Nutrition Innovation Lab (2015) Egypt Literature Review Final (Feb 2016

Understanding the complexity of under and over nutrition in Egypt

Shibani Ghosh, Ashish Pokharel, Patrick Webb, Marwa Moaz, Johanna Andrews-‐Chavez

Grace Namirembe, Elizabeth Marino-‐Costello and Jeffrey K. Griffiths

Report to USAID Mission in Egypt Associative Cooperative Agreement AID-‐263-‐LA-‐14-‐00004

Reference Leader Cooperative Agreement AID-‐OAA-‐L-‐10-‐00006

Understanding the complexity of malnutrition in Egypt

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

1 Based on 2013 GDP of US$272 billion. The level of US$5.5 billion per year is considerably higher than the estimate made in by Abegunde et al. (2007) of the cost of malnutrition to Egypt of US$1.5 billion per year by 2015.


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

Source: El-‐Kogali and Krafft 2015


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Aitsi-‐Selmi A. (2014), Kavle et al. (2015) and El-‐Kofali and Krafft (2015) all concur that stunting rose in Egypt in the late 2000s, and that “the reason for the increase in stunting prevalence requires further research.” (Réstrepo-‐Mendez et al. 2014) (Table 1). A review of the trends clearly demonstrates that: i) national level prevalence rates for stunting increased from 2003 to 2008 (from 20 % to around 30 %), and then fell to about 20 % as of 20142; ii) as in most other countries, the majority of stunting in children is already present before the age of 24 months; iii) the average annual rate of reduction (AARR) in stunting needed for Egypt to achieve the World Health Assembly goal of a 40 % fall between 2010 and 2025 was 3.7 % per annum based on 2008 data (IFPRI 2014). Now that the trend has shifted positively, Egypt will need to focus on bringing the 2014 prevalence rate of about 20 % down to around 11 % in the next decade to meet the WHA goals (MHP/El-‐Zanaty/Macro 2015). Achieving this goal will require a prevalence rate decrease of 1 percentage point per annum, which should be feasible if the right actions are taken. Table 1: DHS estimates of undernutrition in Egyptian children under five years of age DHS 2003 DHS 2005 DHS 2008 DHS 2014

Percentage of Stunted Children

Urban Governorates 15.03 18.69 22.70 19.0 Lower Egypt-‐ Urban 12.89 16.25 38.22 19.3 Lower Egypt-‐ Rural 14.34 20.12 32.85 17.6 Upper Egypt-‐ Urban 21.47 29.97 23.26 29.8 Upper Egypt-‐ Rural 25.05 33.87 26.87 24.8 Frontier Governorates -‐ 26.06 28.66 15.1

Total 19.86 26.78 28.63 21.4

Percentage of Wasted Children


Total 4.7 4.97 7.1 8.4

Percentage of

Underweight Children


Total 7.89 5.48 5.89 5.5

2 A rate that was foreshadowed by the MICS of 2014, which also found just over 21 % moderate stunting (MHP/UNICEF/El-‐Zanaty 2014).


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


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Figure 2: Changes over time in rate of child stunting by wealth quintile, Egypt and Jordan

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

Egypt 2014


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There are still significant knowledge gaps with respect to stunting in Egyptian children. For instance:

Ø What explains the statistically significant rise and then fall in mean stunting prevalence over relatively short periods of time in Egypt?

Ø Why did inequality in the distribution of stunting by wealth practically disappear, and then reappear – and in a form where the richest and poorest wealth quintiles are similar?

Ø Since not all wealth quintiles or geographic regions are seeing an increase in stunting, what might explain relative changes over time by income and location?

Ø Why is severe stunting not increasing at the same pace as moderate? Ø To what extent does the rise in stunting result from the rapid increase in maternal

obesity (which is known to be associated with poor birth outcomes and both child stunting and the foetal and neonatal programming of adult-‐onset chronic diseases)? According to Aitsi-‐Selmi (2014), the trends in data from DHS since 1992 suggest the existence of “a link” between maternal obesity and a rise in the number of households with concurrent overweight/obesity and stunting, but the nature of that link has yet to be found.

Wasting Despite the reversed trend in stunting prevalence between 2008 and 2014, child wasting continued to increase to reach 7 % nationally – up from 3 % in 2000 (MHP/El-‐Zatany/Macro 2015). In 2003, the highest rates of moderate wasting (defined as weight for height Z-‐score that is 2 SDs below the mean of an internationally-‐defined reference set by the World Health Organization) were in the Urban Governorates and in the highest wealth quintile. Moderate wasting carries a 5-‐fold increased risk of preventable child mortality from communicable diseases. By 2014, it is the Frontier Governorates that records the highest prevalence of moderate wasting (14 %), along with the fourth and middle wealth quintiles which have gained the most in terms of stunting since 2008. That being said, there is no difference at all between the top and bottom quintiles of the wealth distribution in terms of wasting prevalence. This contrasts with the small but real gap for stunting in 2014 (Table 1). A 14 % prevalence of moderate wasting (or Global Acute Malnutrition) represents a serious problem according to the crisis classification of the World Health Organization. It is on the threshold of ‘critical’ status, which at 15 % typically triggers a large scale humanitarian response in the context of emergencies (WHO 2003). Severe wasting, which carries an immediate and imminent risk of mortality if not appropriately treated, was the highest in 2005 in the poorest households of rural Upper Egypt. By 2014, this had changed to mirror moderate stunting; with higher rates observed in the Frontier Governorates (followed by urban Upper Egypt) and in the highest 3 wealth quintiles (not the poorest). Knowledge Gaps on wasting:

Ø What explains the very high rates of moderate wasting in the Frontier Governorates – rates that are often associated with humanitarian crises?


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Ø Why is there more wasting prevalence in the 3 higher wealth quintiles than in the lower two (poorer) quintiles? What does this suggest for targeting of interventions for treatment and for prevention?

Ø Based only on the DHS for 2003, Khatab (2010) found that age of mother was statistically correlated with wasting outcomes; that is, the older the mother the more likelihood of wasting. Since age in women is also correlated with obesity (the share of women who are obese more than doubles from 20 % in the 20 to 29 year old category to 65 % in the 40 to 49 years old category), and wasting episodes can contribute to linear growth retardation (stunting), the relationship between obesity and wasting deserves to be explored further (MHP/El-‐Zatany/Macro 2015).

