Breaking the poverty/malnutrition cycle in Africa and the
Middle East
Tola Atinmo, Parvin Mirmiran, Oyediran E Oyewole, Rekia Belahsen, and Lluís Serra-Majem
The cost to developing countries, for current and future generations, of not
eradicating hunger and poverty – in terms of recurrent conflicts and emergencies,
widening inequalities, depleted resources, ill health, and premature death – is
enormous. Although strategies are underway to address certain problems in Africa
and the Middle East, much remains to be done. Breaking the poverty cycle in these
regions demands both local and international attention. Nutrition transition is a key
factor, since many countries in the region also suffer the consequences of the
excessive and unbalanced diets that are typical of developed countries. This paper
reviews the experiences with facing malnutrition in Sub-Saharan and North Africa
and the Middle East.
© 2009 International Life Sciences Institute
INTRODUCTION
In spite of the numerous strategies being implemented at
the national and international levels in order to break the
cycle of poverty in Africa and developing nations in the
Middle East, the problem continues unabated. It is doubtful that any another condition is more damaging to individual dignity or causes greater dependence on others
than persistent deprivation of food, which, along with
water, is one of the most essential ingredients for a
healthy and fulfilling life.
POVERTY AND HUNGER: FOCUS ON AFRICA
Chronic hunger afflicts one in five of the developing
world’s people, assaulting children and individuals in
rural populations in particular. Hunger is both a violation
of dignity and an obstacle to social, political, and economic progress; chronic hunger increases one’s susceptibility to disease, hinders learning ability, and leaves one
weak and unable to work and meet family needs. This
rupturing of self-reliance inhibits developing economies
and contributes to the devastating downward spiral of
hunger and poverty.
There is clear evidence that the major damage caused
by malnutrition takes place in the womb and during
the first 2 years of life. This damage is irreversible and
is linked to lower intelligence and reduced physical
capacity, which in turn diminishes productivity, slows
economic growth, and perpetuates poverty. Moreover,
malnutrition passes from generation to generation
because stunted mothers are more likely to have underweight children.1 As such, it is clear that to break this
cycle, the focus must be on preventing and treating malnutrition in pregnant women and in children aged 0–2
years. School feeding programs – often implemented as
nutrition interventions – may help get children into
school and keep them there, but such programs do not
attack the root causes of malnutrition.
Hunger is as much a cause as an effect of poverty.
Failure to address problems of hunger and undernourishment frustrates and retards the achievement of poverty
alleviation goals. Sub-Saharan Africa has the highest
Affiliations: T Atinmo and OE Oyewole are with the Department of Human Nutrition, University of Ibadan, Nigeria. P Mirmiran is with the
Institute of Nutrition, Endocrine Research Center, Shaheed Beheshti University of Medical Sciences, Iran. R Belahsen is with the Training
and Research Unit on Food Sciences, Laboratory of Physiology Applied to Nutrition and Feeding, Chouaib Doukkali University, School of
Sciences, El Jadida, Morocco. L Serra-Majem is with the NGO Nutrition without Borders, Barcelona and the Department of Clinical Sciences,
University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
Correspondence: L Serra-Majem, Department of Clinical Sciences, University of Las Palmas de Gran Canaria, PO Box 550, 35080 Las Palmas
de Gran Canaria, Spain. E-mail: [email protected], Phone: +34-928-453-477.
Key words: Africa, hunger, Middle East, nutrition transition, poverty
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doi:10.1111/j.1753-4887.2009.00158.x
Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46
proportion of people living in poverty, with nearly half of
the population living below the international poverty
level of US$1 a day.2
Some 300 million people face a daily struggle for
survival, with thousands of them – especially children –
losing the battle. In the case of Africa, there are many
factors that hinder hunger and poverty alleviation efforts,
thus disrupting agricultural productivity, sustainable livelihoods, and effective development initiatives. Such
obstacles to improvement need to be addressed simultaneously and include the following:
Threat to peace. Conflicts across Africa arise from, as well
as generate, poverty, income inequality, and competition
over resources, while simultaneously playing a role in the
displacement and disruption of sustainable activities for
over 15 million people.
