits and vegetables people eat varies depending on seasonal availability and cost. Much of the anemia in MENA countries can be prevented by more diversified diets that include animal products, fruits, and leavened bread. Furthermore, tea should not be consumed with meals and should not be given to small children. Iron fortification of staple food should be also needed. Anemia among children under five years of age is caused by poor feeding practices, childhood illnesses such as diarrhea, and mothers' anemia during pregnancy and lactation. Feeding sweet tea and unleavened bread to infants and toddlers increases their chances of developing anemia. Intestinal parasites, especially hookworm, may also cause anemia although the prevalence of parasites has not been accurately measured. Schistosomiasis is endemic in Egypt, causing hematuria and anemia. In many developing countries, malaria is a major cause of childhood anemia when repeated bouts occur at short intervals, but it is endemic only in Yemen in the MENA region and it is resurfacing in Iraq. Regardless of income level, women in MENA countries are at high risk for anemia due to high fertility, short birth intervals., poor maternal health care, and lack of nutrition education. However, lower income can increase the risk of anemia because there is less money for a balanced diet. Women with lower incomes in rural areas are the highest risk group because they have less diversified diets and lack access to regular health care. This group requires more urgent attention and specific interventions for their own health and the health of their children. Womnen who do receive antenatal care, may avoid taking iron supplements because they can cause stomach discomfort, plus some women believe that the iron pills cause abortion or excess enlargement of the fetus. Consanguineous marriage is common practice and is an important factor contributing to hereditary diseases endemic in M'ENA countries which cause disorders similar to nutrient deficiency (Annex 1). For example, G6PD deficiency and thalassemias cause hemolytic anemia. Premarital genetic counseling would help, but cultural sensitivity must be taken in account. Iodine Iodine deficiency disorders (IDD) are a problem in the region because many of the countries have areas with little iodine in the soil, e.g., the mountainous areas of Iran, Iraq, Lebanon, Morocco, Syria, Tunisia, and Yemen, and also the oases in the deserts of Egypt and Libya.(232) The effects of iodine deficiency are even seen in coastal areas, because not all people eat seafood due to dietary habits or prohibitively high prices. Previously in the MENA region, goiter was believed to be merely a cosmetic issue, and in some communities, a symbol of adulthood, i.e. girls starting to develop goiter were considered to be eligible to marry. In 198c9, the WHO Eastern Mediterranean Regional Office (EMRO) established a Working Group for control of IDD to reduce total goiter rate (TGR) to 10 percent or less by the year 2000.(233) The strategy included national surveys followed by salt iodization and iodized oil supplementation programs. 18 Figure 16: Proportion of Total Population at Risk of IDD 45 - . . .. 30 * E s t r ---------e a ----- ----- --- --- --- --- --- -- - - - - - - -- - - - - - - - 2| -i e t r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CL 0 1994 1997 * Eastern Mediterranean 1111Europe QAmericas ESWestern Pacific O South East Asia E2Africa (WHO Regions) (Source: 5) Table 6: Iodine Deficiency Disorder [IDD) Total Goiter Rate Goiter Prevalence Households Consuming (6-11 year old) Based on Various Iodized Salt (Data between 1981-1994) Subnational Surveys (Data between 1992-1996) Low Income Yemen f 32 J - 21 Lower-middle Income Egypt 5.2 12- 43 0 Egypt (New Valley) 52 - 82 Iraq 7.3 30- 80 50 Morocco 20 18- 80 Syria 73 69- 77 36 Jordan 6- 16 75 Algeria 8.5 23 - 71 Iran 30 82 Tunisia 4.3 15 - 51 98 Lebanon 15 12 - 70 92 Upper-middle Income Oman 10 10 35 Libya 6.3 20- 55 90 Saudi Arabia - 8 - 30 1 High Income United Arab Emirates - 46 - 66 (Source: 148, 151, 207, 221) 19 The most visible result of iodine deficiency is goiter, the enlargement of the thyroid gland visible as a swelling in the front of the neck. Other iodine deficiency disorders include impaired physical and mental development, congenital anomalies, and cretinism (Annex 1). IDD is a major public health problem in many developing countries. Figure 16 shows the Eastern Mediterranean Region7 has the highest proportion of people at risk for IDD. In other regions the incidence of IDD has decreased rapidly during the past three years due to effective interventions, but in MENA, salt iodization has begun only recently. IDD surveillance and control is at different stages in MENA countries (Table 6). In 1989, Iran identified 14 out of 24 provinces as IDD endemic areas and designed control programs for them. They built 22 salt iodization plants, and by 1995, 76 percent of rural households and 87 percent of urban households consumed iodized salt. Iodized oil was also distributed to the hyperendemic areas. In 1990, Syria identified a high total goiter rate of 77 percent in rural areas and 69 percent in urban areas. The single salt producer, the Ministry of Industry, began to iodize salt in 1992, but it reaches only an estimated 36 percent households. The government has distributed iodized oil to children under two years and pregnant women. While no nationwide data are available, a 1991 survey in Yemen indicated that 78 percent of girls and 60 percent of boys in Sana'a had goiter, and that there were hyperendemic rural areas where 95 percent or more of the population had goiter.(2"0O In 1995, the Ministry of Public Health launched a control program in collaboration with UNICEF which aimed to achieve universal salt iodization. By t:he end of 1998, about 70 percent of salt consumed in urban areas in Yemen are iodized.(fieldinterviews) In West Bank and Gaza, neonatal screening for thyroid stimulating hormone (TSH) is carried out on all newborns at the public hospitals and clinics since TSH increases in reaction to low level of thyroid hormones. This screening found 10 positive cases out of 27,000 tested in 1994 and 81 positive cases out of 45,000 tested; higher than the incidence in European countries which is around 0.2 per 1000 births.(21' 218) Endemic hypothyroidism is observed in Khan Younis area in Gaza at about 15 percent goiter prevalence. All salt used in West Bank and Gaza is imported from Israel, but the salt is not iodized and Israeli authorities do not allow production or distribution of iodized salt within West Bank and Gaza.(218' field interviews) Vitamin A Clinical vitamin A deficiency (VAD) is largely under control in the MENA region, in fact, it is the only region in the developing world expected to eliminate clinical VAD before the year 20008 (Figure 17). Diets in the M:ENA countries include generous amounts of leafy green vegetables rich in carotene that are a good source of vitamin A (Annex 1). A 1992 subnational survey in Yemen observed clinical VAD in around two percent of the sample group, the highest prevalence -three percent-occurred among five and six year old children.(222) Clinical VAD was seen more frequently in boys than girls. Subclinical prevalence of VAD among one to five year old children was around 62 percent. Subsequently, a one-time vitamin A supplement program was implemented. A pilot program of universal vitamin A distribution is underway in conjunction with National Immunization Day. 7 Moderate to severe levels of IDD are seen in Afghanistan, Pakistan and Sudan, which are not included in MENA region. 8 The Middle East and North Africa Region of UNICEF includes Djibouti and Sudan, but does not include Israel. 20 In Iraq, where the trade embargo has created a health and nutrition crisis among vulnerable groups, a 1994 survey reported that VAD is increasing. But in general, MENA countries are making progress in reducing the incidence of VAD-Oman found no cases of clinical VAD in children under two in 1991. However, in Egypt and Morocco, significant numbers of young children tested have low serum retinol or low levels of vitamin A in their systems, so subclinical VAD still needs to be addressed (Annex 4). Figure 17: Estimated Clinical VAD Prevalence for % Under 5 Year Children 2 - - - -- -- 1985 1995 |U Middle East!/ North Africa z Latin America / the Caribbean C3 East Asia / Pacificl | South Asia ZC East!/ South Africa 1111 West / Central Africa l (UNICEF Regions) (Source:S5) Vitamin D Vitamin D deficiency causes rickets in children, and osteomalacia (bone softening) and, in the extreme, bone fractures in adults. Vitamin D is found in animal foods, and it is also synthesized by the skin if people are exposed to a sufficient amount of sunlight. The vitamin D deficiency observed in MENA countries is due to the low dietary intake of vitamin D, plus lifestyles that avoid sunlight. Throughout the region, people live in dark houses, infants are wrapped for long periods of time, and many women wear thick, dark veils. In Saudi Arabia, the airborne dust particles may block ultraviolet light. Women of reproductive age and children are the most vulnerable to vitamin D deficiency. Rickets occurs most commonly by the age of one and disappears by the fifth year. Although it is treatable by exposure to sunlight, bone development may be irreversibly damaged. Especially in girls, an underdeveloped pelvis can lead to obstetric complications later. Studies in several MENA countries show a relationship between vitamin D deficiency and people's clothing and living conditions. In 1995, a hospital-based study in Kuwait reported significantly lower vitamin D levels as measured by low serum 25-OHD levels in veiled women.(63) The study suggests that young, unmarried women are particularly at risk because they 21 cover themselves more thoroughly thari the older, married women. Young, otherwise healthy women suffer bone fractures due to vitamin D deficiency. In Saudi Arabia, surveys in 1992 showed lower serum 25-OHD levels in urban areas than in rural areas, lower levels among occupants of mud or brick houses than tents, and lowest levels in female adolescents and preschool children.(143) Another sludy revealed that women in higher income households had higher levels of serum 25-OHD because they had more animal origin food in their diet, lived in better housing, and attended antenatal care more regularly where they received vitamin D supplements. '76) Babies born to mothers with low vitamin D levels are at higher risk for rickets. Studies in Saudi Arabia and Libya report that mothers of infants with rickets had low serum 25-OHD levels.(60 67) These infants begin life with low levels of vitamin D and prolonged breastfeeding by mothers with low vitamin D put the infants at higher risk, because breast milk is their main source of vitamin D. Infants with rickets have weak muscles and poor suck, have trouble with breast milk intake, and are often malnourished. In Yemen, a 1972 survey in six villages in the northern part of Yemen reported that 16.5 percent of children aged six months to four years had rickets, and a 1987 survey in a village in northern Yemen reported an overall prevalence of rickets as high as 27 percent among children under five.(210) During the last three years in Gaza, the 400 cases of rickets found in children imder two years of age were treated successfully by introducing sufficient sunbathing.(field interews) Zinc Cases of zinc deficiency were recorded in Egypt and Iran for the first time in the early 1960s.(166,167, 171) Diets in both cotmtries were based on pulses and unleavened bread made from wheat flour. In fact, diets in these and other MENA countries are low in bioavailable zinc and high in factors that inhibit its absorption. The incidence of zinc deficiency is probably similar to that of nutritional iron deficiency because both are caused by the same dietary pattern. A zinc deficiency may cause low birth weight, severe anemia, or it may retard growth or sexual maturation. Zinc deficiency can be controlled by modifying the diet to include improved varieties (e.g., animal products and milk) and by reducing phytate through bread leavening and fermentation (Annex 4). 3. Causes, Consequences and Determinants of Nutrition Disorders Breastfeeding and Complementary Feeding Inappropriate feeding practices are major causes of child undernutrition. Three important issues of child feeding are: exclusive breastfeeding in early life; duration of breastfeeding; and complementary feeding. International experts recommend exclusive breastfeeding of infants for about six months and breastfeeding with good quality complementary foods up to two years.(231' 234) Significantly in a region with a large Muslim population, the Koran recommends breastfeeding for up to two years. Figure 18 shows that only about half of mothers or fewer in MENA countries exclusively breastfeed their infants for up to three months. Therefore, over half of the infants under three months of age are fed complementary foods or breast milk substitutes. The duration of breastfeeding is gradually declining in most countries, especially in urban areas. A study in urban Riyadh, in Saudi Arabia, showed that only 31 percent of non-employed mothers and 12 percent of employed mothers breastfed their infants; the highest income mothers were the least likely to breastfeed.(9) 22 As a result, inappropriate complementary feeding and weaning practices are major causes of child undernutrition, which is highest in the age group between six months and two years. These hazardous practices include abrupt weaning, mixed breast and bottle feeding as early as the first month, and the premature introduction of complementary food-all of which are commonly found in MENA countries. Complementary foods include tea, sugar water, rice, wheat, milk, vegetables, and breast milk substitutes, often prepared in unsanitary conditions-infant formula diluted with unsafe water in an non-sterile bottle. There are also numerous traditional beliefs and values that undermine good breastfeeding practices which can leave children undernourished and vulnerable to disease at a very early stage in life. For example, some mothers believe colostrum is harmful to newborns, so they do not start breastfeeding until two days after birth. Figure 18: Exclusive Breastfeedina up to 3 Months Egypt - Iran _ Algeria _ Yemen Jordan Morocco Oman Tunisia 0 10 20 30 40 50 60 % (Source: 207, 210) Gender The poor nutrition and health status of women and female children form an inter- generational vicious circle. Low birth weight infants are more likely to be stunted. Stunted girls grow up to be short-height women. Short-height women more frequently suffer from obstetric complications which may endanger their own lives, plus that of the fetus and infants. The incidence of low birth weight is higher among mothers who are short, undernourished, or anemic.!55) To break this vicious circle, it is critical to reach females aged 6 to 24 months, as well as pregnant women. A young girl's anemia worsens after adolescence due to increased iron requirement, and if she becomes pregnant, her baby will have low birth weight and anemia, plus her own health will deteriorate. Anemia in pregnancy increases the risk of maternal deaths, since it lowers the tolerance to blood loss and resistance to infection. Although 25 percent of maternal deaths are directly due to bleeding and 15 percent are due to infection, anemia is a strong contributing factor-depending on the country, anywhere from a quarter to almost all of maternal deaths are linked to anemia.(220' 227) Frequent pregnancies and short intervals between births impede the recovery from worsened nutritional status during pregnancy and lactation. 23 The prevalence of malnutrition is similar among girls and boys, although gender gaps in the region are large compared with other regions.(19") This may require further in-depth study to disaggregate the data in relation to other factors such as age, area of residence, socio-economic status, birth order, and so forth, even though no significant differences appeared in the aggregated average data.(202) Cultural norms in the MEN'A countries may require that, adolescent girls and young unmarried women receive particular attention. Early marriage can result in pregnancy while the mother is still physically growing: this causes extra nutritional burdens. Young women's lower status in the family may deny them nutritious food rich in iron and protein. Unmarried females may develop vitamin D deficiency because they are more heavily veiled and tend to remain indoors. Nutrition disorders including anemia and IDD should be treated before pregnancy, however, unmarried females are less likely to contact health professionals than married women who are pregnant or mothers of srnall children. Obesity prevalence among women is much higher than that among men. Obesity and diet- related non-communicable diseases increase risks of complications of pregnancy and delivery and therefore increase maternal and perinatal morbidity and mortality. Sedentary life styles of obese people, particularly those who are urban and affluent increase the risk. High obesity prevalence among women may be partially due to cultural prohibitions to women's physical exercise. Education and Cultural Background Education Childhood malnutrition is often caused by improper child feeding and caring practices, therefore, the knowledge and values of caretakers, especially mothers, are very important. Women with secondary and higher education tend to have fewer children which can enable them to provide better care, plus improve their own health and nutritional status. In addition, women living in countries that provide them with the opportunity for secondary and higher education are more likely to have access to additional health and social services. In MENA countries the incidence of stunting drops significantly with the increase of female secondary school enrollment rates (Figure 19). (Stunting also drops with the increase of male secondary school enrollment rates but the correlation is not statistically significant-Annex 4.) Since stunting is the most constant indicator of chronic child malnutrition, higher female education level, and overall social development as reflected by the female education level, seem to contribute over time to a decrease in child malnutrition. Education levels influence nutritional status; nutritional status affects children's educational attainment. Children who are undernourished or anemic can be retarded in their cognitive ability development. Likewise, iodine deficiency disorders (IDD) are a major cause of mental retardation and impaired physical development in endemic areas. Even moderate forms of IDD lead to the loss of 10 to 15 IQ points.(187) Additionally, intrauterine growth retardation and low birth weight impede children's cognitive and physical development. Thus, nutritional disorders cause lower school attainment, and consequently, decrease people's long-term economic productivity. 24 Figure 19: Stunting Prevalence and Female Secondary School Enrollment in MENA Countries 45 40 - - 35 30 X 25 " 0L ; 20 1 5- - \ 5 10 O- I IIII 0 20 40 60 80 100 120 Female Secondary School Enrollment (Source 207, 226, 228, 255) Box 3: Delivering Nutrition Messages to the Public Delivering proper dietary information to the general public, especially children and their caretakers, is very important to improve nutritional status. In the early 1970s, all households in Kuwait had at least one television set, and in 1991, 87 percent of urban households and 41 percent of rural households in Yemen had televisions. The mass media has remarkable impacts on food beliefs and practices. After the Tunisian government used TV spots to encourage people to eat lentils, demand increased to the point where the government had to import lentils. Another example is a survey in Bahrain that showed that 42 percent of housewives bought a newly advertised beverage, and 59 percent of children always requested food items advertised on TV. Some mass media advertisements encourage over consumption of nutritionally unbalanced food such as snacks and soft drinks. Messages which may lead to nutritionally unbalanced diets can be found not only in mass media campaigns but also in school textbooks. The UN Food and Agricultural Organization Regional Office of the Near East (FAO/RNE) is advising governments about the nutrition implication of messages on the dietary habits of children. FAO/RNE screened English textbooks used in the Gulf states which contained phrases such as "I like Pepsi, I like tea. -- I don't like milk." But, the food industry can also be a strong ally for delivering nutrition information to the general public. FAO/RNE has prepared nutrition education materials financed by a multinational company that produces fortified cereals. There are no specific advertisements in the education materials, however, the company expects that people who have become more nutritionally conscious are willing to choose the company's fortified products. This innovative partnership between the public and private sectors suggests a direction of the better communication strategy. (49, 150, field interviews) 25 Cultural background Equity in food distribution is important not only at the national level, but the household level among family members. Households living a traditional lifestyle may allocate insufficient quality and quantity of foods to women and children, even though the total household's nutrition intakes are sufficient and balanced.