Ø Are locations and household groups with high rates of severe stunting more prone to acute wasting?

Ø Are the dynamic patterns noted for stunting rates over time in Egypt mirrored by similar, or featuring different, patterns for wasting?

Maternal low BMI This nutrition problem has not featured as a concern for Egypt for good reason – it is almost non-‐existent. In 2003, only 0.5 % of adult women had a body mass index (BMI) <18.5 reflecting thinness or undernutrition – most of those were in the poorest wealth quintile and in the 15 to 19 year-‐old age category. By 2014, those two categories of individuals still had most of the problem of thinness, but its prevalence had dropped overall to only 0.2 %. It is mainly concentrated today in rural Upper Egypt. Preventive actions include enhancing the health and nutrition of adolescent girls and young mothers in the context of Scaling up Nutrition (SUN) also termed as the 1,000 day initiatives. Micronutrient Deficiencies While there are very limited data for Egypt on actual deficiencies in vitamins and minerals (since most DHS and other nationally representative surveys do not typically collect such data other than anemia status), it has been estimated that Egypt loses more than US$814 million (through lost GDP) to micronutrient deficiencies (World Bank 2010). This is likely to be a significant underestimate, given the scale of economic losses associated with stunting that was noted above. The World Bank (2010) has estimated that 12 % of preschoolers and over 20 % of pregnant women were deficient in vitamin A; that 30 % of preschoolers and 45 % of pregnant women were anemic; and that 9 % of the population was at risk for insufficient zinc intake. These represent estimates rather than data derived from nationally representative surveys. One recent study of zinc dietary intake among pregnant women in hospital settings reported zinc deficiency in 53.5 % of the sample (Naem et al. 2014). Similarly, an assessment of vitamin D status among diabetic patients (Egyptian children and adolescents with Type 1, or insulin-‐requiring, diabetes mellitus) found that 55 % of the diabetics were vitamin D deficient (Azab et al. 2013). Importantly, in terms of intergenerational impacts of such deficiencies, El Koumi et al. (2013) found that pregnant women deficient in vitamin D in Egypt bore infants with vitamin D deficiency.


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Other recent related studies include the larger study on folate status by Tawfik et al. (2014). It identified folate deficiency in almost 14 % of just under 2,000 households in 9 Governorates. The highest rates of deficiency were found in Lower Egypt (over 23 %), with the coastal regions showing less than 4 % deficiency. Adolescents showed a slightly lower than average deficiency of around 12 %. Folate deficiency leads to anemia and birth defects such as spina bifida, congenital heart defects, cleft lip, and urinary tract abnormalities. At a national level, the 2014 DHS reports far fewer women in the lowest wealth quintile live in homes that use iodized salt (80 % compared with over 98 % in the top wealth quintile). It also reports that a quarter of children in Egypt suffer from some degree of anemia, although most of this is mild to moderate in nature. Roughly 10 % were found to be moderately anemic, with the remainder classified as mildly anemic. Children in rural households are more likely to be anemic than urban children (29 % and 23 %, respectively). Children in the three Frontier Governorates and in rural Upper Egypt are more likely than children in other areas to be anemic (45% and 30%, respectively). Knowledge Gaps on micronutrient deficiencies:

Ø What are current rates of key micronutrient deficiencies, and how are these distributed by wealth quintile, residence, gender, etc.?

Ø To what extent are micronutrient deficiencies linked to obesity, stunting and wasting (by association and or determination)?

Ø What are current coverage rates of supplementation and fortification interventions in relation to estimates of deficiencies, actual dietary patterns, and other forms of nutrition outcomes?

Overweight and Obesity Egypt has had the biggest rise in overweight and obesity since 1980, and is one of 10 countries that account for more than half of the world’s obesity problem (in terms of absolute numbers affected) (Ng et al. 2014). Overweight is defined as having a body mass index (BMI) > 25, and obesity is defined as a BMI > 30. While overweight and obesity tend to cut across Egypt’s regions and, to some extent, its wealth categories, the country stands out as having one of the highest gender disparities in obesity (IFPRI 2014b). That is, Egypt ranks 8th in the world in terms of adult male obesity, but 3rd in the world in adult female obesity (Badran and Laher 2011). Table 2 shows that there is wide variation across selected countries of the region in terms of this male-‐female differential, which has yet to be adequately explored or explained. Adding in the latest data for Egypt from the 2014 DHS, the difference is likely to have increased – since adult women’s obesity prevalence appears to have risen to 48 % (MHP/El-‐Zatany/Macro 2015) with almost 80% of women classified as overweight. While the DHS does not typically report on male obesity, the Global Nutrition Report (IFPRI 2014b) notes male obesity in Egypt as 22.5 % (about 62% classified as overweight): resulting in a gender difference of 25.5 % (a much higher rate than the 17.2 % rate noted in 2010, Table 1).


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Table 2: Prevalence of obesity (BMI≥30) among adults by gender, selected countries

Country Age (Years) Males (%) Females (%) Difference

(Female% -‐ Male%) Total (%)

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

3 Although Ng et al. (2014) estimate Egypt’s male obesity rate (adults over 20 years) at 26.4 %, which would narrow the difference a little.


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Figure 3: Obese Women (Ever-‐Married, Aged 15-‐49, by Region

Knowledge Gaps on obesity:

Ø What explains the unusually high different in obesity rates between men and women? Ø Can one predict (model) subsequent rates of obesity from prior rates of stunting

depending on location and rate of wealth increase over time? That is, is a stunted child with access to a nutrient-‐poor diet more likely to become an obese adult in certain settings, controlling for education of parents, setting, age, etc.

Ø Why do patterns of overweight and obesity differ by wealth quintile depending on age? That is, <20 year olds do not directly reflect patterns and trends among older women (for whom wealth is less of a distinguishing factor).