Lack of job opportunities. Sub-Saharan Africa has the
highest proportion of unemployed and underemployed
people in the world with approximately 300 million
people living on less than US$1 a day.
Poor health and the spread of HIV/AIDS. Inadequate
nutrition and poor health increase vulnerability to HIV
infection and shorten the HIV incubation period, causing
people to fall ill sooner. Family spending increases while
ability to generate income is reduced.3
Inequitable trade policies and the negative impacts of globalization. Subsidies in developed countries, unsustainable world market prices, and international dumping in
developing markets hinder opportunities for African
farmers to get out of debt or generate profits.
Unsustainable management of natural resources. Augmented deforestation, expansion of arable land, inadequate soil protection and irrigation methods, overuse of
mineral fertilizers, pollution of ground water sources,
and the loss of genetic diversity is affecting weather
patterns and jeopardizing the balance of Africa’s natural
ecosystem.
Gender discrimination. Despite studies that demonstrate
the correlation between women’s development and
household well being, women in many parts of Africa still
don’t have access to education, inheritance rights, and
essential resources such as land and investment inputs.
Recurrent natural and man-made emergencies. Chronic
drought, flooding, conflict, and unreliable food stock
management lead to repeated cycles of food insecurity
Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46
resulting in the need for international crisis
interventions.
The world community can drastically reduce hunger
over the next five decades if developed and developing
countries support rural development in poor countries,
spend more money on research, and reduce barriers in
developed countries to importing agricultural products
from developing countries.
According to studies from the United Nations Conference on Trade and Development, trade rules and
restrictions on poor countries, including the poorest in
Africa, cost these countries around US$100 billion per
year – twice the amount that the entire developing world
receives in aid. Prevailing and proposed trade policies
cannot address poverty and hunger as they persist in
Africa today. Studies demonstrate that even a 1% increase
in world exports from Africa would result in gains in
income and livelihoods that could shift 40 million Africans out of poverty and help promote sustainable
development.4,5
Developed nations must be committed to fair trade
and the allocation of resources (encouraged to consist of
0.7% of gross domestic product) that are earmarked for
international assistance programs. Developing nations
must improve and redirect policies that will provide aid
to rural areas. Additionally, the rural poor themselves
have a central role in seeking sustainable methods of selfdevelopment that respect equality and education.
It is also envisaged that a focus on integrated
approaches to development, transformation of policy
environments, the advancement of rural infrastructure
(health, education, markets), and improved access to rural
livelihood opportunities (agriculture, skills training,
small-business capital) will positively contribute to breaking the cycle of poverty in Africa.6
In order to achieve food security as a means of breaking the cycle of poverty, the following factors become
very relevant: supporting rural livelihoods; improving
natural resource management; promoting women’s
empowerment; training in disaster management and
mitigation; indigenous knowledge and cost-effective
technology; education targeting female children.
NUTRITION TRANSITION
Malnutrition results from the imbalance of nutrients and
energy provided to the body (too low) relative to its needs
(too high). More people now die of heart disease, diabetes, and some cancers in developing countries than in the
developed, and the problem is becoming more serious
among the poor.7 Generally consistent associations of
growth failure in early childhood and the development of
overweight in later childhood along with the associated
risk of elevated blood pressure, glucose, and serum lipids
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Table 1 Child malnutrition, underweight, anemia, obesity and iodine deficiency in select North African countries.