('08) Moreover, undernutrition and obesity may coexist in a same household: for example, mothers of undemourished children are sometimes obese. Information and communication technology has increased people's access to outside information. Commercial messages on television and mass media nutrition campaigns can strongly influence attitudes and behaviors (Box 3). Unless consumers are educated and protected, they may receive messages with harmful nutritional implications, such as commercial messages that encourage over-consumption of soft drinks and snacks. The behavior of people is as important as education and culture and can actually compensate for deficits in education. Demographic Changes and Conflicts Demographic changes The MENA region has high natural population growth rates and significant migration- caused by workers who seek employment in the oil-producing countries and by political unrest and conflict in some countries (Box 4). These demographic issues create pressure on food supply and often increase imports (Annex 3). Migrant workers usually earn enough to feed themselves plus send money home to their families. But refugees can strain local resources, and in many cases they require international assistance to ensure that they are adequately nourished (Annex 2). Box 4: Displaced Population in Southern Iraq People from the marshlands of southern Iraq have had their environment and livelihood destroyed and now malnutrition is widespread. Many of those who could escape have become refugees in Iran. In early 1991, civil war broke out following the Shiite revolt after the Gulf War. Many people fled into the marshlands between the Tigris and Euphrates rivers. An intensified military campaign and blockade by the Iraqi government continued during 1993 conducted zL forced removal of Shiites in and around the marshes. Extensive army and civil engineering projects began to divert water from the marshes and the resulting environmental destruction depleted local food sources to the point where the remaining inhabitants are no longer able to feed themselves; neither can they purchase food due to the blockade. Originally about half a million people lived in the region but by mid-1994, as many as 200,000 had fled their homes and were in hiding in the marshes and up to 50,000 were living in camps in Iran. While many civil conflicts devastate the economy, in this instance the destruction especially affects the food chain and lack of food and potable water are among the major reasons for displacement.(2) 26 Conflicts and economic sanctions - the case of Iraq Before the Gulf War in 1990, Iraq was an oil-rich country that imported two thirds of its food supply. Since the UN sanctions were imposed, Iraq's revenues have plummeted; it is unable to import sufficient food and medicine, or pesticides to control malaria, or materials to rebuild infrastructure destroyed by the war. Scarcity of food and medicine plus damage to water treatnent and sanitation systems are seriously undennining the health and nutritional status of the population. Although massive starvation has been avoided through an efficient rationing system, sanctions have cut people's diets drastically (Table 7). Figure 20 shows the dramatic effect the embargo has had on children-malnutrition has increased, and many children are more susceptible to disease because they lack medicine and basic sanitation. In 1995, the UN Security Council instituted the "oil for food" program to help alleviate the widespread malnutrition caused by sanctions. Since then, the nutritional status of Iraqi children has improved slightly. Until sanctions end and reconstruction begins it will be difficult for the nutritional status and basic health of the population to recover. Table 7: Total Dietary Energy Intake in Iraq before and after the Gulf War Year Total Energy Rations Kcal/cap/day 1984-89 3,372 1990 3,150 1991-95 2,250 1,295 1997 2,424 2,030 (Source: 71) Figure 20: Nutrition Impacts of International Sanctions Gulf War against Iraq UN Resolution 986 OX UN Sanctions Started (Oil-for-Food) 35- 30 25 20 15 10 U Stunting 5 - E | | El Underweight OWasting 0 1990 1991 1992 1993 1994 1995 1996 1997 Year 27 (Source: 71,161,226,229) Economic Development Income and nutrition Poverty and malnutrition are usually strongly linked. Yemen, the only low income country in the region, has the lowest average dietary energy consumption, or food availability, and the highest prevalence of childhood mralnutrition. Industry, markets and social infrastructure such as schools and clinics, water and sanitation, tend to grow in cities, so rural development lags overall economic development and there is a higher incidence of malnutrition in rural areas. But low dietary energy intake does not necessarily correlate with poverty because even poor countries have public welfare programs, including food subsidies and international assistance, that enable some underprivileged people to secure adequate dietary energy. Countries must identify the people most at risk for undernutrition and design programs to reach them effectively-poor people generally and the rural poor specifically must be monitored carefully because they are the most susceptible to nutrition problems. Figure 21: Protein Consumption and GNPIc in MENA Copuntries giday/capita 100 o 90 0 00o/ Average 80 - Protein Consumption 70 0 60 - o 0 5000 10000 15000 20000 US$ GNP/c (Source: 150, 255) At lower income levels, nutrition problems are related more to the balance and quality cf food in the diet than to dietary energy intake. Many nutrition disorders result from an inadequate dietary balance because the poor often cannot afford the variety of foods that maintain good health. People in the higher income countries in the MENA region tend to consume more protein daily (Figure 21), particularly animal-based protein. These foods are good providers of protein, iron, zinc, vitamin A and D; their consumption actually increases the bioavailability of iron and zinc. Higher income is also linked to higher levels of family education and competency, and adequate housing and health care. Thus, positive relationships emerge between eating meat arLd animal products and health, especially in developing countries. People who cannot regularly afford meat and animal products in their diet need good nutritional education to make wise food choices, plus regular health care to monitor growth and signs of micronutrient disorders. Decreased household income often results in decreased variety of foodstuff because it reduces 28 purchases of more expensive meat and fruits, even though total dietary energy intake remains the same (Box 5). Box 5: Influence of Border Closures in Gaza The borders of Gaza Strip and West Bank towns are controlled by Israeli authorities even after the Palestinian National Authority (PA) took over the administrative responsibilities. It is not unusual for the borders to be closed for unspecified periods due to Israeli security concerns. This restricts the movement of people and goods which curtails the income of many Palestinians, particularly in Gaza Strip, who depend on labor and trade inside Israel. In 1996, following a prolonged border closure in February and March, an NGO active in nutrition programs in Gaza Strip conducted a rapid household survey on food security. The results showed that the mean monthly income decreased by 32 percent; on average, the consumption of meat fell by 30 percent from 5.3 kg to 3.7 kg/month/household; eggs by 22 percent from 105 to 82/month/household; and less than 50 percent of households could still buy fruits and milk during the closure. However, the meals per day did not decrease, and more than 90 percent of households could still buy flour and rice; flour consumption remained stable. This survey illustrates how political instability can affect people's nutritional status. Dietary quality and diversity are most affected, while total dietary energy intake can be stabilized, even during the prolonged border closure. However, nutritional education, for example advising people about the high nutritional value of many cheap foods, such as vegetable sources of protein and micronutrients, would be useful in this situation. (107, 249) Dissociation of nutrition status and economic development The stunting prevalence in Egypt9 declined until 1995, although the rate of decline did not directly correlate to the increase of GNP/c (Figure 22). Stunting prevalence actually increased from 22 percent to 30 percent during the rapid economic growth between 1995 and 1996. The urban/rural gap remained constant during the decline in stunting prevalence, but increased when the national stunting prevalence increased (Figure 5; Annex 4). Egypt has the highest average dietary energy consumption in the region despite its income level and stunting prevalence being the second lowest (Table 1, 3). This is due to the heavy food subsidy schemes' which have increased food availability per capita to levels comparable to industrialized countries. 74 150) The food subsidy scheme covered 20 food items and in 1981, accounted for almost 20 percent of total government expenditures. But since the late 1980s, as part of economic structural reform, the Egyptian government gradually decreased the subsidies so that by 1995, they included only bread, wheat flour, sugar, and edible oil, and accounted for only 5.5 percent of total government expenditure.(8 11, 258) In that year, bread and wheat flour accounted for 42 percent of total daily energy consumption in urban households and 23 percent in rural households, thus they are the largest sources of dietary energy in the Egyptian diet. 9 The 1997 interim Egypt Demographic and Health Survey reported a decrease of stunting prevalence and a decrease in the urban/rural gap, but an increase of wasting prevalence (stunting prevalence: total 24.9 percent, urban 20.0 percent, rural 28.2 percent; wasting prevalence: 6.1 percent).(66) 1 Food subsidy issues are analyzed in the regional study on consumer food subsidies.258) 29 Nutritional status is affected by food subsidies, but how they are linked is not yet clear-- there was a major food subsidy reform which was completed by 1992, and the stunting prevalence declined steadily until 1995. The rice subsidy was canceled in 1992, and bread is more heavily subsidized than wheat flour."' This policy may have hurt rural households, since they consume more rice and wheat flour and prepare their own bread at home rather than purchase it. The persistence of child malnutrition in Egypt is related more to child caring practices and infectious diseases, such as diarrhea and intestinal parasite infection, than to food availability. (4) Figure 22: Stinting Prevalence and GNPIc in Egypt 40- 1400 35 1200 ~~~~~-30 ~~~~~~~~~~~~~1000 25 CU 6~~~~~~~~~~~~~~~~~~00 -20 600 z 15 400 5 -- M ~~Stunting (% 200 -| - GNP/c (US$) O - I 4 I II, I I I I * 1- 1 1- *1 - 0 0~~~~~a Year (Source: 5, 228, 255) 4. Improving Nutrition in MENA Countries Major Nutrition Issues in MENA Countries In spite of improvement in income and health status, stunting, or chronic undernutrition among children under five years of age, is still prevalent in some countries, especially in rural areas (Table 8). The urban/rural gap is widening: income differences are growing, inequity in access to social- services exists, and there are other exclusionary factors which explain this polarized development. But it requires further analyses. Nutrition improvements have lagged economic development in Egypt and Tunisia as reflected in their data on stunting prevalence; Morocco, while not as obvious, might also be in the same situation. Table 8 also illustrates the status of micronutrient deficiencies in MENA countries. Certain deficiencies, particularly iron, are prevalent even in high-income countries. Women and ' Consumer price of bread is about one third of actual production cost.('") 30 children are most vulnerable to these deficiencies, which might also explain the relatively high maternal mortality and low birth weight incidences in the region. Iodine deficiency disorders (IDD) also remain a serious public health issue, however, many MENA countries have already started universal salt iodization programs which can eliminate it as a public health issue. Obesity and excess fat intake are problems in the region, particularly in high income countries, in urban areas, and among women. High obesity prevalence increases risks of diet- related non-communicable diseases, such as coronary heart disease and diabetes mellitus, in the years following the change of diet and weight gain. These conditions will result in soaring health care costs in 10 to 20 years, unless intensive preventive campaigns are undertaken. Table 8: Maior Nutrition Issues in MENA Countries Stunting Wasting Low Anemia IDD VAD Vitamin D Obesity Diet-Related Birth Deficiency Non-communicable _ _ _ _ _ I _ _ _ . _ _ _ Weight Diseases Low Income Yemen ++:++ +++ ++ ++ + Z + Lower-middle Income Egypt i++ + + ++_ . + + ++ Iraq ++ ++ ++ ++ + + + Morocco ++ + ++ ++ + Syria t+! . ++S + +4 ++ + Jordan + + 4+ + ++ Algeria + +4 i4 + Iran + ++ . ++- + + + Tunisia +t + ++ + West Bank and + ++ ++ + ++ Gaza . . __E_._ Lebanon + + + ++. + Upper-middle Income Oman ++ 4+ - - ++- + +4 Libya + + + + 4 + + Saudi Arabia + + -:*-:1 + ++-I --+-- Bahrain + E T 4+ ++ ++: High Income Qatar _ + _ _ -_ ++- l+ ++ _ Israel T _ I _ T _ 1 +4 1_ T I_I_-_L_--_--L Kuwait + + + 1 _ 1 + ++ United Arab || ++ +4 Emirates l l _ I _ _ _ I _ _ l: ___AX __ __ __ +-: high/moderate; +: mild/unknown extent; blank: low/no data Possible Strategies and Actions Creating a policy framework Each country should develop a specific operational strategy. Initially, policy makers need to recognize nutritional issues and their causes, prioritize the problems, identify the vulnerable groups in their population, and assess impacts of existing programs and institutional capacity. Next, they must design short-, medium-, and long-term strategies to solve nutritional problems; and to coordinate the efforts of all concerned agencies. They need to choose between specific interventions and comprehensive programs, between targeted or universal approaches. During 31 implementation, progress and impact have to be carefully monitored. As nutrition affects health most directly, Ministries of Healthi should take leading roles in coordinating among sectors, drafting strategies, and implementing interventions. Since nutrition is a multi-sectoral issue, development and improvement in other sectors can greatly affect nutritional status. Therefore, the design and preparation of programs in other sectors should always be assessed for their nutrition implications, and during implementation they should also be monitored for impact on nutrition. Policy changes in agricultural and trade sectors should be monitored for their effect on local food availability and prices. Even within the hea]th sector, it would be more effective to address risk factors for all nutrition disorders simultaneously. For instance, Integrated Management of Childhood Illness (IMCI) by WHO and UNICEF is expected to redtice chronic child undemutrition through a comprehensive approach to address the health and nutrition problems of small children.(182) IMCI is a comprehensive primary health care program including case management of diarrhea, respiratory infection, and malaria, nutrition counseling and management, and drug management. Although IMCI has been implemented in various developing countries in the world, only a few MENA countries, such as Egypt and Morocco, started to introduce this approach. In depth analyses necessary for each country The real impact of food and. agricultural reforms on nutritional status are not completely understood. Despite the fact that nutritional status is one of the best indicators of poverty, people responsible for economic policies and for nutritional assessment do not coordinate policy. Country economic data and nutritional indicators should be analyzed together to figure out why there are discrepancies between the economic development and nutritional improvement. Priority issues in each country can be identified only after conducting in depth studies on nutritional issues and assessments of existing nutrition programs. Before designing interventions, such as micronutrient fortification prograrns, feasibility studies or sector work should be conducted. Various factors, such as household income, status of women, their educational attainment and other cultural factors, critically affect nutrition and nutritional disorders, however, these factors are likely to carry different weights in determining the pattern of nutritional disorders.12 Clarifying a link between the underlying causal factors and the patterns of nutritional disorders would lead to more specificity and a prioritization of policy intervention for each nutrition disorder pattern, and also contribute to stronger policy recommendations at the country level. Capacity building Strong institutions and teclmical capacity are a prerequisite for implementing successful and sustainable nutrition interventions. Many countries have a shortage of qualified nutritionists, plus they are poorly distributed to address nutrition problems. In Egypt, nutritionists are mainly hospital based in large urban areas, (24) but most of the countries' nutrition problems are in rural communities and prevention of nutritional disorders does not take place in hospitals. To achieve a critical mass of qualified technical personnel, regional collaboration should be more encouraged. The WHO/EMRO and the Nutrition Institute in Cairo are conducting regional training courses on nutrition for example.(236) 12 For example, a study in Jamaica indicated that increased child height correlated to increased education of women in a household, marginally correlated to household income, but did not correlate to father's education.(97) 32 Communication for behavior change (CBC) Many nutritional disorders are not expensive to solve, or they can be avoided if people understand the risks and change their behaviors. People need to know the elements of good child feeding practices and how to maintain a balanced diet, regardless of their incomes. Nutrition awareness is essential among the general public, and especially among mothers and caretakers of small children. Communication for behavior change (CBC) programs should be carefully designed, monitored and evaluated to achieve maximum impacts. CBC programs can be delivered through many channels: schools, clinics, communities, youth groups and mass media. For example, health professionals can counsel mothers about breastfeeding and appropriate complementary feeding techniques at clinics or by home visit; school health programs can include nutrition education for children and provide supplemental nutrition. Information with nutrition implications in the newspapers, on television, and elsewhere has to be carefully monitored to avoid spreading misleading information and to protect consumers. Possible interventions to each nutrition disorder Possible interventions for nutritional issues are summarized below. The disorders and their possible interventions are illustrated in Table 9. Examples of nutrition programs in other countries, their costs and cost/benefit analyses of long term diet-related benefits of nutritional supplements on labor productivity relative to the costs of intervention measures are described in Annex 2. For example, iron supplementation to rubber plantation workers in Indonesia lead 15 to 25 percent increase of productivity (benefit-cost ratio of 260:1); and iron fortification of bread in Lebanon is estimated to avert lifetime income loss of $15,000 (benefit-cost ratio of 7,500 to 1). * Child malnutrition Comprehensive public health and nutrition programs targeted to children under two years of age and their care takers, particularly among the rural population, should include growth promotion, IMCI, diarrhea control, and nutritional education regarding breastfeeding and appropriate complementary feeding techniques. * Low birth weight Comprehensive maternal health services: e.g., food and iron supplementation and nutrition monitoring of pregnant women at the antenatal check-up. CBC programs for pregnant women and decision makers in the family including husbands and the elders. * Obesity and diet-related non-communicable diseases CBC programs to address obesity and diet-related non-communicable diseases. Health promotion activities including physical exercises and nutrition counseling. Experience in industrialized countries shows that there are no single universally accepted solution to control obesity epidemic, thus innovative and multidirectional approach will be required. * Anemia Iron and folic acid supplementation to pregnant and lactating women, children particularly under 24 months of age, and adolescent girls through health service channels, schools and communities. CBC programs to promote proper complementary feeding, diet diversification and modification to increase iron intake and absorption. Iron fortification of staple foods. Parasitic disease control programs. Premarital genetic counseling to decrease hereditary anemic diseases. 