Co-‐Existing Burdens Egypt has attracted growing attention of researchers due to the multiple forms of malnutrition occurring across its rapidly increasing population. Most work indicates that despite the variable epidemiological and geographic spread of the different forms, one or more form of poor nutrition (undernutrition as manifested by stunting or wasting, micronutrient deficiencies, overweight and obesity, and associated co-‐morbidities such as diabetes mellitus) are likely to be correlated at the level of the individual or the household. For example, at the individual level Asfaw (2007) reported that the odds of being overweight or obese were 81 % higher for micronutrient deficient mothers in Egypt than for non-‐deficient mothers (controlling for

20

25

30

35

40

45

50

55

60

Percen

tage of W

omen

Urban Governorates

Lower Egypt-‐ Urban

Lower Egypt-‐ Rural

Upper Egypt-‐ Urban

Upper Egypt-‐ Rural

Fronser Governorates (excludes North & South Sinai governorates)

Source: Egypt DHS 2014


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socioeconomic and health variables).4 Asfaw (2007) did not, however, untangle the direction of causality; that is, does being micronutrient deficient contribute towards becoming obese, or does being obese result in deficiencies in certain micronutrients? Conversely, using just the 2000 DHS data, Eckhardt et al. (2008) noted that overweight and obese women had significantly lower odds of being anemic than women who are not overweight; the latter difference was statistically highly significant, but was not found to hold for other countries such as Mexico and Peru. This then raises questions about the generalizable assumptions of underlying physiological mechanisms. It has also been shown that anemia and low vitamin A status are more prevalent among stunted children in Egypt than among non-‐stunted children (Khairy et al. 2010). Indeed, as shown in Table 3, stunted children were also likely to have significantly lower serum levels of calcium, magnesium, zinc, selenium and copper. Again, because of the use of a cross-‐sectional study design, the authors were unable to conclude anything regarding the direction of causality. Table 3: The association between stunting and mineral deficiencies in Egyptian children

Stunted (n=100) Control (n=100) P-‐value

Macro minerals Calcium (mg/dl) 7.55±1.46 8.72±1.35 <0.05*

Phosphorus( mg/dl) 5.60±0.81 5.50±1.10 >0.05 Magnesium (mg/dl) 2.26±0.24 2.37±0.23 <0.05*

Micro minerals Zinc (µg/dl) 98.47±30.45 115.02±25.32 <0.05*

Selenium (µg/dl) 8.53±2.34 11.07±3.18 <0.05* Copper (µg/dl) 86.62±19.95 91.41±16.61 >0.05

Source: Khairy et al. (2010)

At the household level, the co-‐existence of stunted children and obese mothers in the same household increased significantly from the early 1990s to the late 2000s. Aitsi-‐Selmi (2014) found that this pairing rose from 4 % in the 1992 and 1995 DHS rounds, to almost 6 % by 2008. This puts Egypt in the same realm as Bangladesh which has around 4 % of households with both obese mothers and underweight children, and Indonesia’s 11 % of households with such a pairing (Oddo et al. 2012). That said, according to the 2014 DHS for Egypt, moderately stunted children are slightly less likely to be paired with an overweight or obese mother (21%) than paired with a mother with a normal BMI (23.5%). The same is true for severely stunted children and also for wasted children. The one case where the pairings lean towards the obese mother is the 15 % of 4 The author concluded that the co-‐existence of these nutrition problems is important given “the potential impact of the interaction between micronutrient deficiency and chronic diseases is not well known.” (Asfaw 2007)


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children who are themselves overweight (+2 SDs of weight-‐for-‐height) and have an overweight or obese mother. That compares with 13 % of overweight children who have normal weight mothers (MHP/El-‐Zatany/Macro 2015).

Perhaps not surprisingly, the largest share of the 27 % overweight girls and adolescents (5 to 19 years of age) are found in both rural and urban Lower Egypt, which is the location of most maternal overweight and obesity. That pattern holds true for boys and adolescents (5 to 19 years of age), but there is also a high concentration of overweight and obesity among males of this age in urban Upper Egypt. The existence of stunting and overweight/obesity in the same child has been documented globally in Guatemala, Mexico, Russia, China and Brazil (Fernald and Neufeld 2007, Popkin et al 1996). Published analyses of the 2005 Egypt DHS data indicate an interaction of stunting and obesity/overweight within the same individual/child (Dodoo 2011). The author noted that simultaneous stunting and obesity is spread across all social and economic classes though the relationship is complex -‐ and recommended further study and analyses to elucidate factors that influence stunting and obesity in Egyptian children. This is particularly interesting, as research in Latin America has shown that childhood nutritional stunting is associated with impaired fat oxidation, a factor that predicts obesity in at risk populations (Hoffman et al 2000). Furthermore studies done in Brazil on stunted and non-‐stunted children have shown higher fat mass accumulation in stunted boys and less lean mass accumulation, over a 3 year period of observation. Similarly stunted girls also gained less lean mass and had significantly higher values of fat mass when compared to their baseline (Martins et al 2004). This is a significant public health issue since co-‐existence of the double burden within the same child is related to significant risk of metabolic syndrome and later risk of chronic diseases such as diabetes mellitus and cardiovascular diseases. (Popkin et al 1996). Knowledge Gaps on co-‐morbidities:

Ø Did the pairing of stunted child with obese mother continue to increase in the 2014 DHS round? While stunting will have declined, the prevalence of obese mothers has risen dramatically, suggesting that such pairs may reach close to 10 % of households.

Ø Which adverse anthropometric conditions (stunting or wasting versus obesity) are associated with each other (obesity and stunting can coexist at both individual and household levels) or with other nutritional deficiencies?

Ø What is the prevalence of the co-‐existence of stunting and overweight in the same child? Are there similar issue viz-‐a-‐viz fat mass versus lean mass accumulation in stunted children?

Ø Does obesity (or stunting) cause certain micronutrient deficiencies, or are they joint outcomes of a common process?

Ø Can programs aimed at tackling micronutrient status have positive side-‐effects in preventing stunting or obesity in the absence of additional activities?

Ø Do multiple bouts of wasting contribute to stunting in such a way that later obesity is more or less likely in the individual?