Nutrition problem
Evaluation criteria
Country
Algeria
Egypt
Libya
Mauritania
Morocco
Tunisia
Child malnutrition: percent
Moderate and severe
14.3
11.7
4.7
23.0
9.0
4.0
under 5 y who are
Severe
4.3
2.8
0.6
9.2
1.8
0.6
underweight*
Pregnant women
35.2
35.9
5.5
46.2
39.3
30.5
Prevalence of anemia (%)†
Children under 5 y
37.6
40.3
20.3
73.8
45.0
32.2
Non-pregnant women
31.3
32.7
23.5
42.0
34.0
27.0
Males
5.3
22.1
11.5
3.7
3.7
7.7
Prevalence of obesity in
Females
13.5
45.6
22.4
22.7
20.6
30.1
2005 (%)‡
Total goiter rate
8
>5
0
–
22
0.58
Iodine deficiency (%)§
Household iodized salt
68
56
90
1.9*
41
97
* Data from UNICEF.15
Data from FAO.17
‡
Data from WHO.18
§
Data from Azizi and Mehran (2004).11
†
in adulthood have been observed.8 Recent studies suggest
that certain Middle Eastern and African countries are in
the process of nutrition transition.9
Currently developing nutrition transitions are deeply
rooted in the processes of globalization, which is associated with changing incomes and lifestyles. Globalization
is having a major impact on food systems around the
world that affect availability and access to food through
changes in food production, procurement, and distribution. Unfortunately, urbanization and social development
occurring in certain countries are not often accompanied
by steady and significant economic growth. Although
food consumption patterns and dietary quality are highly
income-dependent, dietary choices are also driven by
non-economic forces.10
While the problems of undernutrition still exist, the
burden of overweight and obesity and diet-related
chronic disease is increasing. This can be seen in the case
of Iran, which has an endemic area of iodine deficiency
disorders and where iron-deficiency anemia has been a
major public health problem. Moreover, riboflavin deficiency, repeatedly documented in preschool children, still
constitutes a significant problem. Following is a review of
some of the key malnutrition disorders affecting the
WHO Regional Office for the Eastern Mediterranean
(WHO EMRO), consisting primarily of Middle Eastern
and North African countries, at the beginning of the third
millennium:
Iodine deficiency disorders
Programs of universal salt iodization have been implemented in the WHO EMRO region; Iran, Lebanon, and
Syria have the highest percentages of iodized salt consumption, whereas Afghanistan and Pakistan have the
lowest. The prevalence of goiter in the Islamic Republic of
Iran was found to be between 10% and 60% in 1968. A
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nationwide survey of goiter in 1989 showed that goiter
existed in schoolchildren in most provinces at rates of
between 30% and 80% and it was estimated that 20
million people were at risk of iodine deficiency. After
legislation was passed in 1994 for the mandatory iodization of all salt produced for household use in Iran, more
than 90% of households consumed iodized salt, as shown
in the 1997 survey. In the last national survey, conducted
in 2001, all provinces were iodine sufficient and the total
goiter rate among school children had decreased to
9.8%.11 In the case of North Africa, the evidence is not as
positive. Iodine deficiency affects about 33 million people
in the region and the prevalence of goiter remains high in
Egypt, Algeria, and Morocco (Table 1). In North Africa,
only about half of the households consume iodized salt.11
Iron-deficiency anemia
Updated data for anemia at the national level is only
available for a few countries in the WHO EMRO region.
The prevalence of anemia in women of childbearing age
ranged from around 20% in Jordan and parts of Egypt to
more than 30% in countries like Bahrain, Iran, and Oman
(Table 2).12 Iron fortification of commonly consumed
foods is the most cost-effective option. A consultation
organized by WHO and UNICEF was held in Tehran,
Islamic Republic of Iran, in October 1998 to develop
effective strategies for combating iron deficiency. Initiatives included supplementation with iron, food fortification, and dietary measures such as changing eating
behavior, as well as public health measures.13 Following
this meeting, flour fortification was begun in Iran.
In North Africa, on the whole, data remain scarce and
although improvements have been made in certain countries, notably Tunisia and Morocco, micronutrient deficiencies are still prevalent. Anemia continues to be a
major public health problem in all North African
Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46
Saudi Arabia
17.2
15.9
–
18.3
15.8
64
70
United Arab Emirates
34
14
14
–
–
26
40
countries (Table 1). It affects the population in general,
but the groups most affected are preschool children and
their mothers.14
With respect to vitamin A deficiency (VAD) in North
Africa, VAD is considered to be a subclinical, mild-tomoderate public health problem among preschoolers and
their mothers in Algeria, Morocco, and Egypt; in Tunisia
it has not been identified as a public health problem. It is
prevalent among 40% and 17% of children under the age
of 6 years in Morocco and Mauritania, respectively.15
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Data from Baghchi (2004)12 and WHO.18
Table 2 Prevalence of anemia and obesity in different population groups in select Middle Eastern countries.