33 * Iodine deficiency disorders (IE)D) Universal salt iodization. Iodine supplementation programs to pregnant women and school children in hyper-endemic areas. * Vitamin D deficiency CBC programs to modify child caring practices and life styles. Vitamin D supplementation to pregnant women. Vitamin D fortification of edible oil and milk. Table 9: Nutrition Interventions Nutrition High-Risk 1 Specific Interventions Public Health Nutrition Communication for Disorders Groups I [Monitoring Behavior Change Child Children, 6 to Breast feeding Management Clinic / Clinic / Mass media Undernutrition 24 months Complementary feeding! of childhood community community Growth Promotion illness / Immunization Low Birth Pregnant Food / Micronutrient Management Antenatal Clinic Mass media Weight women supplement of high risk check-up community pregnancy Anemia Pregnant Iron / Folic acid Iron Management Antenatal Clinic Mass media women supplement fortification of high risk check-up community ___________ v___.___pregnancy Adolescent Iron supplement Iron Community ! Community/ Mass media girls fortification School/ School/ Youth group Youth group School age Iron supplement Iron Deworming School School Mass media children fortification Children Complementary Iron Management Clinic Clinic Mass media under 5 years feeding fortification of childhood community community illness IDD Pregnant Iodine Salt Management Antenatal Clinic Mass media women supplement iodization of high risk check-up community pregnancy School age Iodine Salt School School Mass media children supplement iodization Vitamin D Children, 6 to Sun bathing! Vitamin D Clinic Clinic Mass media Deficiency 24 months Complementary fortification community community feeding Young women Vitamin D Vitamin D Antenatal Clinic Mass media supplement fortification check-up community Obesity Adults Diet counseling Health Clinic / Clinic ! Mass media promotion / community community Management of diet related I____________ I____________ I______________diseases I I Source: World Bank Micronutrientsfortfication Staple foods can be fortified or enriched with various micronutrients (Annex 2). The uniit cost of micronutrient fortification programs is usually much less than that of supplementation programs (Table 10). For instance, the estimated annual per capita cost of salt iodization is about one fifth of the cost of iodine supplementation. Iron fortification is one tenth the cost of iron supplementation to pregnant women.(101 244) Fortification is a sustainable and equitable solution to ensure micronutrient coverage of the entire population, if the fortification programs are truly 34 institutionalized, as seen in industrialized countries. Fortification of several food items, such as wheat flour and bakery products, rice, salt, sugar, condiment, and milk, is likely to provide the potential coverage larger than fortification of single food items. Many MENA countries have started to move forward with universal salt iodization. All countries in the region should adopt this policy, including those countries currently not iodizing salt. Iodine compounds can be also added to potable water for the purpose of both water purification and iodization, if water systems permit. Countries should also consider iron fortification of staple foods to decrease the widespread anemia in the region. WHO/EMRO and UNICEF are promoting iron fortification of wheat, as wheat is a major staple food consumed in many MENA countries.(237) The most critical factor for long term success is quality control, both at the plant and consumer levels, to verify specified fortification levels are within acceptable limits. Initial investment in technical and institutional capacity building is likely to be needed, since problems can occur in monitoring and sustaining the quality of the programs.13 Before implementation, feasibility studies are required to identify food consumption patterns, production and distribution systems, legal and institutional framework, and costs and incentive systems. Multi-sectoral commitment and private sector participation are essential.!124) Table 10: Costs of Micronutrient Fortification Programs Country I Food Vehicle Fortificant Cost (US$1personl year) [ Year Several Salt Iodine (50 - 80 ppm) 0.02 - 0.06 1992 India Salt Iodine(50ppm)+ Iron(1,OOOppm) 0.12-0.18 1991 Guatemala Sugar Vitamin A (15,000 iU/kg) 0.29 1994 Guatemala Sugar Iron (1.3 %) 0.1 1981 Egypt L Wheat flour Iron (25 - 35 ppm) 0.15 1980 Venezuela Com flour/ Iron (20 - 50 mg/kg) 0.07 - 0.08 1994 Wheat flour Vitamin A (39,000 lU/kg) (Source: 121, 237, 244) Categorizing nutrition issues in MENA countries Table 8 suggests that MENA countries can be categorized into three types of nutrition disorder patterns. * Type 1: High malnutrition and micronutrient deficiency; low economic and social indicators; e.g., Yemen, Iraq. * Type 2: Relatively large population with malnutrition, with large urban-rural gaps and high micronutrient deficiency; relatively well performing middle-income economy with a significant number of poor; e.g., Iran, Tunisia. * Type 3: High micronutrient deficiency and obesity; relatively high income with pockets of poverty and comparatively low social indicators; e.g., Saudi Arabia, Bahrain. 13 Bahrain started fortifying wheat flour with iron and vitamins in 1993, however, the program was discontinued after one year, primarily because of financial constraints.(237) 35 Combination of interventions for each type Type I countries require bolh specific nutrition interventions and comprehensive health and social programs. Decreasing rnalnutrition among small children and pregnant women should be the first priority. Particularly among MENA countries, Yemen and Iraq require special international support. Yemen, with the most serious malnutrition problems and the lowest income level in the region, needs to increase the effectiveness of its social service sector, including nutrition and health. Iraq could rehabilitate in a relatively short time once the international sanctions are lifted. The international community should prepare a prioritized strategy to rehabilitate the country when the situation allows. Type 2 countries also require both specific nutrition interventions and comprehensive health and social programs targeted to decrease inequity within the country. Nutrition and other social programs should be targeted to the rural population and urban poor, particularly women and small children. Food and agriculture policies should be carefully assessed for effectiveness and real nutritional impacts on the vulnerable groups.'4 Type 3 countries need to emphasize CBC programs for preventing obesity and micronutrient deficiencies and to proceed with micronutrient fortification programs. These countries also require nutrition, health and social programs targeted to their vulnerable groups. They may need technical assistance to bring their programs up to international standards. Strategic Options for the World Bank To assist MENA countries in improving nutrition, the World Bank may consider several strategic options listed below: * Stimulate country discussions. This review, which summarizes major nutrition issues in the region, should be disseminated among stakeholders both in the social and economic sectors of MENA countries. This will stimulate discussions in each country and help put nutrition back on the policy agenda. A regional conference including the public and private sectors, NGOs, and academics may be an option to formulate a regional strategy. * Put nutrition back on the policy agenda. Nutritional status is one of the best proxies to measure poverty and social development. Therefore, nutrition issues should be taken into account in the country assistance strategy (CAS) and should be discussed with governments in the context of economic and social development. For example, the new CAS of Yemen indicates that poverty reduction, health, nutrition and population (HNP'), and education are priorities. A system for regular monitoring of nutrition status has to be established in each country, as well as special surveys to analyze specific issues. * Support specific programs. Bank HNP programs should emphasize nutritional improvement. Nutrition programs'5 should include: maternal and child nutrition care including health services, CBC, training, 4 Countries at risk for undernutrition need to design effective programs to reach the poor. In the case of Egypt, the urban poor receive income transfers and. secure dietary energy intakes from self-targeted food subsidy programs.(8) '5An example of nutritional program package is the Nutrition Minimum Package (MINPAC), which targets: exclusive breast feeding for about six months; appropriate complementary feeding until 24 months; adequate vitamin A intake 36 and monitoring; micronutrients and food supplementation' and micronutrient fortification. Nutritional activities in current national public health programs should be strengthened to meet international standards. To ensure sustainability of the programs, their costs need to be carefully estimated, and feasible financing plans, including donor assistance, need to be prepared. For instance, community involvement will be a key strategic element to sustain programs in Yemen, where the government's resources are scarce and therefore, the Bank will pilot a community-based child development project in partnership with UNICEF. * Partner and facilitate technical assistance. Each country has to improve current programs and prepare new ones to meet international nutritional standards. Even those countries that do not require financial assistance may need technical support for plannming, implementing, and monitoring their nutrition programs. The Bank could facilitate technical assistance in partnership with other organizations such as WHO, UNICEF, FAO, and reputable NGOs, while taking into account of each agency's technical advantage. The Bank could also help to coordinate and mobilize the technical and financial resources of other agencies, including the private sector. * Coordinate and monitor other sector programs. The Bank is a unique agency with multi-sectoral expertise. Other sectors, including water and sanitation, agriculture, education, and industry, can assist in designing and monitoring programs that produce positive impacts on nutrition. All poverty reduction programs should use nutrition indicators, such as the results of periodic national surveys and specific surveys in intervention and control areas, for assessing the impacts of interventions and adjusting them. The Bank could support the institutional capacity building of Ministries of Health, which could play a leading role in intersectoral coordination. 5. Conclusion - Nutrition as a Priority Issue Nutrition disorders impede the economic development of a country. Poor nutritional status will lead to poor educational attainment and decreased economic productivity, plus rising health care costs. Long term economic loss caused by nutrition disorders should not be underestimated because failing to invest in good nutritional outcomes now will incur even greater costs in the future. Improving people's nutritional status should be a priority for all MENA countries. The countries must realize that economic development strategies until now have not improved nutrition as much as expected. Any new development strategy should include specific schemes to improve nutritional status, particularly among women, children, and rural populations; this would also strengthen economic and social development overall. Policy makers need to reach a consensus to make nutrition a country's priority among many developmental issues. Strong political commitment at the highest level is needed to implement and sustain effective nutritional interventions. 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The World Bank, Washington, D.C., 1997. 257. The World Bank. Republic of Yemen: Agricultural Strategy Note (Yellow Cover). The World Bank, Washington, D.C., 1998. 258. The World Bank. MENA Regional Study on Consumer Food Subsidies (Draft). The World Bank, Washington, D.C., 1998. 259. The World Bank. India: Wasting Away - The Crisis of Malnutrition in India (Draft). The World Bank, Washington, D.C., 1998. 260. Zerfias, A. Review and Analysis of National Programs of Action as They Relate to Nutrition. UNICEF, New York, 1993. 46 Annex 1. Nutrition Disorders - Background Information Child Malnutrition Child malnutrition in a certain population is usually evaluated anthoropometrically through stunting, wasting, and underweight, in comparison with a standard reference population such as the United States National Center for Health Statistics (NCHS) tables.<88) Severe malnutrition refers to the status lower than -3SD of the reference population. Moderate malnutrition refers to lower than -2SD but higher than -3 SD. Stunting refers to low height for age, reflecting a relatively long-term malnutrition status. Stunting is slowing of skeletal growth and stature resulted from extended periods of inadequate food intake and repeated childhood diseases. It is considered to be the most stable parameter for child malnutrition. Wasting refers to low weight for height, reflecting an acute malnutrition status that may be caused by temporary famine, sudden economical depression or a war. It is a sensitive index of current nutritional status. Underweight refers to low weight for age. It is a general and simple parameter for malnutrition, but doesn't consider height differences. Marasmus is an extreme form of protein energy malnutrition, characterized by loss of muscle mass and adipose tissue. Marasmus results from a prolonged reduction of food intake under famine-like conditions. Kwashiorkor is another form of extreme protein energy malnutrition, results from a diet with a low protein content relative to energy. It also arises from an inadequate intake of dietary protein concomitant with acute protein losses induced by trauma, sepsis, and so on. Unlike marasmus, kwashiorkor does not result in a depletion of skeletal muscle protein: instead the visceral and serum protein pool is depleted and edema occurs. Unless there are absolute food shortage, child malnutrition is mainly due to incorrect child feeding practices including complementary feeding, repeated childhood diseases such as diarrhea and respiratory infection, incorrect care of sick children, and lack of personal hygiene and environmental sanitation. The incidences of malnutrition are usually the highest among the children over six months and under five years of age. Breastfeeding and Weaning Breastfeeding is internationally promoted as the wide range of benefits is well recognized. It is recommended that breastfeeding should be started immediately after birth, continued exclusively for about six months, with complementary foods for up to two years.(207'231' 234) This is particularly important in developing countries, where bottle feeding practices often fail to meet proper nutritional and sanitary conditions: e.g., baby formula prepared with contaminated water or too diluted. Baby Friendly Hospital Initiative, started in 1991 by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), has transformed over 12,700 hospitals in 14 countries into centers of support for breastfeeding.(207) Breast milk contains nutritional substances ideal in quantity and quality for optimal growth and development of infants. In addition to its nutritional value, breast milk favorably changes the pH of stools and the intestinal flora, thus protecting against bacterial diarrhea.(43) Colostrum is a high caloric, high protein, thin yellow fluid present in the breast before birth and for the first few days thereafter, which contains antibodies, lymphocytes and macrophages as well as nutrients. Colostrum also stimulates the passage of meconium of newborn. 47 On average, about 600 - 750 ml breast milk is produced per day. Lactating mothers require additional 600 - 800 kcal of dietary energy and 15 g of protein per day.(83) Since infants' nutritional requirements increase, complementary solid foods should be introduced after six months. Gradual weaning over weeks or months is recommended. In addition, breastfeeding provides emotional and psychological benefits to both mothers and infants. Suckling stimulates oxytocin excretion, which stimulates milk secretion as well as uterine contraction and helps postpartum recovery. Prolactin, a hormone regulating milk production, inhibits ovulation and causes postpartum amenorrhea. Thus, breastfeeding also provides natural contraception. Fetal Malnutrition Fetal malnutrition usually reflects the status of health and nutrition of pregnant women. Although intrauterine growth retardation (IUGR) is more suitable for assessing fetal malnutrition, it is often difficult to determine accurate gestational age in developing countries.(55) Therefore, low birth weight is usually used for assessing the prevalence of fetal malnutrition. Low birth weight is defined as the birth weight less than 2,500 g.( 55) Low birth weight infants include small for gestational age infants born at term, appropriate for gestational age infants born prematurely, and a few normal infants in the lower end of the growth distribution. The prevalence of low birth weight in developing countries is estimated at about 16 percent; it is about six percent in the industrialized countries. It is sometimes difficult to estimate the incidences of low birth weight in developing countries, since the proportion of the infants weighed at birth varied greatly: e.g. 86 percent in Jordan, 22 percent in Morocco, and only 6 percent in Yemen.(45) IUGR is defined as birth weight below the 1 0th percentile of the birth weight for gestational age, sex specific, single/twins risk curve.(55) IUGR is mainly caused by fetal malnutrition due to maternal malnutrition, pre-eclampsia and other maternal complications, cigarette smoking, and so on. IUGR is also caused by fetal disorders such as chromosomal anomaly and intrauterine viral infection. (62) IUGR is estimated at about 24 percent of live births in developing countries. Fetal malnutrition can lead to structural or functional changes in utero that permanently increase susceptibility to chronic diseases. People born with low birth weight are reported to show higher incidences of high blood cholesterol levels, hypertension, and lower glucose tolerance that may lead to diabetes mellitus.(5 32' 92' 101, 116, 157, 174, 179, 239) Considering that chronic non-communicable diseases are increasing in most developing countries, maternal care requires more attention for decreasing IUJCR and low birth weight infants. Body Mass Index (BMI) Body Mass Index (BMI) is one of the common indicators of adult overweight and obesity, as well as underweight and adult malnutrition. BMI is calculated through the formula below. 88) The incidences of chronic non-coimmunicable diseases such as diabetes mellitus and cardiovascular diseases are lowest when BMI is around 22. Underweight, overweight, and obesity are defined as below. 48 BMI = Weight (kg) / Height (m) 2 Underweight BMI < 20 Overweight BMI > 25 Obesity BMI > 30 Protein, Carbohydrates and Fat Protein, carbohydrates, and fat are macrocomponents of the diet and the principal sources of energy: protein, 4 kcal/g; carbohydrates, 4 kcal/g; and fat, 9 kcal/g.(83) Proteins account for about three-fourths of the dry matter in most human tissues other than bone and adipose tissues. Proteins are made up of about 20 common amino acids: nine amino acids are not synthesized by mammals and are therefore dietary essential, whereas others are synthesized from dietary sources of carbon, usually from carbohydrates, and nitrogen. Amino acids are required for the synthesis of body protein and other important nitrogen-containing compounds, such as creatine, peptide hormones, and some neurotransmitters. Carbohydrates are the principal dietary sources of energy, particularly in developing countries. The principal dietary carbohydrates are sugars and complex carbohydrates. Sugars include monosaccharides, such as glucose and fructose, and disaccharides, such as sucrose, maltose, and lactose. Sugars are found in fruits, milk, honey, corn syrups, candies, sweet desserts and soft drinks. Complex carbohydrates or polysaccharides comprise starches and dietary fibers. Starches are polymers of glucose and found in cereal grains and their products such as bread and rice, potatoes, legumes, and a few other vegetables. Dietary fibers are indigestible complex carbohydrates such as cellulose, pectin, and algal polysaccharides. Dietary fibers bind to mineral elements and interfere with absorption, although consumption of fiber rich diet is related to a reduced risk of cardiovascular diseases and colon cancer. Fats or tryglycerides are composed of three fatty acids esterified to glycerol. Fats are the most concentrated source of dietary energy and sources of a few essential fatty acids. Fats facilitate absorption of fat-soluble vitamins, as well as enhance the palatability of food. Dietary sources of fats are meats, poultry, fish, shellfish, milk and milk products, eggs, edible oils, and margarine. Cholesterol and phospholipids are major components of all cell membranes and of myelin. Cholesterol is also the precursor of the steroid hormones and of the bile acids. High levels of LDL-cholesterol in plasma relate an increased risk of atherosclerotic vascular disease, especially coronary heart disease, whereas high levels of HDL-cholesterol are associated with a reduced risk.