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


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


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Figure 4 shows the UN World Food Programme’s food consumption analysis for Egypt which highlights the poor status of food consumption in Upper Egypt, but especially in Rural Upper Egypt. Of note is the low % recording a ‘poor’ score in the Frontier Governorate. Figure 4: Food Consumption Scores by Region in Egypt (2011)

Source: WFP 2013

WFP’s food score is one approach to assessing dietary adequacy. Others, like the DHS, focus on the absence or presence of specific foods or food groups, particularly those considered to be nutrient dense and contributors to a ‘healthy diet’. Table 5 puts Egypt’s dietary risk factors for cardiovascular disease in a comparative context. While not very different in terms of total number of days of fruit consumption, Egypt falls short of the ideal compared with Jordan in terms of days of vegetables consumed, and especially in terms share of households consuming fewer than the widely recommended 5 daily servings of fruits and vegetables. Table 5: Diet-‐Related Risk Factors for Chronic Diseases, selected countries

Both Sexes

Egypt (2011-‐12) Jordan (2007) Qatar (2011)

No. of Days Fruits Consumed (Per Week) 3.5 4.1 3.4 No. of Days Vegetables Eaten (Per Week) 4.6 6.2 5.5 % Eating < 5 Servings of F&V (Per Day) 95.6 14.2 91.1

Source: WHO STEPS survey data (WHO Qatar 2014; Egypt 2013; Jordan 2009) Figure 5, based on national data from FAOSTAT shows that Egypt’s overall consumption is still heavily dominated by grains, and contains a relatively low share of protein from animal sources. Animal source protein is of high quality, which is considered to be critical to child growth and the prevention of stunting. The heavy reliance on (subsidized) grain for total energy in the diet


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has been remarked on many times, but trends in supply of animal source foods, and fruits and vegetables, deserve more attention. Figure 5: Percent of Dietary Energy Supply by Food Groups, Selected Countries

Other Behavioral Risk Factors Linked to Obesity In Egypt, reported deaths from cardiovascular disease (CVD) have risen from 5 % in the 1960s to almost 50 % by the 2000s (Sibai et al. 2010). The proposed drivers of Egypt’s rise in CVDs include urbanization, sedentary lifestyle, smoking, and unhealthy dietary changes. Table 6 shows that these kinds of risk factors vary across countries, but Egypt has high levels of both physical inactivity and tobacco use. Indeed, when disaggregated by gender, interesting patterns emerge. While in Egypt there are few differences in dietary risk factors between adult men and women, physical inactivity among men is reported as 23 % compared with 42 % among women. In Jordan, slightly more men are inactive than women, but the rates are still so low that neither make the kind of contribution that one sees in Egypt (and Qatar).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Egypt Saudi Arabia Lebanon

Percentage

Countries

Others

Fruits & Vegetables

Milk

Meat, Animal Fats, Eggs,Fish & Seafood

Vegetable Oils

Sugar

Cereal Products

Source: Food Balance Sheet 2011, FAOSTAT


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Table 6: Risk Factors for Chronic Diseases, selected countries

Both Sexes

Egypt (2011-‐12) Jordan (2007) Qatar (2011)

% with Low Physical Activity 32.1 5.2 45.9 % who Currently Smoke Tobacco 24.4 29.0 16.4

Source: WHO STEPS survey data (WHO Qatar 2014; Egypt 2013; Jordan 2009) Linked to Undernutrition Although breastfeeding is reported to be almost universal in Egypt by the 2014 DHS, sub-‐optimal practices are common (i.e. exclusive breastfeeding is not so common), and appropriate infant and young child feeding practices are seen to have fallen quite dramatically in the last two DHS rounds. Table 7 shows that this has happened across all wealth quintiles in relation to the provision of breast milk and/or milk products to infants and young children. Milk contains protein, calcium, and many other critical nutrients. Table 7: Breast milk/milk product consumption among young children

Wealth DHS 2008 DHS 2014 Lowest 97.4 80.9 Second 96.5 78.8 Middle 96.9 79.3 Fourth 95.2 77.4 Highest 98.2 83.3 Total 96.8 79.7 Source: DHS 2008 and 2014

The same is true of appropriate complementary feeding practices for infants and young children, focused on providing 3+ food groups daily (to infants) and 4+ (to young children) (Table 8). The 2014 DHS reports that less than one-‐quarter of children age 6-‐23 months are being fed according to minimum Infant and Young Child Feeding (IYCF) standards for diet diversity and meal frequency, although breastfed children are more likely than non-‐breastfed children to have a minimum acceptable diet.


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Table 8: IYCF practice: 3+ or 4+ food groups among young children

Wealth Quintile DHS 2008 DHS 2014 Lowest 63.7 43.9 Second 66.5 40.3 Middle 70.0 43.2 Fourth 67.1 43.7 Highest 75.0 45.0 Total 68.5 43.2 Source: DHS 2008 and 2014

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


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


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

Ø Are the declines in provision of milk to infants and food groups to young children associated with price dynamics, location, and education?

Ø To what extent are risk factors for non-‐communicable diseases linked to the drivers of stunting and micronutrient deficiencies, controlling for wealth?

Ø Actual consumption patterns are poorly understood, separate from food group consumption or derived energy by food group in the national food supply.

Ø A greater focus on ‘positive deviants’ is warranted, in terms of relatively good outcomes on various nutrition outcomes in locations, quintiles or other categories that would have


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suggested otherwise; in other words, where are the counter-‐factual cases from which lessons might be learned?

Ø Is there a relationship between aflatoxin exposure and growth patterns? How is this relationship modulated by the co-‐existence of overweight and obesity in mothers? How does this relate to differences in stunting/height for age adjusting for geographic location and wealth quintile?

Ø Is there a relationship between EE and growth pattern in Egyptian children? How does this relate to differences in stunting/height for age adjusting for geographic location and wealth quintile?

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


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Within the context of micronutrient deficiencies, there is little information on the current rates of key micronutrient deficiencies and how they are distributed by wealth quintile, geographic location, residence and gender. Not much is known on how these deficiencies manifest within the context of obesity, stunting and wasting (by association or by determination). Furthermore, more documentation is required on the policy initiatives and efforts in the realm of supplementation and fortification interventions relative to the estimates of deficiencies, actual dietary patterns and other nutrition outcomes. A key issue that emerges from the review is the unusually high and differential rates of obesity between men and women. Research is required to understand if one can predict (model) subsequent rates of obesity from prior rates of stunting depending on location and rate of wealth increase over time? That is, is a stunted child with access to a nutrient-‐poor diet more likely to become an obese adult in certain settings, controlling for education of parents, setting, age, etc. Finally, why do patterns of overweight and obesity differ by wealth quintile depending on age? That is, <20 year olds do not directly reflect patterns and trends among older women (for whom wealth is less of a distinguishing factor).