Nutrition problem
Population group
Country
Bahrain
Iran
Lebanon
Prevalence of anemia (%)
Children 6–59 months
48.3
15–30
23
Children 5–14 years
41.6
–
–
Pregnant women
33.5
20–43
25
Women of child-bearing age
37.3
33.4
–
Adult men
20.9
7.9–9.9
–
Prevalence of overweight/obesity
Men
56
57
60
(%)
Women
79
68
53
Oman
–
41
38
40
–
41
42
Protein-energy malnutrition
In the case of Iran, the proportion of underweight,
wasted, and stunted children, plus the infant and under-5
mortality rates, have fortunately all decreased on the
whole over the years. However, the prevalence of stunted
children under the age of 5 years is still relatively high,
nearing 20%. For children under the age of 6 years, 5.2%
are wasted (<2 SD) and 5% are stunted, reflecting malnutrition over the past years. Moderate-to-severe degrees of
underweight have been reported in 3.7% of children
(unpublished data from the Ministry of Health and
Medical Education and the United Nations Children’s
Fund, Tehran).
A rural project aimed at decreasing the incidence of
protein-energy malnutrition among children under the
age of 5 years was conducted in September 1994. The
implementation of nutrition interventions in the primary
healthcare system led to a decrease in the incidence of
malnutrition, dropping from 6.5% to 1.8% in a recent
assessment.16
In the case of North Africa, despite the improvements of nutritional status in young children suggested
by the latest nationwide nutrition surveys available, data
based on anthropometric indicators show that both
undernutrition and overweight are prevalent in children
under the age of 5 years throughout the entire region. In
North African countries, the mean prevalence of undernutrition was 4% from 1992 to 1999 – a figure that represents 39 million children.17
Concerning child malnutrition, as reported by the
UNICEF Global Database on Child Malnutrition,15
underweight is prevalent in children under the age of 5
years in all North African countries, with the highest rates
seen in Mauritania followed by Algeria, Egypt, and
Morocco (Table 1). In adults, underweight has decreased
over the last decade in Morocco, Tunisia, and Egypt, but it
remains elevated in Mauritania.
Overweight and obesity
Alarming increases in the prevalence of obesity and overweight are being observed in the Middle Eastern region;
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Bahrain, Iran, Lebanon, and Saudi Arabia all have a high
prevalence of obesity in both male and female populations (Table 2).18
In the case of Iran, the prevalence of overweight
among urban 15–39 and 40–69 year olds was estimated at
about 22% and 40%, respectively; corresponding values
in rural areas were 16% and 26%, respectively.19 This
demonstrates how Iran is now faced with the need to
simultaneously tackle the double burden of over- and
undernutrition in its population.
As for North Africa, Table 1 shows that overweight
and obesity are prevalent in all countries of the region,
reaching a peak in Egypt, where more than 45% of
women are obese. The trend in obesity prevalence in
North Africa is predicted to continue rising in future
years.20
Changes in the economic, social, and demographic
determinants of health and the adoption of unhealthy
lifestyles are contributing to the observed transformations in disease patterns, characterized by a progressive
and accelerated rise in cardiovascular diseases in the
North African region.