(43' 82) The strongest dietary determinant of blood cholesterol levels is the content of saturated fatty acids, which are mainly present in animal fats. Recommended Dietary Allowance (RDA) US Japan (25-50 year old) (30-39 year old) Male Female Male Female Total Dietary Energy (kcal/day)* 2 Z900 2,200 2,500 2,000 Protein (g/day) 1 63 50 70 60 *Fats contribute about 36 % of total energy in US, whereas 26 % in Japan. (Source: 83, 98) 49 Nutritional Anemia Nutritional anemia is a condition in which the hemoglobin (Hb) content of the blood is lower than normal, as a result of a deficiency of one or more essential nutrients--usually iron, less frequently folic acid or vitamin B112.5) Iron deficiency anemia is the most common nutritional disorder in both developing and industrialized countries. Protein energy malnutrition usually accompanies nutritional anemia, however, iron deficiency anemia frequently occurs in those individuals with sufficient, or even over intakes of, protein and dietary energy. Iron is a constituent of Hb, the oxygen carrying molecule of the red blood cells, myoglobin, and a number of enzymes."83) In addition to these functional forms, as much as 30 percent of the body iron is found in storage forms such as ferritin and hemosiderin, mainly in the spleen, liver and bone marrow, and a small amount is associated with the blood transport protein transferrin. Clinical signs of iron deficiency include hypochromic-microcytic anemia, glossitis, spoon nails, loss of energy, tiredness, increased susceptibility to infection and reduction in intellectual performance and work capacity!"543 216, 235) Measurement of the concentration of Nb in whole blood is the most widely used screening test for iron deficiency anemia. 88) Hb Levels Indicative of Anernia Epidemiological Criteria Age 9 Gender HI) level Prevalence Mild / Moderate Severe Anemia Children 6 months - 5 years c 11 g/dI Anemia (Hb < 7 gJdl) Children 6 - 14 years < 12 g/dl Severe > 40 % > 10 % Non-pregnant Women < 1 2 g/dl Moderate 10 - 39 % 1 - 9.9 % Pregnant Women < I 1 g/dl Mild 1 - 9.9 % 0.1 - 0.9 % Adult Men < l3 g/dl (Source: 5, 216, 235) Iron deficiency arises from inadequate dietary iron intakes, poor absorption, excessive loss caused by gastrointestinal bleeding, menstruation, parasite infection, and so on. Iron is required in greater amount during periods of rapid growth. Women of reproductive age lose 50 percent more iron than men, due to menstrual bleeding. Therefore, women of reproductive age, infants and young children who require higher iron intakes are more susceptible to iron deficiency.(43, 86, 216) Heme iron in animal products such as meat, liver, poultry, seafood, is highly absorbable, while nonheme iron in cereals, vegetables, fruits and dairy products is less bioavailable. Asccrbic acid, or vitamin C, in plant foods increases the absorption of nonheme iron when the two are ingested together. On the other hand, tannins, phytate, and dietary fiber, which are found in tea and bran, decrease nonheme iron absorption substantially. These inhibitors can be reduced by food processing, such as fermentation, sprouting, and cooking.(41' 235) Folic acid and vitamin B12 are water-soluble vitamins which are involved in nucleic acid synthesis. Deficiency of folic acid or vitamin B12 causes megaloblastic anemia.(43' 83) Vitamin. B12 (cobalamin) is also involved in synthesis of myelin in the nervous system, and deficiency may cause irreversible neurological abnormalities. Folic acid is included in green leaves and is essential for cellular replication and differentiation. Since the recovery of anemia is usually better through iron and folic acid supplementation than iron alone, most of the current supplementation programs for pregnant women provide both iron and folic acid. Folic acid is known to prevent congenital neural tube defect when it is supplemented to the folic acid resistant women during the first trimester of 50 pregnancy.(5) Therefore, folic acid should be supplemented when a woman who has previous neural tube defect pregnancies plans to be pregnant again. Iodine Iodine deficiency disorders (IDD) cover a wide variety of clinical conditions including goiter, impaired physical and mental development, spontaneous abortions, still births, congenital anomalies, increased perinatal and infant mortality, and neurological and myxedematous cretinism.(57 1S7) IDD is caused by lack of iodine in the soil of endemic areas, therefore whole population consuming local foodstuffs, regardless income levels, are likely to suffer.(232' 233) Endemic areas include mountainous regions and recurrently flooded plains where iodine in the soil is continually washed away, as well as deserts and oases where iodine is hardly supplied by rainfall. Pregnant women are the most at risk as IDD may cause irreversible damage to the fetus and infants. Iodine requirement for children increases with age, so goiter prevalence also increases with age among children in the endemic areas.(221) Iodine, a trace element present in the human body in minute amounts, is an essential substrate for synthesis of thyroid hormones, i.e. thyroxine (T4) and triiodothyronine (T3).(83' Iodine is present in food and water largely as inorganic iodide and is absorbed rapidly. Seafoods are excellent dietary sources of iodine. Natural goitrogens are present in a certain vegetables such as cabbage, turnips and cassava. Low dietary intakes of iodine decrease thyroid hormone secretion, resulting increased secretion of thyroid stimulating hormone (TSH) through the negative feedback mechanism. If iodine intakes are limited for prolonged periods, hence TSH continues to stimulate the thyroid gland, an iodine deficiency goiter is developed.(43) Surveys of goiter can be done by palpation or ultrasonographic measurement. The total goiter rate (TGR) is the prevalence of visible goiter and goiter detectable by palpation.(57' 221) The most widely used method of assessing iodine status is to determine urinary iodine excretion in a 24-hour urine specimen, or alternatively casual urine specimen in comparison with creatinine excretion.!88) Serum T3 levels rather increase in clinically euthyroid iodine deficient individuals, whereas T4 levels decrease. Serum TSH concentrations are notably higher in chronic severe iodine deficiency. Congenital hypothyroidism is usually screened by using a TSH cut-off of 20- 25 mU/l whole blood (about 40-50 mU/l serum). Severity of Iodine Deficiency Disorders Based on Total Goiter Rate in School-age Children IDD Status TGR Prevalence No IDD / IDD Eliminated < 5 % Mild IDD 5 -19.9 % Moderate IDD 20 - 29.9 % Severe IDD >30 % (Source: 221) Vitamin A Vitamin A, a fat-soluble vitamin, is a group of compounds including retinol, retinaldehyde, and retinoic acid, which is essential for vision, growth, cellular differentiation and proliferation, reproduction and the integrity of the immune system.(5'83, 88) Vitamin A requirement increases 51 during periods of rapid growth and development, lactation, and infections including diarrhea and measles.S2" 80) Preformed vitamin A is present only in foods of animal origin such as liver, fish liver oil, butter, whole milk and egg yolks. Carotenoid precursors of vitamin A, such as ,B- carotene, o- carotene, and cryptoxanthin, are present in carrots and in dark-green, leafy vegetables such as spinach. Prominent clinical signs of vitamin A deficiency (VAD) are ocular and range from night blindness to various signs of xerophthalmia from conjunctival xerosis to comeal ulceration to blindness.(1 43' 82) Other less specific sub-clinical signs include loss of appetite, hyperkeratosis, increased susceptibility to infections, delayed recovery, and metaplasia and keratinization of epithelial cells of the respiratory t-act and other organs. Vitamin A, if ingested in very high doses, causes toxic manifestations, such as headache, vomiting, alopecia, liver damage, spontaneous abortion and birth defects including malformations of the cranium, face, heart, and central nervous system. VAD is commonly assesse(d by ocular clinical signs.(222) Dietary surveys and food balance sheet data can also be used for assessing vitamin A supply in the diet. Serum retinol levels are the commonly measured indicators of vitamin A status, using a cut-off of 0.7 Fmol/l.(88) WHO has set a prevalence >10 % as defining a public health problem. Vitamin D Vitamin D is essential for adequate intestinal absorption of calcium and phosphorus and for regulating bone mineralization.(83) Vitamin D, a fat-soluble vitamin, is a generic term of all steroids including vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol). Dietary sources of vitamin D are animal foods such as liver, butter, fatty fish, and egg yolks. Vitamin D3 is also synthesized in the skin, if exposed to a sufficient amount of sunlight or artificial ultraviolet radiation through photochemical transformation of the precursor, 7- dehydrocholesterol.(SS) The amount of vitamin D synthesized is dependent on the area of skin exposed, age, the wavelength of the ultraviolet light, the intensity of the light which is affected by time, season, and latitude. Dark skin with high melanin content requires a much longer exposure to achieve the same degree of synthesis than lighter skin. Vitamin D deficiency is characterized by inadequate mineralization of the bone.(43' 82) In children, vitamin D deficiency results in rickets, which is deformation of the skeleton including abnormal softness of the skull, enlargement of epiphyses of the long bones and costochondral junction that causes bow legs and knock knees. In the adult, vitamin D deficiency leads to osteomalacia, undermineralizatiori of the bone matrix and in the extreme, bone fractures. Clinical signs of vitamin D deficiency have been associated with serum 25-hydroxyvitamin D (25-OHD) concentrations below 3.0 ng/ml.!88' Zinc Zinc is a constituent of more than 200 metallo-enzymes involved in carbohydrate, lipid and protein metabolism and nucleic acid synthesis and degradation.(83) Zinc is essential for cell replication, tissue repair and growth, stabilization of membranes, hormone production and secretion. Dietary sources of zinc are meat, liver, eggs, seafood especially oysters, milk and dairy 52 products, cereals and legumes. The bioavailablity of zinc in plant products is lower than that in animal products, as phytate and dietary fiber reduce the zinc absorption. The signs of zinc deficiency include loss of appetite, growth retardation, skin changes such as hyperkeratinization, immunological abnormalities, and delayed secondary sexual maturation. (67' 171) Zinc deficiency may be partially responsible for reduced cell-mediated immune function and impaired neurocognitive development in young children.(95) Some studies indicated that zinc deficiency during pregnancy lead to birth defects and low birth weight, whereas other studies failed to show the correlation.(185) Recent studies reported that zinc supplementation enhanced immunity of children against infectious diseases.(23 44) Low zinc concentrations in hair samples collected during childhood reflect a chronic suboptimal zinc status, in case severe protein-energy malnutrition or severe zinc deficiency is absent. Clinical signs of marginal zinc deficiency in childhood such as impaired growth and poor appetite are usually associated with hair zinc concentrations of less than 70 tg/g. (88) Other Micronutrients Micronutrients Deficiency Disorders Micronutrients Deficiency Disorders Iron Anemia, spoon nail Iodine Cretinism, goiter Zinc Growth retardation, hypogonadism Vitamin A Night blindness, xerophtalmia Vitamin D Rickets, osteomalacia Vitamin E Hemolysis, neurologic damage Vitamin K Hemorrhage from deficient prothrombin Vitamin B1 Beriberi, Wemicke-Korsakoff syndrome Vitamin B2 Cheliosis, angular stomatitis, comeal vascularization Niacin Pellagra Vitamin B6 Convulsions in infancy, anemia, neuropathy, seborrhea-like skin lesions Folic acid Pancytopenia, megaloblastic anemia Vitamin B12 Pemicious anemia Vitamin C Scurvy (Source 5, 43, 83, 88) In addition to the previously described micronutrients, such as iron, iodine, vitamin A, vitamin D, zinc, folic acid and vitamin B12, there are essential other vitamins, minerals and trace elements: e.g., vitamin B, (thiamin), vitamin B2 (riboflabin), niacin, vitamin B6 (pyridoxine), vitamin C (L-ascorbic acid), vitamin E, vitamin K, calcium, magnesium, copper and selenium. Specific deficiency disorders of these micronutrients are reported, as shown in the above table, however, negative consequences at subclinical level are likely to affect more people. 53 The levels of disorders vary widely from subclinical levels to small numbers of clinical cases in a limited endemic area to significant numbers of clinical cases in an area wide enough to be recognized as a public health problem. For example, pellagra, the niacin deficiency disorder, was a public health problem in a part of Africa where the diet is mainly composed of maize, whereas it was reported only in a limited area of Egypt.(88, 184) Hereditary Disorders Resembling Nutrition Disorders Various hereditary diseases also cause disorders similar to nutrients deficiency: e.g. hemolytic anemia and congenital hypothyroidism. Hemolytic anemia is caused by hemoglobin and red cell metabolism disorders, such as thalassemias, sickle cell diseases, and glucose-6- phosphate dehydrogenase (G6PD) deficiency.(43) Hereditary diseases such as G6PD deficiency and ,B-thalassemia are endemic in the MENA countries, as shown in the Table below.(2' 140) Neonatal screening for congenital hypothyroidism shows the incidences of 0.33 per 1000) births in Egypt, 0.71 per 1000 births in Iran, 0.37 per 1000 birth in Saudi Arabia, 0.45 per 1000 birth in Oman, and 0.40 per 1000 births in WBG.(21'59 218) These incidences are higher than the incidences in Europe, which are between 0.2 and 0.28 per 1000 births. While the most common cause of congenital hypothyroidisrn in Europe is non-genetic hypoplastic or ectopic thyroid, significant numbers of cases in MElNA countries are caused by genetic dyshormonogenesis. Consanguinity is an important factor in autosomal recessive diseases, since related individuals are much more likely to share the same mutant allele. Only homozygotes have symptoms of thalassemia major and sickle cell anemia.(43) Prevalence of consanguineous marriage in MENA countries is estimated at 20-50 percent.(21) G6PD deficiency, although it is inherited as X-linked recessive, females may account for up to 10 percent in the region. Genetic counseling should be provided to t:he high risk family members to prevent common hereditary diseases, while paying attention to the cultural sensitivity of the issue. 54 Frequency of Hereditarv Disorders Causing Anemia Total Hemoglobin Dis rders Sickle Cell G6PD Consanguineous Carniers Newboms Disease Deficiency Marriages HbS | HbC | pthalassemia Total Carriers Affected Affected | Carriers (%) (%) (%) (%) (%) (per year) (per year)l (per 1000) (%) (%) (%) Bahrain 39 10 3 13 2,000 126 9 2.1 11.2 21-26 Egypt 28 3 3 58,000 808 0 4-26 Iran 18-73 1 1-12 4 95,000 1,896 1 18-23 Iraq 58 0-20 3 6 50,000 1,501 2 1.7 16.0 9-13 Jordan 50 1 3 4 6,000 97 1 5-10 Kuwait 54 + + 4 2,000 47 1 20-22 U Lebanon 17-30 1 3 4 3,000 70 1 0.3 3 Libya 2 1 1-2 4 8,000 166 1 3 Morocco 2 2 3 7 59,000 1,824 2 Oman 5 1 6 4,000 128 2 0.4 6.1 12-27 Qatar 3 3 6 1,000 16 2 Saudi Arabia 54 0-25 + 2 10 59,000 2,845 5 1.4 13.1 3-22 Syria 1 5 6 35,000 1,043 2 Tunisia 2 + 3 6 14,000 390 2 2-7 United Arab 54 2 3 5 2,000 46 1 Emirates I West Bank and 1 3 4 3,000 54 1 Gaza Yemen 4 2 6 38,000 1,571 2 (Source: 21) Annex 2. Possible Nutrition Initerventions and Costs Food Energy Security Emergency assistance In case of a large-scale famine, drought and other natural disasters, wars and conflicts, an emergency relief operation including food distribution is required. However, in many cases, the government of an affected country can not make necessary interventions, or an effective government does not exist in the country. Thus, international assistance plays the major role to secure foods for affected people. United Nations (UN) agencies such as World Food Programnine (WFP), United Nations Children's Fund (UNICEF), and United Nations High Commissioner for Refugees (UNHCR), as well as bilateral donor agencies and non-governmental organizations (NGOs), provide emergency relief including food distribution. For example, the below table shows WFP's emergency relief operations in MENA region in 1995. Emergency assistance can not be a fundamental solution for securing food, therefore, sustainable developmental assistance must be followed the emergency phase assistance. World Food Program Relief Operations (Emergency and Protracted) Approved in 1995 in MENA Reqion Country Operation Beneficiaries Total Food Total WFP Cost (tons) (US$) West Rehabilitation of post-conflict victims in the 35,750 1,835 901,591 Bank and Gaza Strip and Jericho Gaza Iraq Food assistance for destitute and 2,151,000 184,232 86,178,874 vulnerable persons Algeria Food assistance to Western Saharan 80,000 10,220 4,733,947 refugees (Source: 219) Direct transfer Public assistance is a tool to secure food and nutrition, particularly dietary energy, for the vulnerable population in the country. Food stamps or ration books are distributed to the eligible families and individuals to obtain foods or purchase at subsidized prices. It is an effective method in the higher income countries where the eligible population is rather limited and legal and administrative structures are established. However, it is often difficult to define and monitor the eligibility. Managing the program is rather complicated and it is often difficult for the governments of developing countries to run the programs efficiently and effectively. In addition, it is not uncommon that the poor sell the subsidized food to buy other goods. Food supplement Supplement foods, as well as micronutrient supplements, can be distributed to the target population, such as pregnant and lactating women, small children, and school age children in developing countries. Supplement foods such as vegetable oil or soybean milk are distributed to the pregnant women who visit clinics that encourage them to receive antenatal check-ups. It would be a better option to give lactating mothers food supplements than to give infants breast milk substitutes. School feeding schemes also encourage the parents to send their children to 56 schools: e.g., a WFP program in Yemen provides girls attending schools with supplement foods. However, the nutrition impacts of school feeding schemes are rather limited, as the schemes cover only a part of nutrition needs of the children. Food subsidy Food subsidy schemes aim to control the prices of staple foods to secure the availability of foods and alleviate protein energy malnutrition. Some countries universally subsidize foods such as wheat, bread, sugar, vegetable oil, and milk; other countries use self-targeted mechanisms by subsidizing only food items that are mainly consumed by the poor. Although food subsidy schemes are usually successful for securing dietary energy, these schemes are often untargeted, benefiting the better off population rather than the poor, become a heavy burden of the state budget, and discourage efficient and increased agricultural production by keeping prices low. Although most MENA countries have food subsidy schemes, many of them started to review the schemes so that it would target the needy population and be financially sustainable in the framework of structural reform. However, food subsidy issues are often too politically sensitive for radical reform.1 Micronutrients Fortification Generally consumed foodstuff can be fortified or enriched with various micronutrients. For example, salt can be fortified with iodine and iron; cereals with iron, vitamin A and B1; milk with vitamin A and D; and sugar, margarine and edible oil with vitamin A.5'83 124 232, 235, 244) Fortification programs are well established in industrialized countries, e.g., Switzerland and the United States of America (US) introduced salt iodization programs in the 1920s; and fortified milk is a major dietary source of vitamin D in the US. The unit cost of micronutrient fortification programs is usually much less than that of supplementation programs. For instance, estimated annual per capita cost of salt iodization is US$ 0. 1, while that of iodine supplementation is US$ 0.5; estimated annual per capita cost of iron fortification is US$ 0.2, while that of iron supplement to pregnant women is US$ 2.(1o8, 244) Fortification is a sustainable and fundamental solution, if the fortification programs are truly institutionalized as seen in industrialized countries. Salt iodization programs are ongoing in several MENA countries, such as Iran, Syria, and Yemen. Iran has established 22 salt iodization plants and 76 percent households in rural areas and 87 percent households in urban areas consumed iodized salt by 1995. In Syria, the single salt producer, Ministry of Industry, has been iodizing salt since 1992, however, it is estimated that only 36 percent of households are consuming iodized salt.(221) In Yemen, a universal salt iodization program started in 1995, and about 70 percent of salt consumed in urban areas is iodized by the end of 1998.(fieldinteews) Several MENA countries are now planning to start iron fortification of wheat flour. Quality control and compliance are most important to succeed fortification programs. The required conditions for successful fortification programs are: sufficient technical and institutional capacity to implement and monitor the programs; quality control systems for monitoring concentrations and quality of fortified nutrients both at the plant and consumer levels; intersectoral coordination among health, industry and transportation for production and distribution; existence of only limited number of producers for ensuring the coverage of fortified Food subsidy issues are analyzed in the regional study on consumer food subsidies.