Substantial population overlap exists across different morbidities-‐ especially stunting and overweight/obesity in maternal-‐ child dyads. DHS data from 2014 needs to be examined to determine if the prevalence of pairing of stunted child with obese mother increased. While stunting will have declined, the prevalence of obese mothers has risen dramatically, suggesting that such pairs may reach close to 10 % of households. A clear area for research is the relationship between repeated bouts of wasting and its effect of stunting and future overweight/obesity. There is need to delineate the association amongst the different anthropometric conditions (stunting or wasting versus obesity) and other nutritional deficiencies. An area that needs further exploration is the change in prevalence of the co-‐existence of stunting and overweight in the same child. Furthermore, can programs tackling micronutrient deficiencies have positive side effects through prevention of stunting and obesity in the absence of additional activities? Actual food consumption patterns are poorly understood in Egypt and there is need to separate food group consumption or energy consumption from actual nutrient intake. The relationship between access, availability and intake of different foods and foods groups by young children in relation to price dynamics, location and education has to be explored. A greater focus on ‘positive deviants’ is warranted, in terms of relatively good outcomes on various nutrition outcomes in locations, quintiles or other categories that would have suggested otherwise. The area of non-‐nutrition determinants requires further exploration. For instance, is there a relationship between aflatoxin exposure and growth patterns? If so, how is this relationship modulated by the co-‐existence of overweight and obesity in mothers? How does this relate to differences in stunting/height for age adjusting for geographic location and wealth quintile? Finally, given the water, hygiene and sanitation issues and their potential link to EE, there is need to examine the relationship between EE and growth pattern in Egyptian children and how


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that relates differences in stunting/height for age adjusting for geographic location and wealth quintile.

In conclusion, three important researchable facets emerge from this review of existing literature and preliminary assessment of survey findings relating to nutrition in Egypt:

1. The nutrition challenges facing academia, programmers, decision makers and policy makers in Egypt are not simply multifaceted; they are dynamic (changing quite rapidly in multiple ways in many directions), and diverse. Patterns and trends are playing out in sometimes unexpected ways -‐ the sharp increase and then decline in stunting, the gender divide in adult obesity, the subnational overlays of some nutrition problems but not others, and the variegated manifestations of severe versus moderate conditions across wealth quintiles, levels of educational attainment, and diets and the interrelationships of environmental and behavioral risk factors with nutrition problems. There is however little information on how nutrition policy and strategy formulation in Egypt is addressing these multifaceted challenges. Furthermore, any strategy or policy formulation needs to take a more nuanced approach to considering policy options – blunt instruments (remove all food subsidies, maximize supplementation coverage, ensure universal exclusive breastfeeding) are unlikely to work the same way in all locations and equally on all manifestations of nutrition problems. There has never been a more clear case that one-‐size-‐fits-‐all policymaking will not suffice. Further, little is known of the current policy initiatives and how they aim to address these multifaceted challenges. Given this, it is critical to understand the current policy environment including barriers and facilitators of formulating a multi-‐sectoral nutrition, food and agricultural policy that is integrated and that focuses not only on quantity but also on quality of food and services available. An analysis of current barriers and facilitators within the context of nutrition policy will allow policy makers to better strategize future policymaking.

2. The dominant public health perspective to nutrition has generated many analyses that rely on Odds Ratios and bivariate associations leading to recommendations focused on behaviour change communication, enhanced coverage of classic targeted nutrition interventions (such as supplementation), and infant feeding (Kavle et al. 2015; Atsi-‐Selmi 2014). It will be critical to determine what additional value can be gained from non-‐parametric and other more advanced econometric multivariate analyses that go beyond the calculation of paired Odds Ratios using single datasets. There are fortunately several surveys starting from the 1990s through 2014 that would allow a researcher to go beyond the single year comparisons and use higher level regression modeling to understand the relationships of the co-‐morbidities across the different population types and geographic locations in Egypt. Furthermore, most (although not all) nutrition analyses have been conducted through a public health lens, relying on demographic and health data. While other forms of data exist that could broaden understanding of the multiple drivers of the diverse outcomes seen in nutrition, little is known about, for example, how changes in agriculture productivity have been linked to food options and


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prices in the market, how food price substitution influences choice in different subnational regions, or the role that packaged/processed foods have in changing diets (potentially supplying micronutrients, dairy and other animal source nutrients).

3. Most secondary analyses are unable to consider the lagged effects (prior wasting to

stunting, prior stunting to obesity, prior obesity to low birth weight and wasting, etc.) on nutrition outcomes. Furthermore, the role of water and sanitation (controlling for diarrhoeal and other diseases), food safety concerns specifically associated with aflatoxin contamination, and multilayer models that address ‘neighborhood effects’ in the data that may confound results and our understanding of implications require specialized studies and data collection in specific populations such as pregnant women. Nutrition Innovation Lab’s primary data collection activity will aim to generate evidence on the possible factors for stunting and poor nutritional status. We predict that mycotoxins exposure through food, leaky gut through ingestion of harmful microorganisms in drinking water, and poor hygiene will explain stunting among young children and poor nutritional status of mothers. For this study, we will enroll on 400 pregnant mothers, their 3-‐5 year old child, and their newborn infant from a rural catchment area around El-‐Araby Hospital in the Nile Delta Region. For the purposes of this study, we will examine the following: mother’s and child’s mycotoxin levels in blood, water quality at their household, gut permeability through dual sugar tests, and microbiota in their stool samples. Furthermore, we will administer a survey that assesses nutrition knowledge and behavior, sanitation practices and food consumption patterns. Another component of the study also features examining probiotic yogurt consumption and its effect on gut permeability. The study will last for a period of 4-‐6 months and data will be collected at 2 different time points. We predict that collecting data at 2 different time points will help us to find causal relationship between stunting and environmental exposures like mycotoxins and other harmful microorganisms, poor sanitation etc

In conclusion, there is currently no clear narrative for Egypt’s nutrition transition. The patterns are too varied and unpredictable to conform to a simple understanding of problems that are rapidly emerging and transforming on multiple fronts. Other countries in the Middle East North Africa region are not like this. There is an urgent need for a reassessment of the drivers of co-‐morbidities in time and space, of projected trends to 2020 (when the next DHS survey is published), and how these interlocked burdens might be addressed in a more comprehensive fashion through multiple sector actions underpinned by public and private sector commitments.