In Libya, a survey carried out in 1998 and 1999 found
that diabetes is emerging as an important public health
problem with a prevalence slightly higher in urban than
in rural areas (14.5% versus 13.5%).21 In Tunisia, a household epidemiologic survey of a representative sample of
the adult urban population of Soussa (n = 957) showed a
high prevalence of hypertension (>160/95 mm Hg) in
18.8% (adjusted rate: 15.6%), a history of diabetes in
10.2%, obesity (BMI > 30) in 27.7% (with a higher
[34.4%] prevalence in women), and android obesity in
36% of the study sample.22
In Algeria, the first detailed prevalence data for an
Algerian population,23 consisting of a sample of 1457 subjects aged 30–64 years from Setif Wilaya, showed that the
prevalence of type 2 diabetes and glucose intolerance has
an important socioeconomic impact. Also, a 2003 pilot
survey conducted in Setif and Mostaganem demonstrated
that 27.6% of the population was hypertensive and 6%
was diabetic.20
In Morocco, data on the anthropometric status of
children under the age of 5 years show that both undernourishment and overweight are prevalent.24,25 In adult
data from the 1984 national household consumption and
expenditure survey, prevalence rates of 21.4% for overweight (16.9% men and 25.5% women) and 4.1% for
obesity (1.6% men and 6.4% women) were observed.26
More recently, in the year 1998, the prevalence of overweight increased to 27.1% (21.1% men versus 29%
women) and obesity increased to 11.7% (4.3% men versus
16% women). The prevalence of CVD risk factors also
increased.27 In fact, a more recent national-level survey,
carried out in the year 2000 on 1500 men and women
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aged 15–60 years,28 indicated that the prevalence of
obesity had doubled among women, to 17.8%, and
showed high rates diabetes (6.6%), hypertension (33.6%),
and hypercholesterolemia (29%).
In the same way, various surveys in Egypt have concluded that the primary nutritional problem for many
Egyptian adults is a tendency towards obesity. According
to the study in 2000, there was an increase in BMI, reaching an average of 30 ⫾ 4 kg/m2, as well as an increase in
the prevalence of obesity (BMI ⱖ 30 kg/m2) in mothers
(42%).29
Being overweight is associated with a higher risk of
CVDs, type 2 diabetes, ischemic heart disease, hypertension, and certain cancers.30 In almost all populations in
the North African region, CVD risk factors and metabolic
syndrome have been increasing with age, affect more
women than men, are higher in urban versus rural areas,
and are associated with obesity,31,32 which is reaching
immense proportions, particularly among women. A
pressing need exists in this region to intensify efforts to
strengthen programs for the prevention and control of
obesity.
Sedentary behavior is one of the main factors
contributing to increased obesity rates and related cardiovascular risk factors. Data demonstrate a sedentary
lifestyle is highly prevalent in the North African population. Indeed, a high percentage of the population has
decreased the amount of physical activity engaged in
during both work and leisure by spending more hours
per week watching TV and by utilizing more vehicles
and activity-saving appliances.33 Results of a survey conducted in 2002 among Moroccan women older than 15
years on the association between physical inactivity and
cardiovascular risk factors indicated that physical inactivity appears to play a critical role in the development
of body fat and may be a risk indicator for features of
metabolic syndrome.34,35
Although most national public health programs and
policies in North Africa focus on undernutrition and its
effects on survival, mortality, and the development of
mothers and children, more efforts should be made to
decrease other types of malnutrition in this region.
North African countries, as well as other countries in the
Middle East, are undergoing health and nutrition transition. There is no doubt that if malnutrition and micronutrient deficiencies are not eradicated, there will be an
increased prevalence of noncommunicable diseases.
However, noncommunicable diseases are often not recognized as a high public health priority in the majority
of countries in these regions, which are still confronted
with the heavy burden of infectious diseases and poor
maternal and child health. The health and nutrition
transition is happening in the absence of steady and significant economic growth.
Nutrition Reviews® Vol. 67(Suppl. 1):S40–S46
Studies show that the shift of dietary habits from a
traditional diet to industrial food could explain, in part,
the nutritional and metabolic disorders reported in these
population groups. Unhealthy dietary practices include
the high consumption of saturated fats and refined carbohydrates, low consumption of fiber, and increasingly
sedentary behavior. Growing urbanization has also been
accompanied by a progressive increase in cardiovascular
risk factors such as obesity, hypertension, diabetes, and
hypercholesterolemia.
CONCLUSION
Poverty, hunger, malnutrition, nutrition transition, and
obesity and noncommunicable diseases are coexisting in
Africa and parts of the Middle East, creating inequalities
that need to be addressed politically. Countries in these
regions need nutrition solutions that are adapted to their
circumstances and that combine supplement use as well
as agricultural and educational actions to achieve better
and sustainable nutrition for improved public health.
Acknowledgment
Declaration of interest. The authors have no relevant
interests to declare.
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