(258) 57 items; restriction of leakage of unfortified items; appropriate price setting and incentive systemns for retailers and consumers; consumer preference that accept fortified food.('6 124,178, 232) In addition, reliance on a single fortification approach to control micronutrient deficiencies is often a fragile strategy.(5) Therefore, forti:fying a variety of different products rather than a single widely consumed food may be a better strategy in future. Some countries also legally regulate food fortification. The below table shows some examples of legislation in various countries. Legislation PertainingC to Salt lodization Countrv Status Level of Iodine (ppm) | Compounds Used Iran Mandatory 40 Lebanon Mandatory 10-200 KIO3/KA Morocco 8010 K103 Bolivia Mandatory 50 KIOAKI Honduras Mandatory >67 K103 Pakistan Legislation in process 60-70 K103 Nigeria Mandatory 50, 30 KI Hungary Voluntary 10 KI Switzerland Mandatory 15 KI France Voluntary 10-15 Nal United States Voluntary 100 KI Legislation Pertaining to Wheat Flour Fortification Country Status Legislation Consump tion Lebanon Prohibited Widely Morocco No legislation Widely Honduras Voluntary Vitamin B, = 4.4; Vitamin B2 = 2.6; Niacin = Not widely 35.2; Iron = 28.7; Calcium = 1,100 (mg/kg) Malawi Voluntary INutrition labeling requirement Hungary Voluntary One serving must contain 1/3 of RDA Norway Prohibited Switzerland Voluntary Vitamin B1 = 4.4; Vitamin B2 = 2.0; Niacin = 50; Iron = 29 (mg/kg) New Zealand Prohibited ILegislation under review _ (Source: 135) Supplementation Micronutrients can be supplemented directly to the target population, such as pregnant and lactating women and small children. Supplementation programs are usually integrated with other public health interventions, such as maternal and child health care or school health programs. Pregnant women in many developing countries receive iron and folic acid supplements during their antenatal visits. To avoid irreversible disorders of fetus and infants, pregnant women in the IDD endemic areas should receive oral or intramuscular administration of iodized oil as an interim measure before salt is fully iodized.(5"188 232) Vitamin A supplementation to children is integrated with regular health care visits and immunization programs including the National 58 Immunization Day.(5) It is recommended that lactating women in high VAD areas receive a high dose vitamin A supplement within eight weeks of delivery. Pregnant women should receive a low dose supplement but should avoid the high dose supplement, which may cause toxic disorders to the fetus. School health programs include iron, iodine, and vitamin A supplementation to school age children. Supplementation programs are more targeted to the population in need than to universal fortification, although it is unlikely that all the affected population is covered. The unit costs of supplementation programs are usually much higher than that of fortification programs. For instance, estimated annual per capita cost of iodine supplementation is US$ 0.5, while that of salt iodization is US$ 0. 1; estimated annual per capita cost of iron supplement to pregnant women is US$ 2, while that of iron fortification is US$ 0.2.(108 244) The initial costs of supplementation programs are lower, as they simply utilize the existing public health service channels. Supplementation programs integrated to the public health services are efficient and sustainable, however, compliance varies and is hardly monitored, unless supplements are injected or orally administered at the presence of health professionals: e.g., women may not take iron supplement because of the discomfort of side effects and misconceptions.(35' 150) When micronutrient deficiency problems are serious and urgent, specific interventions such as vitamin A supplementation or intramuscular iodine oil injection campaigns should be considered. If people are aware of their needs for micronutrient supplements, as is often the case in industrialized countries, they are willing to buy supplement tablets. Social marketing of micronutrient supplements in combination with nutrition education programs could be tried in developing countries. Public Health An important factor of child malnutrition is repeated childhood diseases such as diarrhea and respiratory infection. These diseases decrease intake and absorption of nutrients and increase consumption of dietary energy and other nutrients such as vitamin A.(5' 80) Parasite infection including hookworm and malaria causes anemia. Therefore, public health interventions to prevent and treat childhood diseases, including immunization programs, control of diarrhetic diseases, malaria control programs, and deworming programs, are expected to improve nutrition status. Water and environment sanitation programs are expected to improve nutrition status, since improving access to clean water and management of sewage and solid waste reduces risks of communicable diseases, such as diarrhea. Family planning programs decrease fertility and increase the intervals between pregnancies, therefore, contribute to reduce undernutrition and anemia among women and children. Public health interventions used to be specific national programs, such as national population projects or national diarrhea control programs. Recently, these interventions are taking more integrated approach. For example, Integrated Management of Childhood Illness (IMCI)(182) includes case management of diarrhea, respiratory infection, malaria, and nutrition monitoring; and school health programs include growth monitoring, deworming, and micronutrient supplementation. 59 Communication for Behavior Change (CBC) Delivering proper nutrition messages and educating the general public, particularly child care providers, is one of the most important nutrition interventions. Many nutrition disorders are caused by incorrect child caring practices, food habits, misallocation of food within a family, and lifestyle choices, but not by absolute shortage of nutritious food. People, especially mothers, need to be educated regarding breastfeeding and weaning practices, food items rich in micronutrients, combination and preparation of food to maximize absorption of nutrients, obesity as a risk factor of more serious diseases and healthy diet to avoid obesity. Communication for behavior change (CBC) programs should be carefully designed, monitored and evaluated to achieve maximum impacts. Nutrition education can be provided interpersonally at schools, clinics, and communities. A mass media campaign is another strong measure to approach wider audience. Many developing countries may require international technical assistance, as skilled cormmunication professionals are in shortage and institutional capacity to develop and continue the programs is weak. In addition, an incentive system needs to be designed to motivate health professionals to promote CBC programs. Social and Economic Development Since undernutrition is strongly related to the levels of poverty, poverty reduction through social and economic development is one of the essential factors to improve nutritional status. In the longer term, countries need to secure food supply through developing the agricultural sector, trade and transportation systems, and sound public financing policies. Trade and tariff policies, as well as food subsidy schemes, largely affect agricultural production and food pricing. Food distribution systems need to be improved for more equitable allocation of available food within a country. Since there are significant urban rural gaps in many developing countries, comprehensive rural sector development is required to improve nutrition in rural areas. Examples of Program Costs and Impacts in Other Countries The following are examples of nutrition intervention programs, their costs and impacts: * Food supplementation targeted to children and mothers in Latin American countries * Micronutrients fortification in various countries * Iron supplementation to female factory workers in Indonesia * Comprehensive nutrition and health interventions targeted to children in India Food supplementation Food supplementation programs targeted to children, pregnant and lactating women are widely implemented in many countries in various scales. The ration and distribution methods vary among programs and countries: the annual costs per beneficiary range from around US$4 to over US$60 in the below examples of Latin American countries. Most programs aim to provide around 300-350 kcal per child. 60 Food Supplementation to Children and Mothers in Latin America Beneficiares Food rations Costs (1990, US$) Bolivia 78,000 infants and preschool 250 ml of Chicolac (wheat flour, $1,506.920 (1989) urban children (8 months to 5 years) powdered milk and vegetable $19.32 beneficiary areas selected by family income, oil); a piece of com bread. Beneficiaries fee: $0.36 location and nutritional status per child/month (weighed once a year).. Bolivia 75,000 infants and preschool Skim milk, butter oil and wheat $790,523. (1989) rural areas children (8 months to 5 years) flour (donated). Meals are $10.54 / beneficiary Meals are distributed in a prepared for 260 days a year Beneficiaries contribute church or households. providing 350 kcal and 16 g to cover transportaton, protein per child. energy costs, and the .packing of food. Brazil About 2 million children under 2 kg /month (4 kg for adult) of $123 million 3 years of age, and pregnant formulated foods and powdered $62.81 I beneficiary. and lactating women, in low- milk. Significant income households. improvement observed. 6 million children under 3 Normally 1 kg each of powdered $104 million (1989) years, and pregnant and milk, sugar, rice, beans, $16.78 I beneficiary. lactating women, in low- commeal and manioc flour per Results not significant. income households month. Ecuador 14,888 children under 5 years, 2-3 kg of leche-avana for $4,122,540(1989) 23,107 malnourished children, children (237-354 kcal and 13.7- ($3,199,211 donated and 28,050 pregnant and 20.5 g protein) foods; $27,200 lactating women, for a total of 1 kg of leche-avana and 5 kg of transportation; $10,600 66,045 in the first trimester of rice for women (1,936 kcal and storage; 1990. 50.8 g protein) per month. $885,529 personnel) $62.42 I beneficiary. Guatemala 197,148 children under 7 1.38 kg each of com and $791,944 years and pregnant and soybean, wheat, and rice, and $4.01 / beneficiary lactating women from low- 0.46 kg of oil are distributed at Similar program which income groups. health posts. (639 kcal and 16g provides 894 kcal and Nutrition education, protein/day) 26.2 g protein per day immunization and other health and costs $27.5 per services are also provided. beneficiary just for food costs. Peru 234,451 infants and preschool Monthly ration for an entire $5,077,181 children in day care centers, family is 6 kg bulgur, 3 kg corn ($4,494,279 for food and 84,317 households (about and soybean, 1.5 kg oil and 2 kg $136,000 transportation 421,600 persons) at high dry peas (1,756 kcal and 56.4 g $446,902 personnel) risks. Program also provides protein/day, ration for children $7.74/beneficiary nutrition education and growth provides 359 kcal, 9.3 g monitoring protein/day). (Source: 152) 61 Micronutrients fortification The popular vehicles for micronutrient fortification are salt, sugar, and cereals. The annual costs for the fortification per person range from around US$ 0.01 to 0.3, at the highest around $1.00: e.g., the iron fortification of biscuits in Chile. Costs of Micronutrient Fortification Programs Count Food Vehicle Fortificant [ Cost (US$/person/yearL Year Several Salt Iodine (50 - 80 ppm) 0.02 - 0.06 1992 India Salt Iodine (50 ppm) + Iron (1,000 ppm) 0.12-0.18 1991 Guatemala Sugar Vitamin A (15,000 lU/kg) 0.29 1994 Guatemala Sugar Iron (1.3 %) 0.1 1981 Egypt Wheat flour Iron (25 - 35 ppm) 0.015 1980 Venezuela Corn flour / Iron (20 - 50 mg/kg) 0.07 - 0.08 1994 Wheat flour Vitamin A (39,000 lU/kg) _ (Source: 121, 237, 244) Estimated costs for the production of iodized salt in developing countries are as below. The average annual cost is US$0.037 per person, which adds 1.2 percent to the retail price of salt. Estimated Production Costs of Iodized Salt in Developing Countries Average Average per person |______________________________ tRange (US$/ton) (US$/ton) per year (US$/5 kg) Cost components Iodine (40-100 ppm) 0.50- 1.30 0.90 0.0045 Processing 2.35 - 5.50 4.00 0.0200 Extra packing material (if required) 0 - 4.00 Administrative overhead 0.60 - 1.50 1.00 0.0050 Amortization 0.50 - 2.50 1.50 0.0075 Total iodization cost 3.95 - 14.80 7.40 0.0370 Retail price of salt 250 - 1,000 625.00 3.12 lodization cost as % of retail price 1.0 - 1.5 % 1.2 % 1.2 % (Source: 121) The table below shows estimates of costs and benefits of iron fortification in Lebanon. The calculation assumes that; annual salary is $5000; a person works for 30 years; anemia reduces productivity by 20 percent; and 50 percent of anemia prevalence. Fortified bread could supply iron about 60 percent of RDA. The estimation shows a very high benefit-cost ratio of 7,500 to 1, regarding the lifetime income. Costs and Benefits of Iron Fortification; Estimation for Lebanon (US$) Capital costs Feeder and installation ($6,000 x 11 mills x 2 sets) 132,000 Inspection 90,00) Annual operation costs Fortificant costs (300,000 ton bread) 90,000 Total fortification costs (300,000 ton bread) 312,000 Annual fortification cost per person (110 kg bread/person/year) 0.03 Fortification cost per person per lifetime 2 Anemia cost per person per lifetime 15,000 Benefit - cost ratio 7,500: 1 (Source: 237) 62 Micronutrients supplementation The Indonesian government launched iron supplementation programs in domestic companies in 1996 to reduce the level of anemia from 30 percent to 20 percent by 1998. Iron supplements (one tablet daily for 90 days or one tablet weekly for 16 weeks) were distributed to female factory workers, mainly in reproductive ages, in pay packets, in cafeterias, or in company clinics. In one of the companies, 35 percent of anemia cases were prevented at the cost of only US$3.47 per worker, or less than US$10 per anemia case prevented. Costs and Benefits of Iron Supplementation Programs in Sample Companies in Indonesia Province East Kalimantan | Central Jawa Jambi Company Sumalindo Djarum Kudus Nasan Pnima Number of workers receiving supplements 637 1,260 100 Compliance 92 % 83 % 95 % Cost breakdown (US$) Promotion Meetings, transportation 50.15 31.34 220.23 Personnel 22.57 112.83 78.56 Monitonng and Communication/Education Pamphlets 242.37 0.00 123.28 Personnel and visits 268.28 133.72 251.15 Reporting Meetings, report supplies 109.90 1037.61 36.77 Personnel 24.66 112.41 78.14 Administration support 4.60 9.19 3.76 Blood Tests 675.30 1,752.19 321.35 Iron supplement distribution Iron tablets 239.45 572.09 206.85 Opportunity costs for workers 199.75 3,349.77 235.27 Personnel 22.98 262.43 156.71 Total costs by company (US$) 1,856.66 7,376.09 1,711.66 Running costs of province (US$) 356.46 1,200.59 179.69 Total costs (US$) 2,213.12 8,576.68 1,891.35 Costs per worker (US$) 3.47 6.81 1,8.91 No of cases of anemia prevented 223 (35 %) 498 (39 %) 19 (19 %) Cost for case of anemia prevented (US$) 9.90 17.22 99.54 Note: US$1.00 = Indonesia RP 2393.0 (January 1997) (Source: 211, 213) The iron supplementation also improves productivity by raising workers' capacity. It was reported that anemic women produce an average 5.3 percent less in factory work and perform 6.5 hours less housework per week.(73) Another example of iron supplementation program for the rubber plantation workers in Indonesia in 1974 showed a dramatic increase in productivity. After provision of iron pills for 60 days (at a cost of $0.13/worker/day), productivity increased by approximately 15 percent for tappers and 25 percent for weeders. The benefit-cost ratio in terms of latex production could be as high as 260: 1. Comprehensive child nutrition intervention The Second Tamil Nadu Nutrition Project funded by the World Bank aimed to reduce severe malnutrition among preschool children and infant mortality in the state of Tamil Nadu, 63 India. The project targeted more than 5 million children under 72 months of age and 2 million pregnant and lactating women in disadvantaged population groups. Estimated Costs of the Second Tamil Nadu Nutrition Project (1991-1998) Cost (US$ million) Project Component A. Service delivery Nutrition and health education; referral services; 1. Nutrition 91.09 therapeutic food supplementation; equipment and drugs 2. Health 30.12 for maternal and child health; training for health/nutrition 3. Training 6.61 workers. B. Communications 3.53 Demand stimulation; child feeding and care practices; community involvement. C. Project management Project coordination office; monitoring and evaluation 1. Project coordination office 4.99 systems, a new institution for nutrition communication and 2. Communication/Training 1.07 training activities, center 3. Monitoring and evaluation 1.38 Total base cost 138.71 Contingencies 0.38 Total project cost 139.09 (Source: 241) Nutrition Components in the Current World Bank Projects and Nutrition Sector Works in MENA Region Current Lending Proiects Count | FY Proect ] Nutrition Components Yemen 1999 Child Development Nutrition management including micronutrient supplementation and growth monitoring for under five children through community-based activities Egypt 1998 Health Sector Vitamin A and iron supplementation, growth monitoring for under five children Morocco 1996 Social Priority l: Basic Health Matemal and child health components including breast feeding and iron supplementation West Bank 1995 Education and Health School health and nutrition education program and Gaza Rehabilitation Non-Lending Sector Works Country FY Title Regional 1998 Nutrition Issues in the Middle East and North Africa Region Regional 1998 Consumer Food Subsidy Tunisia 1996 From Universal Food Subsidies to a Self-Targeted Program: A Case Study in Tunisian Reform (prepared by the Agricultural Operations Division, Country Department I, MENA. Morocco 1992 Kingdom of Morocco: Nutrition and National Development Issues and Options 64 Annex 3: Overview of Food and Health Issues in MENA Countries Food Supply Most countries in the Middle East and North Africa (MENA) region are lower middle income countries.' However, the region includes high income countries such as oil producing Gulf states and one of the lowest income countries, Yemen. The climate of the region is generally harsh with little rainfall. Most of the land in the region are arid deserts, and less than 10 percent of the land is arable.("50) About 3040 percent of the arable land is irrigated. The agricultural sector consumes about 80 percent of the scarce water resources in the region, and water management and drainage systems are not yet sufficient. Food crops produced in each country in the region are diverse based on available resources and production potentials. Iran, Egypt, Morocco and Saudi Arabia produce 70-80 percent of cereals. Iran and Egypt are the only major rice producers. Sugar, vegetables, and fruits are also produced in the region: Lebanon, Syria, Jordan, and Egypt export fruits and vegetables. Livestock production is practiced under nomadic conditions in the semi-arid areas, which makes it difficult to increase production without overgrazing. In spite of the high potential for fishery production, 80-90 percent of the fish are caught by small scale fishernen. Foreign fleets operating in the Arab waters take about half of the total fish catch. Morocco, Tunisia, and Saudi Arabia managed to develop the fishery industry to the level of exporting fish and fish products. Iran has a large fishing area- including the Caspian- and exports $3040 million worth of caviar annually. Although MENA countries are increasing their food production, self-sufficiency ratios are declining. For example, the Gulf states, notably Saudi Arabia, managed to increase wheat production from 330,000 ton deficit in 1970 to 1,500,000 ton surplus by 1990. However, wheat self-sufficiency ratio is expected to decline again to about 60 percent by 2000.(150) This is mainly due to the rapid natural population growth, urbanization and intemational migration. Total wheat import to the MENA countries has increased about five times, meat about nine times, and sugar about three times in the last 20 years. Consumer demands are also changing, especially in the high income Gulf states; the Gulf states consume one third of all livestock products imported to the region. Most MENA countries subsidize staple foods, such as wheat, bread, sugar, vegetable oil, and milk.(8' 11, 74, 150, 190, 243, 246, 251 258) Food subsidy policy aims to ensure availability of food and nutrition, however, it tends to become a heavy burden on the state budget, and does not necessarily target or benefit the poor. Therefore, MENA countries are reviewing their food policies and attempting to restructure their subsidy programs to be more sustainable and targeted.2 For example, Tunisian food subsidy policy has changed from universal subsidy to self-targeted program that subsidizes food items consumed mainly by the poor, such as breads made from high extraction rate flour.('90) The definitions of income groups are: low-income as GNP/c $765 or less; lower-middle-income as $766-$3,035; upper-middle-income as $3,036-$9,385; and high-income as $9,386 or more.(254) 2 Food subsidy issues are analyzed in the World Bank regional study on consumer food subsidies.