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References Abdel Wahab M, Mostafa M, Sabry M, el-‐Farrash M, Yousef T. 2008. Aflatoxins as a risk factor

for hepatocellular carcinoma in Egypt. Mansoura Gastro-‐enterology Center study. Hepatogastroenterology 2008, 55 (86-‐87): 1754-‐1759.

Abegunde D. et al. 2007. The Burden and Costs of Chronic Diseases in Low-‐Income and Middle-‐Income Countries. Lancet 370:1929–38. Afshin A, Micha R, Khatibzadeh S, Fahimi S, Shi P, et al. 2015. The impact of dietary habits and

metabolic risk factors on cardiovascular and diabetes mortality in countries of the Middle East and North Africa in 2010: a comparative risk assessment analysis. BMJ Open 2015;5:e006385. doi:10.1136/bmjopen-‐2014-‐006385

Aitsi-‐Selmi A. 2014. Households with a Stunted Child and Obese Mother: Trends and Child Feeding Practices in a Middle-‐Income Country, 1992-‐2008. Matern. Child Health Jou. DOI: 10.1007/s10995-‐014-‐1634-‐5. Anwar WA, Kahled HM, Amra HA, El-‐Nezami H, Loffredo CA. 2008. Changing pattern of

hepatocellular carcinoma (HCC) and its risk factors in Egypt: possibilities for prevention. Mutat Res 2008 659(1-‐2):176-‐184.

Asfaw, A. 2007. Micronutrient deficiency and the prevalence of mothers’ overweight/obesity in Egypt. Economics and Human Biology, 5, 471–483. AUC (African Union Commission, NEPAD (New Partnership for Africa’s Development) Planning and Coordinating Agency, UNECA (United Nations Economic Commission for Africa, and UN World Food Programme. 2014. The Cost of Hunger in Africa: Social and Economic Impact of Child Undernutrition in Egypt, Ethiopia, Swaziland, and Uganda. Addis Ababa: UNECA. Azab S, Saleh S, Elsaeed W, Abdelsalam S, Ali A and Esh A. 2013. Vitamin D Status in diabetic

Egyptian children and adolescents: a case control study. Ital J Pediatr, 15: 39: 73. Doi: 10.1186/1824-‐7288-‐39-‐73.

Aziz NH, Youseef YA. 1991. Occurrence of aflatoxin and aflatoxin-‐producing moulds in fresh and processed meat in Egypt. Food Addit. Contam. 1991; 8(3):321-‐331. Badran M and Laher I. 2011. Obesity in Arabic-‐Speaking Countries. Journal of Obesity, http://dx.doi.org/10.1155/2011/686430. Baum R, Kayser G, Stauber C, Sobsey M. 2014. Assessing the Microbial Quality of Improved

Drinking Water Sources: Results from the Dominican Republic. Am J Trop Med Hyg 2014 90(1):121-‐123.

Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb P, Lartey A, Black RE, Lancet Nutrition Interventions Review G, Maternal, Child Nutrition Study G 2013. Evidence-‐based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382(9890):452-‐77. doi: 10.1016/S0140-‐6736(13)60996-‐4. PubMed PMID: 23746776.

Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-‐McGregor S, Katz J, Martorell R, Uauy R and the Maternal and Child Nutrition Study Group. 2013. Maternal and child nutrition and overweight in low income and middle income countries. www.thelancet.com Published online June 6, 2013 http://dx.doi.org/10.1016/S0140-‐6736(13)60937-‐X 1


27

CAPMAS 2014. Income, Expenditure and Consumption Survey 2012/2013. Vol 111: Patterns of Household Expenditure according to socio-‐economic characteristics of households. 280 pages

Dawoud S. D.Z. 2014. Econometric analysis of the changes in food consumption expenditure patterns in Egypt. J. of Dev and Ag Economics, 6(1) 1-‐11.

Deng J, Xiang Y, Hao W, Feng Y, Yang G, Ren G, Han X. 2014. Research on the food security condition and food supply capacity of Egypt. Scientific World Journal.

doi: 10.1155/2014/405924. D’Mello JPF, Placinta CM, Macdonald AMC. 1999. Fusarium mycotoxins: a review of global

implications for animal health, welfare and productivity. Animal Feed Science and Technology. 1999;80(3-‐4):183-‐205.

Dodoo ND. Simultaneous Stunting and Obesity in Egypt’s Children. Population Association of America; Washington DC2011

Eckhardt C , Torheim L, Monterrubio E , Barquera S and Ruel M. 2008. The overlap of overweight and anaemia among women in three countries undergoing the nutrition transition. European Jou Clinical Nutrition. 62, 238–246. El-‐Kogali and Krafft C. 2015. Expanding Opportunities for the Next Generation: Early Childhood Development in the Middle East and North Africa. Directions in Development Paper. Washington, D.C.: World Bank. El Koumi M, Ali Y, and Abd El Rahman R. 2013. Impact of maternal vitamin D status during

pregnancy on neonatal vitamin D status. Turk J Pediatr. 55(4): 371-‐7. EMOHP (Egypt Ministry of Health and Population). 2012. Egyptian Nutrition Landscape Analysis Report. Cairo, Egypt: Government of Egypt/UNICEF/WHO. El-‐Nezami HS, Chrevatidis A, Auriola S, Salminen S, Mykkanen H. 2002. Removal of common

Fusarium toxins in vitro by strains of Lactobacillus and Propionibacterium. Food Addit Contam 2002 19(7):680-‐6.

El-‐Zanaty F and Way A. 2009. Egypt Demographic and Health Survey 2008. Cairo, Egypt: Ministry of Health, El-‐Zanaty and Associates and Macro International. FAO (Food and Agricultural Organization). 2011. FAOSTAT Food Balance Sheets 2011. Fernald L, and Neufeld L. Overweight with concurrent stunting in very young children from rural

Mexico: prevalence and associated factors. European Journal of Clinical Nutrition (2007) 61, 623–632.