(258) 65 The extensive food subsidy schemes in Egypt have successfully increased food availability per capita to levels comparable to industrialized countries and levels higher than those of other countries in the region. By 1980, the subsidy schemes included 20 foods and benefited 90 percent of population, but it accounted for 19.5 percent of total govemment expenditure by 1982. In the late 1 980s and early 1 990s, the prices of subsidized foods had increased and the number of subsidized foodstuff had decreased. In 1995, the food subsidy scheme included only bread, wheat flour, sugar and edible oil, and accounted for about five percent of total government expenditure.("1) Health and Population Health and other social indicators vary among the MENA countries, depending on the level of economic and social development of each country."253) Infant mortality rate (IMR), for example, is 8 in Israel and 11 in Kuwait, while it is estimated at 93 in Yemen and 161 in Iraq. Maternal Mortality Ratio (MMR) ranges from three in Israel to 1,000 in Yemen, and safe water access ranges 45 percent of population in Iraq to 100 percent of population in Bahrain and Qatar. Diarrhea and acute respiratory infection are still major causes of death in the poor areas such as Yemen and rural Egypt and Morocco, while 25 to 45 percent of adult deaths in the Gulf states, Jordan and West Bank and Gaza (WBG) are caused by cardiovascular diseases. (150, 247, 248, 249) The epidemiological transition is underway in most MENA countries; non-communicable diseases are increasing, whereas infectious diseases still remain major causes of morbidity and mortality among less privileged people. The epidemiological transition has financial implications on the health care system in each country, since treatment of non-communicable diseases are much more costly than public health interventions to communicable diseases. In addition, unregulated introduction of modern medical technology increases health care cost rapidly. Now most of MENA countries are facing the pressure to reform their health care systems to be more efficient, effective, equitable, and sustainable. Most social indicators in MVENA countries are comparable to the countries of similar level of economic development in other regions, however, population growth rate and total fertility rate (TFR) in MENA countries are unusually high. TFR in the middle income countries in other regions are, for example, 1.5 in Croatia, 2.4 in Brazil, and 2.7 in Indonesia. On the other hand, TFR is 6.2 in Saudi Arabia and 7.0 in Oman, which are similar to the poorest countries such as Mozambique and Rwanda.(254) Although countries such as Tunisia and Egypt have implemented successful family planning programs, population in the region is expected to double in 30 years, even if annual population growth declines to 2.3 percent. In addition to the natural growth, increased migration from rural to urban areas and from low and lower-middle income countries in and outside the region to high income Gulf states have significant social and economic impacts. The influx of foreign workers to the Gulf states resulted in five to seven percent annual population growth in the 1970s. The oil-producing countries attract workers from Egypt, Jordan, Syria, WBG, Yemen, Bangladesh, India, Indonesia, Korea, Pakistan, the Philippines, etc. Jordan exports workers to the Gulf states, while imports workers from Egypt. Local food habits have been also influenced by massive migration of foreign workers.(150) The high fertility in the region is likely linked to the relatively low educational level of women. The adult literacy rates of females in over half of MENA countries are less than 60 percent and much lower than males. The secondary school enrollment rates of females are less 66 than 60 percent in around half of the countries. Women's education level is one of the most influential factors in reducing fertility and improving children's health and nutrition.(248) Most people in the region speak Arabic (except fran- and Israel) and are Islamic (except Israel). Local tradition, which is not necessarily related to religion, often has implications for health, nutrition, education, and other social sectors. Women's status is mainly determined by local cultures and tradition, which vary along with economic, social and political situations. United Nations Development Programme (UNDP) reported that women's participation in key economic and political areas and decision making remained low in most MENA countries regardless their income levels.(191) 67 Basic Indicators in MENA Countries GNP/c Area Arable Land Total Population Adult Literacy Rate Secondary School Safe Water per capita Population Annual Enrollment Access (thousand (1991) Growth Rate Male Female Male Female (us $) sq. km) (million) ( ( (%) (%) Low Income Yemen 260 | 5281 1,714 15.7 | 3.7 ] 53 26 1 37 9 Lower-middle Income Egypt 790 1.001 1,761 63.3 T 1.8 64 9 82 71 84 Iraq - 435 6,051 20.6 2.1 71 45 53 34 45 Morocco 1,110 447 4,264 27.0 2.0 57 31 43 32 59 Syria 1,120 185 5,680 14.6 2.9 86 56 50 41 87 Jordan 1,510 89 1,358 5.6 4.2 93 79 52 54 89 co Algeria 1,600 2,382 3,202 28.8 2.0 74 49 66 58 - Iran 1,780 1,648 4,438 70.0 2.5 78 59 76 62 90 Tunisia 1,820 164 6,361 9.2 1.6 79 55 58 53 86 WBG 1,870 6 - 2.3 3.7 84 - - - Lebanon 2,660 10 1,685 3.1 1.9 95 90 75 83 - Upper-middle Income Oman 4,820 212 806 2.3 4.7 71 46 67 61 56 Libya - 1,760 5,334 5.6 3.6 88 63 95 95 90 Saudi Arabia 7,040 2,150 2,441 18.8 3.4 72 50 57 47 93 Bahrain 7,840 1 80 0.6 3.6 85 85 97 100 100 High Income Qatar 11,600 11 [ 100 0.6 | 5.3 | 79 79 82 | 82 100 Israel 15,920 211 - 5.7 2.6 95 89 83 89 99 Kuwait 17,390 181 291 1.7 1 2.7 82 75 65 64 - UAE 17,400 84 1 127 1 2.5 1 3.1 1 79 80 88 97 98 Life Expectancy at Birth IMR U5MR MMR TFR Stunting Wasting Underweight Low Birth [Anemia | TGR Male Female (per 1000 (per 1000 (per 100000 (Under 5) (Under 5) (Under 5) Weight (Women) (y_____ ears) (years) live birth) live birth) live births) (%) (%) (%) (%) (%) Low Income Yemen 56 571 93 145 1,000 71 39 13 39 19 5 - 361 32 Lower-middle Income Egypt 60 63 57 78 170 4 30 5 12 10 17 - 79 5 Iraq 60 62 161 145 310 6 28 9 25 21 18 7 Morocco 64 68 64 74 372 3 24 2 9 9 20 - 40 20 Syria 66 71 28 34 179 6 27 9 13 1 1 30 - 52 73 Jordan 68 72 21 25 45 5 16 2 9 7 4 - 46 - Algeria 68 71 34 39 140 4 18 9 13 9 19 - 42 9 Iran 68 69 33 37 120 5 19 7 16 9 20- 50 30 Tunisia 68 70 28 35 138 3 23 4 9 8 41 4 West Bank 70 74 28 - 70 6 14 6 15 - 23 - 56 - and Gaza Lebanon 68 71 33 40 - 3 12 3 3 10 27 - 49 15 Upper-middle Income Oman 68 73 15 18 1 901 7 23 13 23 8 1 15- 54 10 Libya 63 67 50 61 220 1 - 15 31 5 51 6__ 6 SaudiArabia 69 71 25 30 18 I 6 14 3 I 14 _ 7 5_-57_ Bahrain 71 75 18 22 60 - 10 6 7 _ 6__ 40 - 49 High Income Qatar 70 75 17 21 - - 8 2 6 5 30 Israel 75 79 8 9 7 3 _ _ _ _ 7 1 18- 61 _ Kuwait 74 79 13 14 . 18 3 12 3 - 6 7 31 - 42 United Arab 74 76 15 18 20 4 - - - 6 22 - 62 - Em irates I I lIl_l_l_l_l_l_l_l_l (Source: 55,148,150,151, 206, 207, 216, 220, 221, 226, 228, 247, 248, 249, 254, 255) Annex 4: Supplementary Data Analyses Low Birth Weight Figure 1 shows the strong positive correlation (p 25 a- g 20 ~15 10 5 % 0 0 20 40 60 80 100 120 Female Secondary School Enrollment (Source: 207,226, 228, 255 It is generally accepted that a mother's education contribute to reduce diarrhea in children, however, the pathways by which education brings this effect has remained largely speculative. (58 71 other social services, also affect nutrition and nutritional disorders. These factors are likely to carry different weights in determining the pattern of nutritional disorders. For example, a study in Jamaica(97) indicated that the increased child height correlated to the increased education of women in a household and the decreased distance to a private physician, marginally correlated to household income, but did not correlate to the father's education. ! iFure 4: Stunting Prevalence and Male Secondary School Enrollment in MENA Countries 45 40 - 35 C 30- > 25 - ~20- = 15 -,, 10 O 5 0 20 40% 0 20 40 60 80 100 120 Male Secondary School Enrollment (Source: 207, 226, 228) Figure 5: Underweight Prevalence and Female Secondary School Enrollment in MENA Countries 1/0 45 40 A 35 . 30 ~25A 2- -- A 3" 20 15 A Ak A~ A- 10 A A lo-~~~~~~~~~~~~~~l AA - s- ~~A 4s As A - 0 - I 0 20 40 60 80 100 120 Female Secondary School Enrollrent (Source: 207, 226, 228, 255) 72 Figure 6: Wasting Prevalence and Female Seconda!y School Enrollment in MENA Countries 14 - 12 - 0 10 - C > 8- E UE co 6- 4- - 0~ 0 20 40 60 80 100 120 Female Secondary School Enrollment (Source: 207, 226, 228, 255) Figure 7: Low Birth Weight and Female Secondary School Enrollment in MENA Countries 25 - 20 - *o 15 ' 10- O-- 0 o 0 20 40 60 80 100 120 Female Secondary School Enrollment (Source 55, 27, 2, 255) 73 Figure 8: Breastfeeding and Female Secondary School Enrollment in MENA Countries 60 50 - *E 40 MmO E30 ,, 20 - 10 - 0 , 0 10 20 31) 40 50 60 70 80 % Female Secondary School Enrollment (Sorca: 207, 2t0, 255) Nutrition and Economic Development Childhood malnutrition is sirongly linked to poverty, because poor people often can not afford to take adequate food and nutrition.(108' 242) Availability of food in general can be estimated by the amounts of dietary energy consumption. However, dietary energy consumption averages can be misleading about the level of poverty that exists, since food can be secured through public social welfare programs such as food subsidies and international assistance. Similarly, a national average dietary energy consumption rate gives no indication of how many people are underprivileged or the severity of their deprivation. Even if dietary energy is secured, the poor usually cannot afford a sufficient variety of foodstuffs, especially the more expensive items such as meats, seafood and fruits; instead they tend to rely on cereals as major sources of dietary energy and protein. Decreased household income often leads to less variety, even when total dietary energy intake remains the same. Consumption of animal-origin foods is strongly linked to higher income, which in turn is linked to education, parental competency,, housing and health conditions. Positive relationships between consumption of animal origin foods and indicators of health and growth are commonly observed in developing countries.(47) Animal origin foods not only provide nutrients including protein, iron, zinc, vitamin A and D, but also increase bioavailability of iron and zinc by decreasing intakes of plant origin inhibitors such as phytate. The poor cannot afford diversified diets so they are more susceptible to micronutrient deficiency, which in turn retards child growth and disease susceptibility. Figure 9 shows that the average dietary energy consumption and gross national products per capita (GNP/c) in MENA countries do not have a significant correlation. Figure 10 shows that the average protein consumption in MENA countries has a significant positive correlation with GNP/c. The average fat consumption has a positive, but less significant, correlation with GNP/c (Figure 11). The results reilect that most MENA countries secure foods in terms of dietary energy, and that people in the higher income countries in MENA region tend to consume increased amount of animal origin protein daily.(149 150) 74 Figure 9: Dietary Enerav Consumption and GNP/c in MENA Countries kcallday/capita 2 3,400 Oo O OO 0 _ 3,000 r O O us w 2,60 e 2,200 O 0 5000 10000 15000 200\0$ GNPCc (Source: 150, 255) Figure 10: Protein ConsumPtiOn and GNPlc in MENA Copuntries g/daylcapita 100 O 90- ~ 3,000 Average 80 - Protein/ Consumption 70 - 60- 0 5000 10000 15000 2000 Us$ GNPlc (Soure. 150, 255) 75 Figure 11: Fat Consiumption and GNP/c in MENA Copuntries glday/capita O 100 O / / 8 50 Average Fat Consumption O 0 5000 10000 15000 20000 US$ GNPlc {Source: 150, 255) Although poverty is linked to malnutrition, economic development has contributed little to decrease childhood malnutrition. Figure 12 shows that stunting prevalence in MENA countries has a significant negative correlation with GNP/c in the low and lower-middle income levels, but less correlation in the range higher than upper-middle income levels. The prevalence of underweight, wasting, and low birth weight have no significant correlation with GNP/c in MENA countries (Figure 13, 14, 15). Usually economic development increases the quantity and variety of foods, the development of basic social services and infrastructure-including health, water, sanitation-and improvements in education. All of these factors contribute to reduce the risk of childhood malnutrition. However it takes more than general economic improvements to raise child nutrition status. It may also be necessary to raise public awareness and to invest in specific nutrition interventions. Figure 12: Stunting Prevalence and GNP/c in MENA Countries 40 - o 30 - Stunting Prevalence o 0 20 - 0~~~~~~ 10 - 0 0 5000 1oo0o 15000 20000 Us$ GNP/c (Source: 207, 228, 249, 254, 255) 76 Figure 13: Underweight Prevalence and GNP/c in MENA Countries 45- 40- 35- , 30- 2 25- 5 -A - 20- 15- A A 10 - A A A A us$ 0 0 5000 10000 15000 20000 GNP/c (Source: 207, 228, 249, 254, 255) Figure 14: Wasting Prevalence and GNPlc in MENA Countries 14 12- 010- 8 wC m s6- * -- 4 - 2 - U US$ 0 - l l 0 5000 10000 15000 20000 GNP/c (Source: 207, 228, 249, 254, 255) 77 Figure 15: Low Birth Weight and GNP/c in MENA Countries 20- 18 16 14 <',12 - t 10 6 4 2 US$ 0 0 5000 10000 15000 20000 GNP/c (Source: 55, 207, 254, 255) Figure 16 shows the relationship between stunting prevalence and GNP/c in Egypt.2 Stunting prevalence constantly declined until 1995, although the decrease did not correlate directly with the increase in GNP/c. It increased from 21.6 percent to 29.8 percent during the rapid economic growth between 1995 and 1996. (5228, 255) Figure 17 shows the trend of stunting prevalence in the rural and urban areas in Egypt. While the stunting prevalence declined between 1988 and 1993, the difference between urban and rural areas continued to be about 10 percent. The urban/rural gap increased in 1 996 when the national stunting prevalence increased. The UN Food and Agriculture Organization (FAO) estimated average food supply based on agriculture production and international trade.(77 78) Average supply of dietary energy and protein in Egypt constantly increased from 1970 to 1994 and is higher than in any other countly in the region even though it has the second lowest income level, because some foods are heavily subsidized. As a result, food availability per capita has increased to levels comparable to industrialized countries,(74, 150) and Egyptian households are able to secure food even during periods of high inflation.(t1 2) In 1981, the food subsidy scheme covered 20 food items and accounted for 19.5 percent of total government expenditures. Siince the late 1980s, the Egyptian government gradually decreased the subsidies as a part of the economic structural reform.(8 11, 258) By 1995, the scheme covered only bread, wheat flour, sugar, and edible oil, and accounted for only 5.5 percent of total government expenditure. Bread and wheat flour accounted for 42 percent of total daily energy 2 The 1997 interim Egypt Demographic and Health Survey reported a decrease of stunting prevalence and a decrease in the urban/rural gap; but an increase of wasting prevalence (stunting prevalence: total 24.9 percent, urban 20.0 percent, rural 28.2 percent; wasting prevalence: 6.1 percent).(66) 78 consumption in urban households and 23 percent in rural households, thus they are the largest sources of dietary energy in the Egyptian diet. The FAO and the United Nations Economic and Social Commission for Western Asia (ESCWA) reported that the average consumption amounts changed as follows between 1985 and 1991,(74/ before and after a major food and agricultural policy reform: (1) Increased: protein, wheat, rice, sugar, fruits, milk, fish; (2) Decreased: fat, edible oil, vegetables, meat, eggs; (3) No significant change: dietary energy, animal protein. The availability of rice and fruits increased because the total production increased due to the agricultural reform. Wheat was still subsidized, but the price increase rationalized consumption, loss and waste caused by the irrationally low price. The nutrition impacts of the reform of food subsidy programs are yet unclear, since the major reform had taken place by 1992, while the stunting prevalence declined steadily until 1995. The cost of food subsidies increased from 1.3 percent of GDP in 1995 to 1.5 percent of GDP in 1996. The rice subsidy was canceled in 1992, and bread is more heavily subsidized than wheat flour.3 This policy may hurt rural households more because they consume more rice and wheat flour and bake their own breads at home.4 The persistence of childhood malnutrition in Egypt is more related to child caring practices and infectious diseases such as diarrhea and intestinal parasite infection than food availability.(4) The recent increase of stunting prevalence, particularly in rural areas, may suggest that the investment in social sectors including health and sanitation has not been sufficient to improve and sustain the quality of the social services despite the economic development. Figure 16: Stunting Prevalence and GNP/c in Egypt % US$ 40 1400 35 1200 ~~~~ 30 ~~~~~~~~~~~~1000 ~25 D s r OD X OD CO CO800 a) ~~~~~~~~~20~~~~~~~~~~~~~0 600 1 5 10 400 5- -4 GNPIc (US$)20 00 0) 0 0) 0) 0o 0o 0)0) 0) 0) 0 Year (Source: 5, 228, 2551 3Consumer price of bread is about one thirds of actual production cost.( 1) 4 The poor in urban areas receive income transfers and secure dietary energy intakes from self-targeted food subsidy programs.(8) 79 Figure 17: Stunting Prevalence in Rural and Urban Areas in Egypt 40 35 30 25- i; 20 ~ ' 15 10 +-*- Rural Areas --- Urban Areas 0 I 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Year (Source: 228) Figure 18 shows the trend of stunting prevalence and GNP/c in Tunisia.5 GNP/c in Tunisia grew steadily, whereas stunting prevalence increased from 17.9 percent in 1988 to 22.5 percent in 1995.(5 228, 255) Figure 19 shows the trend of stunting prevalence in the rural and urban areas in Tunisia. The gap between rural and urban areas also widened between 1988 and 1995, and the national stunting prevalence increased. The stunting prevalence was as high as 32.6 percent in rural areas in 1995, compared to only 14.5 percent in urban areas. The food subsidy programs in Tunisia increased the availability of foods during the 1980s.1158) In 1990, roughly 58 percent of dietary energy intake and 62 percent of protein intake were derived from subsidized food."901 Since the programs were not well targeted and reached 9.5 percent of total government expenditure in 1989, the Tunisian government started to refornm the food policy from universal subsidies to a self-targeted program. (90' 258) As the reform has taken place gradually since the early 1 990s, nutrition impacts of the reform are not yet fully evaluated. Figure 20 shows the trend of the average protein supply6 and GNP/c in Tunisia based onl the FAO estimation.(77' 78) The supply of total and animal origin protein increased until 1989, when the stunting prevalence decreased. Since 1989, the protein supply declined despite the steady increase of GNP/c. Figure 21 shows the trend of stunting prevalence and supply of animal origin protein. TIhe supply of animal origin protein increased until 1989, when the stunting prevalence decreased, then it decreased again. Consumption of protein, particularly animal origin protein, is most likely to reflect an increase in income. Although the average supply does not necessarily reflect the actual amount of consumption or the situation of underprivileged groups of the population, it suggests that the quality of life of people might have declined despite economic development and that poverty and poor social services prevail particularly in rural areas. 5 Preliminary results of 1996/98 survey conducted by the National Institute for Nutrition indicated a significant decrease of child undernutrition in Tunisia (stunting prevalence: total 9.5 percent, urban 7.6 percent, rural 11.6 percent; wasting prevalence 1.3 percent).(field interviews) 6 Food consumption data in Tunisia after 1985 were not available. 80 Figure 18: Stunting Prevalence and GNP/c in Tunisia % US$ 45 2500 40 - 35 - 2000 30- o 25 1500 U z so 205 2 | | ~ 1000 ~15- 10 | Stunting (%/6) 500 5 - | +GNP/c (US$) | 1l Year (Source: 5, 228,255) Figure 19: Stunting Prevalence in Rural and Urban Areas in Tunisia 35 - 30 - ~25 - X 20 - 15- 10 - -4-Rural Areas 5 Urban Areas 0I I 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Year (Source: 228) 81 Figure 20: Food Supply and GNPIc in Tunisia g/day/capita US$ I Protein 90 - Animal Protein 2500 80 -+- GNP/c (US$) 70 2000 ~60 Yer1500 45 - _--2 z 40 a30 -& 20 500 10I 0- :- -i- 0 Year (Source: 77, 78, 255) Figure 21Stupitin2g Prevalence and Food Supply in Tunisia % ~~~~~~~~~~~~~~~~~~~~g/day/capita 45 --25 40- 35- 20 30 C 25 ~~~~~~~~~~~~~~~~15 ' ~'20-a 10~~~~~~~~~~~~~~~~ ~ Stnting (% 5 ~~~~nimal Protein 0 , i i i i i~ - i~ i , 0 N~ r- m LO - Om LO TI- o- o-- o- c o~  o~ a0 co o m o C Year (Sourre: 5,7T7, 78, 228) 82 Micronutrient Deficiency Iron There is high anemia prevalence among women and children throughout MENA countries, regardless of income level. For example, the anemia prevalence among reproductive age women in a high income country, Kuwait, is 42 percent, which is similar to lower income countries such as Egypt and WBG, while the obesity prevalence among Kuwaiti women is as high as 44 percent. The anemia prevalence among children under five year old in many MENA countries is alarmingly high, between 40 and 80 percent. The anemia prevalence among school age children is also high, although it is generally lower than that of under five year children. The major dietary source of iron in MENA countries is cereals.(216' 235) Unlike heme iron in animal products, the bioavailability of nonheme iron in cereals is low, and tannin, phytate, and dietary fiber significantly reduce the absorption. People in MENA countries consume a lot of tea, which is high in tannin, during meals and social occasions. Unleavened breads and breads baked with high extraction rate flour are high in phytate and dietary fiber, that reduce bioavailability of iron. Vitamin C from fruits and vegetables can increase absorption of nonheme iron, however, fruits are consumed in various amounts depending on seasonal availability and income. It is necessary to raise people's awareness of how anemia can be prevented by more diversified diets including animal products, fruits, and leavened bread, by not consuming tea during meals, and not giving tea to small children. Iron fortification of staple food should be also needed. High fertility, short birth intervals, poor maternal health care, unbalanced diet, and lack of nutrition knowledge are all risk factors for high anemia prevalence among women in MENA countries regardless of income levels. Although iron supplementation is offered at the antenatal check-ups, compliance is often problematic. Pregnant women often do not take the iron supplements because of the side effects such as stomach discomfort, or misconceptions that iron supplements may cause abortion or excess enlargement of the fetus."50) The coverage of supplementation programs is also an issue, since lower socio-economic groups have the highest risk and are less likely to receive regular antenatal check-ups. Adolescent girls, especially in rural areas, require more attention and specific interventions. Anemia among children under five years is caused by incorrect child feeding practices, high child morbidity such as diarrhea, and mothers' anemia during pregnancy and lactation. Bread and sweet tea are common complementary foods that could cause anemia in young children. One of the major causes of anemia among school age children is intestinal parasite infection, although an accurate prevalence has not been established. Iodine Iodine deficiency disorders (IDD) are major public health problems since most MENA countries have areas with little iodine in the soil, e.g. mountainous areas of Iran, Iraq, Lebanon, Morocco, Syria, Tunisia, and Yemen, and oases in desert areas of Egypt and Libya.(232' 233) Very high TGR was reported in Iran, Syria, Yemen, and the New Valley area in Egypt.(207' 221) IDD is seen even in coastal areas because people do not consume enough seafood due to dietary habits or high prices. Iran has made a significant progress on IDD control. The national survey in 1989 indicated that 14 of 24 provinces were IDD endemic areas. The survey was followed by a series of national IDD control programs: 22 salt iodization plants have been established, 76 percent of 83 households in rural areas and 87 percent of households in urban areas consumed iodized salt b-y 1995; iodized oil has been distributed to the hyperendemic areas.(137' 221) The national IDD surveillance was also conducted in Syria in 1990.(221) TGR exceeded 80 percent in many areas including rural Damascus, Aleppo, Idleb, Reqqa, Sweida, Der'a, Tartous and Quneitra. TGR was 77 percent in rural areas, and 69 percent in urban areas. The single salt producer, Ministry of Industry, has been iodizing salt since 1992, however, it is estimated that only 36 percent of households are consuming iodized salt. Oral iodized oil has been also distributed to children under two years of age and pregnant women. LDD control in Yemen has just begun.7 Although no nationwide surveillance data are available, a survey was conducted in 1991 in the mountainous central highlands, including Sana'a, Dhamar, Ibb and Hajja, where more than 60 percent of the population reside.(210) The survey showed that 78 percent of girls and 60 percent of boys in Sana'a had goiter, and the goiter prevalence reached over 95 percent in some hyperendemic rural areas. The Ministry of Public Health, in collaboration with UNICEF, launched a national IDD control program in 1995, targeting universal salt iodization. Iodized salt is currently consumed by only 21 percent of households. In WBG, neonatal screening for thyroid stimulating hormone (TSH) is carried out on all newborn infants at the public hospitals and clinics. The neonatal screening found 10 positive cases out of 27,000 tested in 1994 and 81 positive cases out of 45,000 tested. 218) Endemic hypothyroidism is observed in Khan Younis area in Gaza at about 15 percent goiter prevalence, however, this may due to hereditary factors. All salt used in WBG is imported from Israel, but the salt is not iodized, and Israeli authorities do not allow production or distribution of iodized salt within W13G(218, field interviews) Vitamin A Vitamin A deficiency (VAD) is largely under control in MENA countries. ACC/SCN expects that MENA will be the only region of developing countries that can eliminate clinical VAD before the year 2000. The MENA countries' dietary patterns include a relatively large amount of green leafy vegetables, which are rich in carotene, the precursor of vitamin A. The 1995 national VAD survey in Egypt showed 0.2 percent of clinical VAD prevalence among the children between six months and three years, and 11.3 percent of subclinical VAD with low serum retinol levels.(') VAD is increasing in Iraq: according to a subnational survey in 1994, clinical VAD among children under five years in Iraq was 2.4 percent. In Morocco, the 1997 national survey showed subclinical VAD prevalence was 41 percent. A 1992 survey in Tihama region in Yemen observed an overall clinical VAD prevalence of 1.7 percent and a total of 2.1 percent in children aged one to six years, with the highest prevalence of 2.9 percent seen in children aged five to six years.(222) Clinical VAD was more frequently seen in boys than girls. The subclinical VAD prevalence among children aged one to five years was 62.4 percent. Subsequently a one-time vitamin A supplement activity was implemented in the region and a pilot program is being implemented of universal vitamin A distribution in conjunction with the National Immunization Day.(210) 7 By October 1998, about 70 percent of satt consumed in urban areas in Yemen is iodized. The Ministry of Public Health conducted a national IDD surveillance in October and November, 1998.(field inteews) 84 A national survey in 1994 in Oman found that 20.8 percent of subclinical VAD with low serum retinol levels.i2221 Children of 18 months of age were most affected with a prevalence of 22.8 percent. A survey in 1981 indicated a clinical VAD prevalence of 1.5 percent with higher rates among boys than girls, however, another survey in 1991 on children under two years old found no clinical VAD cases. These data may indicate that clinical VAD is under control in Oman. Vitamin D Despite the abundant sunlight in the region, vitamin D deficiency exists in many MENA countries including Iran, Kuwait, Libya, Morocco, Saudi Arabia, WBG and Yemen.(60 63, 67X 148, 151, 176, 210, field interviews) Vitamin D deficiency in MENA countries is due to the low dietary vitamin D intake and life styles and habits that avoid sunlight. People live in dark houses; keep infants wrapped for long periods; and women wear thick dark veils. In Saudi Arabia, another possible factor is an increase in ultraviolet light insulation due to air borne dust particles. Rickets is usually most common at the end of the first year, and it disappears by the fifth year. A hospital based study in Kuwait in 1995 reported that serum 25-hydroxy vitamin D (25- OHD) levels were significantly lower in a sample of 50 veiled women than in another sample of 22 unveiled women.(63) The women were between 14 and 45 years of age, had no other health problems, and had no more than three previous pregnancies. Two clinical osteomalacia cases were found among the veiled women, in addition to the four cases found previously at the same hospital. All six cases were single women between 14 and 24 years old, showing clinical symptoms from bone pains to fracture of a femur and radiological signs in pelvis, femur, scapula and ribs. All were treated successfully by administering vitamin D. This study suggests that clinical and subclinical vitamin D deficiency is widespread among veiled Kuwaiti women and that young unmarried women are particularly at risk, as they tend to cover themselves more thoroughly than the older married women. In Saudi Arabia, surveys in 1992 showed that serum 25-OHD levels are lower in the population in northern provinces and higher in western provinces, lower in urban areas than in rural areas, lower among the occupants of mud or brick houses than the occupants of tents, and the lowest in female adolescents and preschool children than other age and gender groups. A hospital-based survey in 1991 showed 1.3 percent of rickets cases among 16,125 children admitted. '48) Another study showed that women in the higher socio-economic group had higher 25-OHD levels, since they ate more animal origin food, lived in better housing, and attended antenatal care more regularly to receive vitamin D supplements.(176) Mothers of infants with rickets were found to be low serum 25-OHD levels.(60) In addition, hereditary disorders such as familial vitamin D resistance rickets were also reported in Saudi Arabia.(148' 151) Low serum 25-OHD levels in mothers of infants with rickets were also reported in Libya.(67) These mothers usually wear traditional veils. Infants born from low 25-OHD level mothers have low 25-OHD levels at birth. Prolonged breast feeding by mothers with low 25- OHD levels was likely to increase the risks, as breast milk is the major source of vitamin D. The infants with rickets were often malnourished, since rickets causes hypotonia and poor suck, and therefore decreases breast milk intake. In Yemen, a 1972 survey in six villages in the northern part of the country reported 16.5 percent of rickets prevalence among children aged six months to four years, and a survey in a village in the north in 1987 reported an overall prevalence of rickets as 27 percent among under five children.(210) In Gaza, about 400 rickets cases have been found in children under two years of 85 age during the last three years. They were treated successfully by introducing sufficient sun bathing. (field interviews) Zinc Human zinc deficiency cases, were recorded for the first time in Egypt and Iran in the early 1960s.(166,167 171) Egyptian cases showed severe anemia, retarded growth and sexual maturation, complicated with hookworm infection and schistosomiasis. Iranian cases showed similar symptoms, without hookworm infection and schistosomiasis but accompanied by geophagia.8 Their diets consisted mainly of beans and bread made of wheat flour but animal products were rarely consumed. In both cases, the symptoms were eased by zinc supplementation therapy. A study of pregnant women in Egypt in 1982 reported that most of the 42 women studied had zinc intake of less than two thirds of RDA, and a third of the women were overweight.!" ') More than half of their zinc intake was from cereals, and one fourth was from dairy, meat and eggs. The plasma zinc concentration was positively associated with the birth weight, and also motor performance in infants at six months of age. Prevailing dietary patterns in MENA countries are low in bioavailable zinc and high in inhibitory factors such as phytate, zinc deficiency may be the underlying cause in the high prevalence of child growth retardation, low birth weight and anemia. Although the prevalence of zinc deficiency is unknown, mild and moderate forms are likely to be widespread in the region. The prevalence of zinc deficiency is probably similar to that of nutritional iron deficiency because the same dietary pattern induces both. Dietary modification interventions, including improved cereal varieties and reduction phytate by leavening and fermentation, should be promoted."5 83" 141) Geophagia is the habit to eat clay. Clay wvill compose insoluble complex with zinc, and reduce zinc bioavailability. In Shiraz province in south Iran, each person ate about 500 clay per day in the early 1 960s. Zinc deficiency accompanied to geophagia is reported in Turkey, too.(167,17 86 Annex 5: MENA Nutrition Data Tables A lgeria__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 39 /1000 live births 207 1980 139 /1000 live births 1960 255 11000 live births Infant Mortality Rate 1996 34 /1000 live births 207 1960 152 /1000 live births Crude Birth Rate 1996 30 /1000 207 1970 49 /1000 Crude Death Rate 1996 6/1000 207 1970 16 /1000 Life Expectancy at Birth 1995 68 years Male 255 71 years Female 1970 53 years 196 Maternal Mortality Ratio 1994 140 /100000 live births 255 Low Birth Weight 1990s 9 % Breastfeeding 1990s 48 % Exclusively breasffed (0-3m) 207 1990s 29 % Breastfed with complementary food (6-9m) 1990s 21 % Still breastfeeding (20-23m) Stunting (under 5y) 1995 18.3 % Total, moderate & severe 228 6.8 % Total, severe 18.3 % Male, moderate & severe 7.0 % Male, severe 18.2 % Female, moderate & severe 6.6 % Female, severe 18.0 % Urban, moderate & severe 7.0 % Urban, severe 18.5 % Rural, moderate & severe 6.5 % Rural, severe Underweight (under 5y) 1995 12.8 % Total, moderate & severe 228 3.4 % Total, severe 13.0 % Male, moderate & severe 3.1 % Male, severe 12.5 % Female, moderate & severe 3.6 % Female, severe 12.7 % Urban, moderate & severe 3.8 % Urban, severe 12.8 % Rural, moderate & severe 3.0 % Rural, severe Wasting (under 5y) 1995 8.9 % Total, moderate & severe 228 2.8 % Total, severe 9.0 % Male, moderate & severe 2.8 % Male, severe 8.8 % Female, moderate & severe 2.8 % Female, severe 10.1 % Urban, moderate & severe 3.1 % Urban, severe 7.7 % Rural, moderate & severe 2.4 % Rural, severe 87 Overweight (under5y) 1995 9.2% Total 8.5 % Male 9.8 % Female 10.9 % Urban 7.4 % Rural Energy Intake 1989 2,866 Kcal per day 150 1981 2,604 Kcal perday 1971 1,834 Kcal perday 1961 1,736 Kcal perday Protein Intake 1989 76.6 g perday 150 1981 66.9g perday 1971 48.1 g per day 1961 47.9 g perday Fat Intake 1989 61.2 g per day 150 1981 59.6 g per day 1971 35.9g per day 1961 32.1 g per day Anemia 1987 28 % Urban, prevalence of anemia 30 1987 19 % Semi-urban, prevalence of anemia 1987 32 % Rural, prevalence of anemia 1987 29 % Urban, prev. of iron deficiency in anemia cases 1987 27 % Semi-urban, prev. of iron def, in anemia cases 1987 22 % Rural, prev. of iron deficiency in anemia cases 1987 48 % Urban, prev. of folic acid def. in anemia cases 1987 45 % Semi-urban, prev. of folic acid def. in anemia 1987 22 % Rural, prev. of folic acid def. in anemia cases Total Goiter Rate (6-1 1y) 1990s 9 % 207 % Household Consuming 1990s 92 % 207 Iodized Salt Bahrain Indicator Year Datai Unit Note, Ref. No. Under-5 Mortality Rate 1996 22 /1000 live births 207 1980 42 /1000 live births 1960 203 /1 001 live births . Infant Mortality Rate 1996 18 /1000 live births 207 1960 130 /1 000 live births Crude Birth Rate 1996 22 /1000 207 1970 40 /1000 Crude Death Rate 1996 4/1000 207 1970 9/1000 . Life Expectancy at Birth 1995 71 years Male 255 75 years Female 1970 62 years . 196 Maternal Mortality Ratio 1990 60 /100000 live births 207 Low Birth Weight 1990s 6 % 207 Stunting (under 5y) 1989 9.9 % Total, moderate & severe 228 1989 3.0 % Total, severe 1989 10.3 % Male, moderate & severe 1989 3.0 % Male, severe 1989 9.6 % Female, moderate & severe 1989 3.0 % Female, severe 88 1989 12.1 % Urban, moderate & severe 1989 3.8 % Urban, severe 1989 7.8 % Rural, moderate & severe 1989 2.2 % Rural, severe Underweight (under 5y) 1989 7.2 % Total, moderate & severe 228 1989 0.8 % Total, severe 1989 7.8 % Male, moderate & severe 1989 0.9 % Male, severe 1989 6.7 % Female, moderate & severe 1989 0.8 % Female, severe 1989 8.7 % Urban, moderate & severe 1989 1.0 % Urban, severe 1989 5.8 % Rural, moderate & severe 1989 0.7 % Rural, severe Wastng (under 5y) 1989 5.5 % Total, moderate & severe 228 1989 0.9 % Total, severe 1989 5.7 % Male, moderate & severe 1989 0.8 % Male, severe 1989 5.2 % Female, moderate & severe 1989 1.0 % Female, severe 1989 6.5 % Urban, moderate & severe 1989 1.3 % Urban, severe 1989 4.5 % Rural, moderate & severe 1989 0.5 % Rural, severe Overweight (under 5 y) 1989 4.7 % Total, >2SD 228 3.5 % Male, >2SD 5.9 % Female, >2SD Overweight (age 15-21) 1993 15.6 % Male, BMI >= 25 144 17.4 % Female, BMI >= 25 Anemia 1997 39.2 % Preschool male 151 29.6 % female 30.1 % Primary school male 29.7 % female 22.5 % Intermediate school, male 50.3 % female 12.5 % Secondary school male 49.0 % female 33.8 % Urban, Preschool male 25.4 % female 24.1 % Urban, Primary school male 23.1 % female 26.7 % Urban, Intermediate school male 43.3 % female 8.4 % Urban, Secondary school male 31.7 % female 44.8 % Rural, Preschool male 33.8 % female 38.5 % Rural, Primary school male 41.5 % female 18.3 % Rural, Intermediate school male 56.7 % female 16.7 % Rural, Secondary school male 89 66.7 % female l_ l Hypertension 1992 12 % | 149 Diabetes 1992 9- % 149 Decayed, Missing, 1980s 3.2 6yr(deciduous teeth)M 149 or Filled Teeth 2.5 6yr(deciduous teeth)F 2.8 6yr(deciduous teeth)T 1.1 12yrM 1.6 12yrF 1.3 12yrT 1.7 15yrM 2.1 15yrF 1.9 I 5vrT Egypt Indicator Year Data | Unit Note Ref. No. Under-5 Mortality Rate 1996 78/1000 live births 207 1980 175 11000 live births 196 1960 282 /1000 live births 196 Infant Mortality Rate 1996 57 11000 live births 207 1960 189 /1000 live births 196 Crude Birth Rate 1996 27 /1000 207 1970 40/1000 196 Crude Death Rate 1996 7/1000 207 1970 17/1000 196 Life Expectancy at Birth 1995 60 years Male 255 63 years Female 1970 51 years 196 Maternal Mortality Ratio 1990 170 /100000 live births 207 Low Birth Weight 1990s 10% 207 Breastfeeding 1990s 53 % Exclusively breastfed (0-3m) 207 1990s 37 % Breasffed with complementary food (6-9m) Stunting (under 5y) 1990s 25 % Moderate & severe 207 1996 29.8 % Total, moderate & severe 228 13.4 % Total, severe 31.0 % Male, moderate & severe 14.1 % Male, severe 28.4 % Female, moderate & severe 12.7 % Female, severe 22.8 % Urban, moderate & severe 9.4 % Urban, severe 34.4 % Rural, moderate & severe 14.1 % Rural, severe Stunting (age 8-18) 1992 23 % Young male working children 62 Both Wasting and Stunting 1992 3 % Young male working children 62 (age 8-18) Underweight (under 5y) 1990s 15 % Moderate & severe 207 1990s 4 % Severe 1996 12.4 % Total, moderate & severe 228 2.6 % Total, severe 12.7 % Male, moderate & severe 2.9 % Male, severe 12.2 % Female, moderate & severe 90 2.4 % Female, severe 9.9 % Urban, moderate & severe 1.7 % Urban, severe 14.1 % Rural, moderate & severe 3.3 % Rural, severe Wasting (under 5y) 1990s 6 % Moderate & severe 207 1996 4.6 % Total, moderate & severe 228 1.2 % Total, severe 4.7 % Male, moderate & severe 1.5 % Male, severe 4.5 % Female, moderate & severe 1.0 % Female, severe 4.7 % Urban, moderate & severe 1.3 % Urban, severe 4.5 % Rural, moderate & severe 1.2 % Rural, severe Wasting(age 8-18) 1992 16 % Young male working children 62 Overweight (under 5y) 1996 8.6 % Total 228 1996 7.4 % Male 1996 9.9 % Female 1996 8.7 % Urban 1996 8.5 % Rural Overweight (8-18y) 1992 3 % Young male working children 62 Anemia (8-18y) 1992 77 % Young male working children 62 Total Goiter Rate (6-1 ly) 1990s 5 % 207 % Household Consuming 1990s 0% 207 Iodized Salt Energy Intake 1989 3,336 Kcal per day 150 1981 3,206 Kcal perday 1971 2,467 Kcal per day 1961 2,272 Kcal perday Protein Intake 1989 83.5 g per day 150 1981 79.4 g per day 1971 64.7 g perday 1961 61.3 1 per day Fat Intake 1989 78.4 g per day 150 1981 73.3 g per day 1971 53.3 g per day 1961 45.2 per day Parasite Infection (8-18y) 1992 72 % Prevalence in young male working children 62 Iran Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 37 /1000 live births 207 1980 126 /1000 live births 196 1960 233 /1000 live births 196 Infant Mortality Rate 1996 33 /1000 live births 207 1960 145 /1000 live births 196 Crude Birth Rate 1996 35 /1000 207 1970 45 /1000 196 Crude Death Rate 1996 6/1000 207 1970 161/1000 196 91 Life Expectancy at Birth 1995 68 years Male 255 69 years Female 1970 55 years 196 Maternal Mortality Ratio 1990 120/100000 live births 207 Low Birth Weight 1990s 9 % .