Fisher Walker CL, Perin J, Aryee MJ, Boschi-‐Pinto C, Black RE. 2012. Diarrhea incidence in low-‐ and middle-‐income countries in 1990 and 2010: a systematic review. BMC Public Health 2012, 12:220 doi:10.1186/1471-‐2458-‐12-‐220

Galal O. 2001. The nutrition transition in Egypt: obesity, undernutrition and the food consumption context. Public Health Nutr 5:141–148. Gong YY, Cardwell K, Hounsa A, Egal S, Turner PC, Hall AJ, Wild CP. 2002. Dietary aflatoxin

exposure and impaired growth in young children from Benin and Togo: cross sectional study. Bmj. 2002;325(7354):20-‐1. PubMed PMID: 12098724; PubMed Central PMCID: PMC116667.

Gong YY, Egal S, Hounsa A, Turner PC, Hall AJ, Cardwell KF, Wild CP. 2003. Determinants of aflatoxin exposure in young children from Benin and Togo, West Africa: the critical role


28

of weaning. International journal of epidemiology. 2003;32(4):556-‐62. PubMed PMID: 12913029.

Haj Bakri A and Al-‐Thani A. 2013. Chronic Disease Risk Factor Surveillance: Qatar STEPS Report 2012. The Supreme Council of Health. Qatar. Hassan H, Moussa W, and Ismail I. 2006. Assessment of dietary changes and their health implications in countries facing the double burden of malnutrition: Egypt, 1980 to 2005.

The double burden of malnutrition, case studies from six developing countries. Food and Nutrition paper No 84. Rome, FAO.

Hatem NL, Hassab HM, Abd Al-‐Rahman EM, El-‐Deeb SA, El-‐Sayed Ahmed RL. 2005. Prevalence of aflatoxins in blood and urine of Egyptian infants with protein-‐energy malnutrition. Food and Nutrition Bulletin 26:49–56. Hifnawy MS, et al. 2004. The role of aflatoxin-‐contaminated food materials and HCV in developing hepatocellular carcinoma in Al-‐Sharkia Governate, Egypt. J Egypt Soc Parasitol. 34 (1 Suppl): 479-‐88. Hoddinott, J, Alderman H, Behrman J, Haddad L, and Horton S. 2013. The Economic Rationale for Investing in Stunting Reduction. Maternal and Child Nutrition 9: 69–82. Hoffman DJ, Sawaya AL, Verreschi I, Tucker KL, Roberts SB. Why are nutritionally stunted

children at increased risk of obesity? Studies of metabolic rate and fat oxidation in shantytown children from São Paulo, Brazil. American Journal of Clinical Nutrition. 2000;72:702–7

Hopkins NS, Mehanna SR. 2003. Living with Pollution in Egypt. Environmentalist, March vol 23, Issue 1 pp17-‐28.

Hossain M, Nahar B, Hamadani J, Ahmed T, Roy A, Brown K. Intestinal mucosal permeability of severely underweight and nonmalnourished Bangladeshi children and effects of nutritional rehabilitation. J Pediatr Gastroenbterol Nutr 2010, 51(5):638-‐644. IDB (International Diabetes Foundation. 2010 (2014 updates). Diabetes Atlas.

http://www.diabetesatlas.com/content/middle-‐east-‐and-‐north-‐africa. IFPRI (International Food Policy Research Institute). 2014. Global Nutrition Report 2014. Washington, D.C. IFPRI (International Food Policy Research Institute). 2014b. Global Nutrition Report 2014

Nutrition Country Profile. Washington, D.C. https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/27857

IFPRI/WFP (International Food Policy Research Institute/World Food Programme). 2013. Tackling Egypt’s Rising Food Insecurity in a Time of Transition. IFPRI/WFP Country Policy Note. Cairo, Egypt. Kavle J, El-‐Zanaty F, Landry M and Galloway R. 2015. The rise in stunting in relation to avian influenza and food consumption patterns in Lower Egypt in comparison to Upper Egypt: results from 2005 and 2008 Demographic and Health Surveys. BMC Public Health, 15:285. DOI 10.1186/s12889-‐015-‐1627-‐3. Kavle J, Mehanna S, Saleh G, Fouad M, Ramsey M, Hamed D, Hassan M, Khan G and Galloway R. 2014. Examining Factors Associated with Stunting in Lower Egypt in Comparison to Upper Egypt. Report to USAID’s Maternal and Child Health Integrated Program, Washington, D.C. Khairy S, Mattar M, Refaat L and El-‐Sherbeny S. 2010. Plasma Micronutrient Levels of Stunted


29

Egyptian School Age Children. Kasr El Aini Medical Jou. 16 (1): 1-‐6. Khatab K. 2010. Childhood Malnutrition in Egypt using Geoadditive Gaussian and Latent Variable Models. Am J Trop Med Hyg. 82 (4): 653–63. doi: 10.4269/ajtmh.2010.09-‐0501. Kimanya ME, De Meulenaer B, Roberfroid D, Lachat C, Kolsteren P. 2010. Fumonisin exposure

through maize in complementary foods is inversely associated with linear growth of infants in Tanzania. Molecular nutrition & food research. 2010;54(11):1659-‐67. doi: 10.1002/mnfr.200900483. PubMed PMID: 20521269.

Kirksey A, Wachs T, Yunis F, Srinath U, Rahmanifar A, McCabe G, Galal O, Harrison G, and Jerome N. 1994. Relation of Maternal Zinc Nutriture to Pregnancy Outcome and Infant Development in an Egyptian Village. American Jou Clinical Nutrition 60 (5): 782–92. Leroy J. Chid Stunting and Aflatoxins 2013 [cited 2014 Nov 3]. Available from:

http://www.ifpri.org/sites/default/files/publications/focus20.pdf. Lunn PG, Northrop-‐Clewes CA, Downes RM. Intestinal permeability, mucosal injury, and growth

faltering in Gambian infants. 1991. Lancet 338:907-‐910. Marei H, Kubbara O, and El-‐Lozy Y. 2014. Water Sanitation in Egypt: A focus on the sewage

system in rural areas. Accessed 2015. http://www.aucegypt.edu/research/conf/eureca/journal/Documents/HusseinMarei_OlaKubbara_YosraElLozy.pdf

Marotta D and Yemtsov R. 2010. Determinants of households’ income mobility and poverty dynamics in Egypt. Draft World Bank paper presented at the 5th IZA-‐World Bank conference on Employment and Development, Cape Town, South Africa, May 2010. Martins PA, Hoffman DJ, Fernandes MTB, Nascimento CR, Roberts SB, Sesso R, et al. Stunted

children gain less lean body mass and more fat mass than their non-‐stunted counterparts: a prospective study. British Journal of Nutrition 2004;92 819–25.