__ 207 Breastfeeding 1990s 53 % Exclusively breastfed (0-3m) 207 Stunting (under 5y) 1995 18.9 % Total, moderate & severe 228 5.3 % Total, severe 19.5 % Male, moderate & severe 5.2 % Male, severe 18.4 % Female, moderate & severe 5.3 % Female, severe 12.2 % Urban, moderate & severe 2.9 % Urban, severe 24.8 % Rural, moderate & severe 8.1 % Rural, severe Underweight (under 5y) 1995 15.7 % Total, moderate & severe 228 2.9 % Total, severe 15.0 % Male, moderate & severe 2.7 % Male, severe 16.3 % Female, moderate & severe 3.1 % Female, severe 13.3 % Urban, moderate & severe 1.8 % Urban, severe 18.7 % Rural, moderate & severe 3.8 % Rural, severe Wasting (under 5y) 1995 6.6 % Total, moderate & severe 228 0.6 % Total, severe 6.1 % Male, moderate & severe 0.4 % Male, severe 7.1 % Female, moderate & severe 0.8 % Female, severe 6.9 % Urban, moderate & severe 0.8 % Urban, severe 6.4 % Rural, moderate & severe 0.4 % Rural, severe Total Goiter Rate (6-11 y) 1990s 30 % 207 % Household Consuming 1990s 82 % Iodized Salt Cretinism Prevalence 1990 20 % 134 Energy Intake 1989 3,181 Kcal per day 150 1981 3,046 Kcal perday 1971 2,328 Kcal per day 1961 1,929 Kcal per day Protein Intake 1989 84.1 g per day 150 1981 79.9 g perday 1971 61.2 g perday 1961 52.1 per day Fat Intake 1989 62.2 g per day 150 1981 67.6g perday 1971 45.0 p erday 1961 34.0 g perday 92 Na 1981 186|mEq/24h 24h urinarysodium excretion >=14yr 159 141 mEq/24h I_ I Hypertension 1981 12 % Male, >=30yr prevalence, >140/90 159 Iraq Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1995 145 /1000 live births 226 1980 83 /1000 live births 196 1960 171 /1000 live births 196 Infant Mortality Rate 1995 161 /1000 live births 226 1960 11 7 /1000 live births 196 Crude Birth Rate 1996 37 /1000 207 1970 48 /1000 196 Crude Death Rate 1996 9/1000 207 1970 16 /1000 196 Life Expectancy at Birth 1995 60 years Male 255 62 years Female 1970 55 years 196 Maternal Mortality Ratio 1990 31 0 /1 00000 live births 207 Low Birth Weight 1995 21 % 226, 229 Stunting (under 5y) 1997 28 % Moderate & severe 229 1991 21.8 % Total, moderate & severe 228 7.3 % Total, severe 20.0 % Urban, moderate & severe 24.7 % Rural, moderate & severe Underweight (under 5y) 1997 25 % Moderate & severe 229 1991 11.9 % Total, moderate & severe 228 2.3 % Total, severe 11.4 % Urban, moderate & severe 24.7 % Rural, moderate & severe Wasting (under 5y) 1997 9 % Moderate & severe 229 1991 3.4 % Total, moderate & severe 228 0.4 % Total, severe 3.3 % Urban, moderate & severe 3.5 % Rural, moderate & severe Total Goiter Rate (6-1 1y) 1990s 7% 207 1992 41.5 % Female of child bearing age in Ninewah 134 1993 44.2 % School age children 134 57 % Ninevah (north) 54 % Baghdad (central) 37 % Basnah (south) % Household Consuming 1990s 50 % 207 Iodized Salt Energy Intake 1989 2,887 Kcal per day 150 1981 2,815 Kcal per day 1971 2,291 Kcal per day 1961 2,066 Kcal per day Protein Intake 1989 71.8 g perday 150 1981 73.8 g per day 1971 61.3 g perday 1961 58.3g per day 93 Fat Intake 1989 75.3 g per day 150 1981 62.1 g per day 1971 43.6 g perday 1961 41.9 aperday Israel Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 9 /1000 live births 207 1980 19 /1000 live births 196 1960 39 /1000 live births 196 Infant Mortality Rate 1996 8 11000 live births 207 1960 32 /1000 live births 196 Crude Birth Rate 1996 21 /1000 207 1970 26 /1000 196 Crude Death Rate 1996 6/1000 207 1970 7/1000 196 Life Expectancy at Birth 1995 75 years Male 255 79 years Female 1970 71 years 196 Maternal Mortality Ratio 1990 7 /100000 live births 207 Low Birth Weight 1990s 7 % 207 Stunting (18months) 1981 32.7 % Cohort study, baseline 84 (lOyr, same cohort) 1990 7.2 % follow up (9 months) 1982 17.5 % Cohort study, baseline (lOyr, same cohort) 1990 8.2 % follow up Low BMI in the Aged 1996 1.1 % <19kg/m2 123 Low Serum Albumin 1996 11.4 % Male, <35g/l 123 in the Aged 16.9 % Female, <35g/l High BMI in the Aged 1996 13.5% >30kg/m2 123 Anemia 1983 44.7 % Jewish, Hb25 Obesity (adult) 36.4 % BMI>30 Overweight (<5yr) 1993 5.2 % wtlht>120% of reference population 149 1979 1.8 % Overweight (6-7yr) 1984 18.1 % Male, wVht>120% of reference population 149 26.8 % Female Overweight (6-9yr) 1995 12.8 % Male, wt/ht>120% of reference population 149 14.9 % Female Overweight (6-14yr) 1992 20.0 % Male, wt1ht>120% of reference population 149 23.1 % Female 1985 49.0 % Male, wVht>120% of reference population 149 59.0 % Female 1981 24.6 % Male, wt/ht>120% of reference population 47.9 % Female Energy Intake 1989 3,195 Kcal perday 150 1981 2,961 Kcal perday 1971 2,640 Kcal per day 1961 2,594 Kcal Per day Protein Intake 1989 95.3 g per day 150 96 1981 90.2 g per day 1971 74.6 g per day 1961 76.8 q per day Fat Intake 1989 104.9 g per day 150 1981 93.0 g per day 1971 71.3 g perday 1961 76.0 9 per day Stroke Incidence 1997 27.6 /100000 Crude 7 145.6 /100000 Adjusted Diabetes 1980 17.8 /1000 Total (excluding non-Kuwaiti) 149 17.0 /1000 Male (excluding non-Kuwaiti) 18.7 /1000 Female (excluding non-Kuwaiti) Hypertension (>20yr) 1985 19.3 % Total 149 22.6 % Male 16.1 % Female Dental Caries (pre-school 1985 18 % >=5 decayed, missed, or filled teeth prevalence 10 18-48m) Lebanon Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 40 /1000 live births 207 1980 40 /1000 live births 196 1960 85 /1000 live births _ 196 Infant Mortality Rate 1996 33 /1000 live births 207 1960 65 /1000 live births 196 Crude Birth Rate 1996 25/1000 207 1970 35 /1000 196 Crude Death Rate 1996 7/1000 207 1970 11 /1000 196 Life Expectancy at Birth 1995 68 years Male 255 71 years Female 1970 64 years 196 Maternal Mortality Ratio 1990 300 /100000 live births 207 Low Birth Weight 1990s 10 % 207 Stunting (under 5y) 12.2 % Total, moderate & severe 228 12.6 % Male, moderate & severe 3.3 % Male, severe 11.8 % Female, moderate & severe 2.5 % Female, severe Underweight (under 5y) 1996 3.0 % Total, moderate & severe 228 3.3 % Male, moderate & severe 0.4 % Male, severe 2.8 % Female, moderate & severe 0.1 % Female, severe Wasting (under 5y) 1996 2.9 % Total, moderate & severe 228 3.0 % Male, moderate & severe 0.8 % Male, severe 2.8 % Female, moderate & severe 0.6 % Female, severe Total Goiter Rate (6-11y) 1990s 15% 207 Thyroid Enlargement 1990s 40--75 1% 134 (mountain) 97 (coastal areas) 17 % % Household Consuming 1 990s 92 % 207 Iodized Salt _ Energy Intake 1989 3,274 Kcal per day 150 1981 2,875 Kcal per day 1971 2,474 Kcal perday 1961 2,466 Kcal per day Protein Intake 1989 86.2 g per day 150 1981 83.0 g per day 1971 64.2 g per day 1961 65.0 9 per day Fat Intake 1989 97.1 g per day 150 1981 85.2 g perday 1971 51.9 9 per day __________________ 1961 32.21g perday_ _ _ Libya Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 61 /1000 live births 207 1980 118 /1000 live births 196 ___________________ 1960 269 /1000 live births __ 196 Infant Mortality Rate 1996 50/1000 live births 207 1960 160 /1000 live births ___ 196 Crude Birth Rate 1996 41 /1000 207 1970 | 491/1000 196 Crude Death Rate 1996 7 /1000 207 1970 16/1000 _ 196 Life Expectancy at Birth 1995 63 years Male 255 67 years Female 1970 52 years ___ 196 Maternal Mortality Ratio 1990 220 /100000 live births 207 Low Birth Weight 1994 5 % 207 Stunting (under 5y) 1995 15.1 % Total, moderate & severe 228 4.5 % Total, severe 16.4 % Male, moderate & severe 5.1 % Male, severe 13.8 % Female, moderate & severe 3.9 % Female, severe 13.9 % Urban, moderate & severe 4.1 % Urban, severe 18.1 % Rural, moderate & severe 5.3 % Rural, severe Underweight (under 5y) 1995 4.7 % Total, moderate & severe 228 0.6 % Total, severe 5.0 % Male, moderate & severe 0.8 % Male, severe 4.4 % Female, moderate & severe 0.4 % Female, severe 4.2 % Urban, moderate & severe (.5 % Urban, severe 5.9 % Rural, moderate & severe 0.8 % Rural, severe 98 Wasting (under 5y) 1995 2.7 % Total, moderate & severe 228 0.4 % Total, severe 2.7 % Male, moderate & severe 0.5 % Male, severe 2.7 % Female, moderate & severe 0.3 % Female, severe 2.5 % Urban, moderate & severe 0.3 % Urban, severe 3.3 % Rural, moderate & severe 0.7 % Rural, severe Total Goiter Rate (6-1 1y) 1990s 6% 207 1993 23 % Children of all ages in the north 134 % Household Consuming 1990s 90 % 207 Iodized Salt Energy Intake 1989 3,324 Kcal per day 150 1981 3,564 Kcal per day 1971 2,506 Kcal per day 1961 1,654 Kcal per day Protein Intake 1989 80.5 g per day 150 1981 88 g perday 1971 60.5 g per day 1961 39.2 q per day Fat Intake 1989 108.3 g per day 150 1981 128.9 g per day 1971 73.8 g per day 1961 32.2 per day Hair Zinc Concentration 1983 213+/-36 ug/g 122 (newborn) (toddlers) 88+/-35 ug/g (school children) 89+/-25 ug/g Morocco Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 74 11000 live births 207 1980 152 /1000 live births 196 1960 220 /1000 live births 196 Infant Mortality Rate 1996 64 /1000 live births 207 1960 135 /1000 live births 196 Crude Birth Rate 1996 26 /1000 207 1970 47 /1000 196 Crude Death Rate 1996 7/1000 207 1970 17 /1000 196 Life Expectancy at Birth 1995 64 years Male 255 68 years Female 1970 52 years 196 Maternal Mortality Ratio 1995 372 /100000 live births 255 Low Birth Weight 1990s 9 % 207 Breastfeeding 1990s 31 % Exclusively breastfed (0-3m) 207 33 % Breasffed with complementary food (6-9m) 20 % Still breastfeeding (20-23m) Stunting (under 5y) 1992 24.2 % Total, moderate & severe 228 8.7 % Total, severe o9 24.2 % Male, moderate & severe 9.1 % Male, severe 24.2 % Female, moderate & severe 8.3 % Female, severe 13.2 % Urban, moderate & severe 3.1 % Urban, severe 30.0 % Rural, moderate & severe 11.6 % Rural, severe Underweight (under 5y) 1992 9.5 % Total, moderate & severe 228 2.0 % Total, severe 10.1 % Male, moderate & severe 2.0 % Male, severe 8.9 % Female, moderate & severe 2.0 % Female, severe 3.3 % Urban, moderate & severe 0.6 % Urban, severe 12.7 % Rural, moderate & severe .______ 2.8 % Rural, severe Wasting (under 5y) 1992 2.2 % Total, moderate & severe 228 0.4 % Total, severe 2.5 % Male, moderate & severe 0.6 % Male, severe 1.9 % Female, moderate & severe 0.3 % Female, severe 1.9 % Urban, moderate & severe 0.4 % Urban, severe 2.4 % Rural, moderate & severe 0.5 % Rural, severe Overweight (<5yr) 1992 6.8 % Total 228 6.0 % Male 7.6 % Female 9.0 % Urban 5.6 % Rural Total Goiter Rate (6-1ly) 1990s 20% 207 1993 22 % Total 134 44 % Mountain 19 % Coast TSH>5muIml prevalence 1993 9 % WHO survey 134 Urinary Iodine Excretion 1993 18 ug/l 25 24 ug/l 117 ug/l Energy Intake 1989 3,020 Kcal per day 150 1981 2,697 Kcal per day 1971 2,464 Kcal per day 1961 2,1 41 Kcal perday Protein Intake 1989 81.3 g per day 150 1981 71.2 g per day 1971 65.5 g per day 1961 57.3 9 per day Fat Intake 1989 55.6 g per day 150 1981 49.6 g per day 1971 42.1 g per day 100 | 1961 | 35.319 Iper day l Oman Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 18 /1000 live births 207 1980 95 /1000 live births 196 1960 280 /1000 live births 196 Infant Mortality Rate 1996 15 /1000 live births 207 __________________ 1960 164 /1000 live births 196 Crude Birth Rate 1996 44 /1000 207 1970 50 /1000 196 Crude Death Rate 1996 4/1000 207 1970 21 /1000 196 Life Expectancy at Birth 1995 68 years Male 255 73 years Female 1970 47 years 196 Maternal Mortality Ratio 1990 190 /100000 live births 207 Low Birth Weight 1990s 8 % 207 Breastfeeding 1990s 28 % Exclusively breastfed (0-3m) 207 85 % Breastfed with complementary food (6-9m) 64 % Still breastfeeding (20-23m) Stunting (under 5y) 1995 23.0 % Total, moderate & severe 228 8.0 % Total, severe 23.1 % Male, moderate & severe 8.2 % Male, severe 22.9 % Female, moderate & severe 7.9 % Female, severe 21.2 % Urban, moderate & severe 8.3 % Urban, severe 25.6 % Rural, moderate & severe 7.6 % Rural, severe Underweight (under 5y) 1995 23.3 % Total, moderate & severe 228 3.3 % Total, severe 23.1 % Male, moderate & severe 3.9 % Male, severe 23.6 % Female, moderate & severe 4.3 % Female, severe 20.6 % Urban, moderate & severe 2.8 % Urban, severe 27.5 % Rural, moderate & severe 4.0 % Rural, severe Wasting (under 5y) 1995 12.8 % Total, moderate & severe 228 1.5 % Total, severe 13.7 % Male, moderate & severe 1.9 % Male, severe 12.8 % Female, moderate & severe 1.2 % Female, severe 11.8 % Urban, moderate & severe 1.7 % Urban, severe 14.3 % Rural, moderate & severe _ _ _ 1.3 % IRural, severe Total Goiter Rate (6-11y) 1990s 10 207 101 % Household Consuming 1990s 35jl Ilodized Salt I I II Qatar Indicator Year Datai Unit Note Ref. No. Under-5 Mortality Rate 1996 21 /1000 live births 207 1980 551/1000 live births 196 1960 239 /1000 live births 196 Infant Mortality Rate 1996 17 /1000 live births 207 1960 145 (1000 live births 196 Crude Birth Rate 1996 19 /1000 207 1970 34 /1000 196 Crude Death Rate 1996 4 /1000 207 1970 13/1000 196 Life Expectancy at Birth 1995 70 years Male 255 75 years Female 1970 61 years 196 Low Birth Weight 1988 5 % 255 Stunting (under 5y) 1995 8.1 % Total, moderate & severe 228 8.3 % Male, moderate & severe 8.4 % Female, moderate & severe Underweight (under 5y) 1995 5.5 % Total, moderate & severe 228 6.9 % Male, moderate & severe l________________ ____4.7 % Female, moderate & severe Wasting (under 5y) 1995 1.5 % Total, moderate & severe 228 1.7 % Male, moderate & severe 1.4 % Female, moderate & severe Overweight (<5yr) 1995 6.8 % Total 228 5.3 % Male 8.6 % Female Overweight (adults) 1989 30.1 % 149 Obesity (adults) 1989 33.61% Saudi Arabia Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 30 /1000 live births 207 1980 85 /1000 live births 196 1960 292 /1000 live births 196 Infant Mortality Rate 1996 25 /1000 live births 207 1960 170 /1000 live births 196 Crude Birth Rate 1996 35/1000 207 1970 48 /1000 196 Crude Death Rate 1996 4/1000 207 1970 18/1000 196 Life Expectancy at Birth 1995 69 years Male 255 71 years Female 1970 52 years 196 Maternal Mortality Ratio 1993 18 /100000 live births _ 255 Low Birth Weight 1990s 7 % 207 Breastfeeding 1995 92.4 % Urban 19 (prevalence) 94.5 % Rural (duration) 11 months Urban 102 13 months Rural Stunting (under 6y) 1980 14.0 % Urban, moderate & severe 228 41.0 % Rural, moderate & severe _______ __ 13.0 % Rural, severe Underweight (under 6y) 1980 14.0 % Urban, moderate & severe 228 46.0 % Rural, moderate & severe 8.0 % Rural, severe Wasting (under 6y) 1980 3.0 % Urban, moderate & severe 228 12.0 % Rural, moderate & severe 1.0 % Rural, severe BMI mean 1993 25+1-5 kglm2 Male age 33+/-15yr 149 26+l-6 kg/m2 Female age 33+/-15yr Overweight Prevalence 1993 29 % Male age 33+1-15yr 149 27 % Female age 33+1-15yr Obesity Prevalence 1993 16 % Total, Male age 33+/-15yr 24 % Total, Female age 33+/-15yr 18 % Urban, Male age 33+/-15yr 28 % Urban, Female age 33+/-15yr 12 % Rural, Male age 33+/-15yr 18 % Rural, Female age 33+/-15yr Overweight (adults) 1997 31.2 % Total 15 33.1 % Male 29.4 % Female Obesity (adults) 1997 22.1 % Total 17.8 % Male 26.6 % Female Urinary Iodine <10 ug/dI 1994 22 % National iodine survey on children (8-lOyr) 134 <5 ug/di 7 % Energy Intake 1989 2,874 Kcal per day 150 1981 2,777 Kcal per day 1971 1,886 Kcal per day 1961 1,772 Kcal perday Protein Intake 1989 86.5 g perday 150 1981 77.7 g per day 1971 48.3 g per day 1961 48.1 g per day Fat Intake 1989 82. g per day 150 1981 80.2 g per day 1971 33.9g per day 1961 26.5 9 perday Vitamin D 1984 5.7 ng/ml Median 25-OHD in pregnant women 176 25.2 % 25-OHD <4ng/ml in pregnant women Mean Serum 1993 10 mmol/L Male 149 Glucose Concentration 12 mmol/L Female Prevalence of IGT 1993 10 % Total, Male 149 9 % Total, Female Prevalence of Diabetes 11.8 % Total, Male 12.8 % Total, Female 16 % 35-64yr,Male 20 % 35-64yr,Female 11.7 % Urban, Male 13.8 % Urban, Female 103 6.8 % Rural, Male 7.4 % Rural, Female Mean Serum 1993 4+/-1.5 mmol/L Male 149 Cholesterol 4.25+/-1.5 mmol/L Female Prevalence of 10 % 5.2-6.2mmol/L Hypercholesterolemia 12 % 5.2-6.2mmol/L 7.5 % >6.2mmol/L 9 % >6.2mmol/L 6 % >6.2mmol/L, urban % >6.mmol/L, urban % >6.2mmol/L, Rural 9 % >6.2mmol/L, Rural Syria Indicator Year Datai Unit Note Ref. No. Under-5 Mortality Rate 1996 34 /1 000 live births 207 1980 73 /1000 live births 196 1960 201 /1000 live births 196 Infant Mortality Rate 1996 28 /1000 live births 207 1960 136 /1000 live births 196 Crude Birth Rate 1996 31 /1000 207 1970 47 /1000 196 Crude Death Rate 1996 5/1000 207 1970 14 /1000 196 Life Expectancy at Birth 1995 66 years Male 255 71 years Female 1970 56 years 196 Maternal Mortality Ratio 1990 179 /100000 live births 255 Low Birth Weight 1990s 11 % _ 207 Breastfeeding 1990s 50 % Breastfed with complementary food (6-9m) 207 Stunting (under 5y) 1990s 21.0 % Moderate & severe 207 1993 26.6 % Total, moderate & severe 228 11.9 % Total, severe 27.8 % Male, moderate & severe 12.9 % Male, severe 25.8 % Female, moderate & severe 11.0 % Female, severe 26.0 % Urban, moderate & severe 11.4 % Urban, severe 27.6 % Rural, moderate & severe 12.5 % Rural, severe Underweight (under 5y) 1990s 13.0 % Moderate & severe 207 1990s 4.0 % Severe 1993 12.1 % Total, moderate & severe 228 3.0 % Total, severe 12.9 % Male, moderate & severe 2.8 % Male, severe 11.3 % Female, moderate & severe 3.2 % Female, severe 11.5 % Urban, moderate & severe 2.7 % Urban, severe 12.8 % Rural, moderate & severe 104 3.3 % Rural, severe Wasting (under 5y) 1990s 9.0 % Moderate & severe 207 1993 8.1 % Total, moderate & severe 228 2.1 % Total, severe 8.5 % Male, moderate & severe 2.6 % Male, severe 7.7 % Female, moderate & severe 1.5 % Female, severe 8.7 % Urban, moderate & severe 2.0 % Urban, severe 7.5 % Rural, moderate & severe 2.1 % Rural, severe Total Goiter Rate (6-11 y) 1990s 73 % % Household Consuming 1990s 36 % 207 Iodized Salt Energy Intake 1989 3,003 Kcal per day 150 1981 3,105 Kcal per day 1971 2,412 Kcal per day 1961 2,362 Kcal per day Protein Intake 1989 78.6 g perday 150 1981 84.2g per day 1971 64.2g per day 1961 65.1 e y Fat Intake 1989 82.7 g per day 150 1981 93.7g per day 1971 65.0 per day ~~~~~~~~1961 59.7 9_per day Tunisia Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 35 11000 live births 207 1980 100 /1000 live births 196 1960 254 /1000 live births 196 Infant Mortality Rate 1996 28 /1000 live births 207 1960 170 /1000 live births 196 Crude Birth Rate 1996 24 /1000 207 1970 39 /1000 196 Crude Death Rate 1996 6 /1000 207 1970 14 /1000 196 Life Expectancy at Birth 1995 68 years Male 255 70 years Female 1970 54 years 196 Maternal Mortality Ratio 1990 138 /100000 live births 255 Low Birth Weight 1990s 8 % 207 Breastfeeding 1990s 12 % Exclusively breastfed (0-3m) 207 16 % Still breasffeeding (20-23m) Stunting (under 5y) 1995 22.5 % Total, moderate & severe 228 22.3 % Male, moderate & severe 10.1 % Male, severe 22.6 % Female, moderate & severe 8.5 % Female, severe 14.5 % Urban, moderate & severe 105 32.6 % Rural, moderate & severe Underweight (under 5y) 1995 9.0 % Total, moderate & severe 228 8.0 % Male, moderate & severe 2.2 % Male, severe 9.3 % Female, moderate & severe 1.8 % Female, severe 6.0 % Urban, moderate & severe 12.0 % Rural, moderate & severe Wasting (under 5y) 1995 3.9 % Total, moderate & severe 228 3.5 % Male, moderate & severe 1.2 % Male, severe 4.3 % Female, moderate & severe 1.2 % Female, severe 3.7 % Urban, moderate & severe 4.1 % Rural, moderate & severe Total Goiter Rate (8-10y) 1980s 9.5 % 134 (6-11y) 1990s 4.3 % 207 % Household Consuming 1990s 98 % 207 Iodized Salt Energy Intake 1989 3,119 Kcal per day 150 1981 2,779 Kcal per day 1971 2,368 Kcal per day ___________________ 1961 . 2,103 Kcal perday Protein Intake 1989 83.3 g per day 150 1981 77.5 g per day 1971 63.1 g per day ____ __ 1961 56.4 q per day Fat Intake 1989 85.7 g per day 150 1981 65.3 g per day 1971 57.6 g per day 1961 43.1 q lperday United Arab Emirates Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1996 18 /1000 live births 207 1980 64 /1000 live births 196 1960 240 /1000 live births 196 Infant Mortality Rate 1996 15 /1000 live births 207 1960 160 /1000 live births 196 Crude Birth Rate 1996 19/1000 207 1970 36 /1000 196 Crude Death Rate 1996 3 /1000 207 1970 11 /1000 196 Life Expectancy at Birth 1995 74 years Male 255 76 years Female 1970 61 years 196 Maternal Mortality Ratio 1990 20 /100000 live births 255 Low Birth Weight 1 990s 6 % 207 Breastfeeding 1 990s 26 c/c Still breastfeeding (20-23m) 207 Overweight (Adult) 1993 32.8 % BMI 25-29.9 149 Obesity (Adult) 38.3 % BMI >30 Total Goiter Rate (6-1 1y) 1990s 461% Al Jazeera, hospital based 134 106 66 % Al Mafrag, hospital based _ _l _ l Energy Intake 1989 3,309 Kcal per day 150 1981 3,199 Kcal perday 1971 3,208 Kcal per day 1961 2,814 Kcal perday Protein Intake 1989 101.6 g per day 150 1981 101.6 g perday 1971 78.2 g per day 1961 72.5 9 per day Fat Intake 1989 111.5 g per day 150 1981 110.3 g perday 1971 76.1 g per day 1961 85.2 9 per day West Bank and Gaza Indicator Year Data Unit Note Ref. No. Infant Mortality Rate 28 /1000 live births 249 Life Expectancy at Birth 1995 70 years Male 249 74 years Female Maternal Mortality Ratio 70 /100000 live births 249 Stunting (under 5y) 1995 14.2 % Gaza, moderate & severe 228 3.7 % Gaza, severe 13.8 % Gaza, male, moderate & severe 3.5 % Gaza, male, severe 14.6 % Gaza, female, moderate & severe 3.9 % Gaza, female, severe Underweight (under 5y) 1995 15.1 % Gaza, moderate & severe 228 2.3 % Gaza, severe 16.5 % Gaza, male, moderate & severe 2.1 % Gaza, male, severe 14.0 % Gaza, female, moderate & severe 2.4 % Gaza, female, severe Wasting (under 5y) 1995 5.7 % Gaza, moderate & severe 228 0.2 % Gaza, severe 6.5 % Gaza, male, moderate & severe 0.3 % Gaza, male, severe 5.0 % Gaza, female, moderate & severe 0.1 % Gaza, female, severe Yemen Indicator Year Data Unit Note Ref. No. Under-5 Mortality Rate 1995 145 /1000 live births 248 1980 198 /1000 live births 196 1960 340 /1000 live births 196 Infant Mortality Rate 1995 93 /1000 live births 248 1960 230 /1000 live births 196 Crude Birth Rate 1996 53 /1000 207 1970 48 /1000 196 Crude Death Rate 1996 23 /1000 207 1970 11 /1000 196 Life Expectancy at Birth 1995 57 years 248 56 years 255 107 1970 57 years 196 Maternal Mortality Ratio 1995 1,000 /100000 live births 248 Low Birth Weight 1990s 19 % ___ 207 Breasffeeding 1990s 31 % Still breasffeeding (20-23m) 207 Stunting (under 5y) 1993 39.0 % Total, moderate & severe 228 22.7 % Total, severe 41.5 % Male, moderate & severe 23.1 % Male, severe 36.1 % Female, moderate & severe 22.3 % Female, severe 29.0 % Urban, moderate & severe 14.0 % Urban, severe 44.4 % Rural, moderate & severe 27.5 % Rural, severe Underweight (under 5y) 1993 39.0 % Total, moderate & severe 228 13.1 % Total, severe 41.3 % Male, moderate & severe 14.1 % Male, severe 36.5 % Female, moderate & severe 12.0 % Female, severe 31.2 % Urban, moderate & severe 6.9 % Urban, severe 43.0 % Rural, moderate & severe 16.2 % Rural, severe Wasting (under 5y) 1992 12.7 % Total, moderate & severe 228 2.9 % Total, severe 14.3 % Male, moderate & severe 3.4 % Male, severe 11.4 % Female, moderate & severe 2.5 % Female, severe Total Goiter Rate (6-1 1y) 1990s 32 % 207 % Household Consuming 1990s 21 % Iodized Salt _ Vitamin A Deficiency 1990s 7.2 % Prevalence of serum retinol