MHP/El-‐Zanaty/Macro (Ministry of Health and Population [Egypt], El-‐Zanaty and Associates [Egypt], and ICF International). 2015. Egypt Demographic and Health Survey 2014. Cairo, Egypt and Rockville, MD: Ministry of Health and Population and ICF International. MHP/UNICEF/El-‐Zanaty (Ministry of Health & Population, UNICEF and El-‐Zanaty & Associates). 2014. Multiple Indicator Cluster Survey in the rural areas covered by the Integrated Perinatal Care and Nutrition Programme in Egypt 2013-‐14, Key Findings. Cairo, Egypt: Ministry of Health & Population, UNICEF and El-‐Zanaty & Associates. Mohammad M, Hussein L, Yamamah G, Rawi S. 2007. The impact of probiotic and/or honey

supplements on gut permeability among Egyptian children. J Nutrition & Environmental Medicine 2007; 16(1):10-‐15.

Naem N, El-‐Sayed N, Nossier S, Abu Zeid A. 2014. Zinc status and dietary intake of pregnant women, Alexandria, Egypt. Journal of Egypt. Public Health Assoc. 89 (1):35-‐41.

doi: 10.1097/01.EPX.0000443987.44261.9b. Ng M, Fleming T, Robinson M, et al. 2014. Global, regional and national prevalence of overweight and obesity in children and adults during 1980-‐2013 : A systematic analysis for the Global Burden of Disease Study 2013. Lancet, 284 (9945): 766-‐81, doi: 10.1016/S0140-‐6736(14)60460-‐8. Oddo V, Rah J, Semba R, Sun K, Akhter N, Sari M, de Pee S, Moench-‐Pfanner R, Bloem M, and Kraemer K. 2012. Predictors of maternal and child double burden of malnutrition in rural Indonesia and Bangladesh. Am J Clin Nutr. 95 (4): 951-‐8.


30

Pestka JJ. 2008. Mechanisms of deoxynivalenol-‐induced gene expression and apoptosis. Food additives & contaminants Part A, Chemistry, analysis, control, exposure & risk assessment. 25(9): 1128-‐40.

Piekkola, S, Turner P, Abdel-‐Hamid M, Ezzat S, El-‐Daly M et al. 2012. Characterisation of aflatoxin and deoxynivalenol exposure among pregnant Egyptian women. Food Addit. Contam. Part A: Chem. Anal. Control Expo. Risk Assess. 29 (6):962-‐971. Polychronaki N, Turner PC, Mykkanen H, Gong Y, Amra H, Abdel-‐Wahhab M, El-‐Nezami H. 2006.

Determinants of aflatoxin M1 in breast milk in a selected group of Egyptian mothers. Food Additives and Contaminants 23:700–708.

Polychronaki N – Doctoral Dissertation. 2007a. http://epublications.uef.fi/pub/urn_isbn_978-‐951-‐27-‐0745-‐4/urn_isbn_978-‐951-‐27-‐0745-‐4.pdf

Polychronaki N, West RM, Turner PC, Amra H, Abdel-‐Wahhab M, Mykkanen H, El-‐Nezami H. 2007b. A longitudinal assessment of aflatoxin M1 excretion in breast milk of selected Egyptian mothers. Food and Chemical Toxicology 45:1210–1215.

Polychronaki N, Wild CP, Mykkanen H, Amra H, Abdel-‐Wahhab M, Sylla A, Diallo M, El-‐Nezami H, Turner PC. 2007c. Urinary biomarkers of aflatoxin exposure in young children from Egypt and Guinea. Food and Chemical Toxicology. in press.

Popkin B, Adair L and Ng S. 2012. Global nutrition transition and the pandemic of obesity in developing countries. Nutrition Reviews, 70 (1): 3-‐21. Popkin B, Richards M and Montiero C. Stunting is associated with overweight in children of four

nations that are undergoing the nutrition transition. Journal of Nutrition [1996, 126(12):3009-‐3016]

Prendergast A and Kelly P. 2012 Enteropathies in the developing world: neglected effects on global health. American Journal of Tropical Medicine and Hygiene .86(5):756-‐63. doi: 10.4269/ajtmh.2012.11-‐0743.

Raisuddin S, Singh KP, Zaidi SI, Paul BN, Ray PK. 1993. Immunosuppressive effects of aflatoxin in growing rats. Mycopathologia.124(3): 189-‐94.

Restrepo-‐Mendez M, Barros A, Black R and Victora C. 2014. Time trends in socio-‐economic inequalities in stunting prevalence analyses of repeated national surveys. Public Health Nutrition, doi: 10.1017/S1368980014002924. Rotter BA, Thompson BK, Prelusky DB, Trenholm HL, Stewart B, Miller JD, Savard ME. 1996.

Response of growing swine to dietary exposure to pure fumonisin B1 during an eight-‐week period: growth and clinical parameters. Natural toxins. 4(1): 42-‐50.

Ruel MT, Alderman H, Maternal, Child Nutrition Study G. 2013. Nutrition-‐sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet. 382(9891):536-‐51. doi: 10.1016/S0140-‐6736(13)60843-‐0.

Salazar-‐Martinez E, Allen B, Fernandez-‐Ortega C, Torres-‐Mejia G, Galal O, and Lazcano-‐Ponce E. 2006. Overweight and obesity status among adolescents from Mexico and Egypt, Archives of Medical Research, 37 (4): 535–542. Selim MI et al. 1996. Aflatoxin B1 in Common Egyptian Foods. J AOAC International. 79(5):1124-‐

1129. Shuaib FM, Jolly PE, Ehiri JE, Yatich N, Jiang Y, Funkhouser E, Person SD, Wilson C, Ellis WO,

Wang JS, Williams JH. 2010. Association between birth outcomes and aflatoxin B1


31

biomarker blood levels in pregnant women in Kumasi, Ghana. Tropical medicine & international health : TM & IH. 2010;15(2):160-‐7. doi: 10.1111/j.1365-‐3156.2009.02435.x. PubMed PMID: 20003033.

Sibai A, Nasreddine L, Mokdad A, Adra N, Tabet M, Hwallla N. 2010. Nutrition Transition and Cardiovascular Disease Risk Factors in Middle East and North Africa countries: Reviewing the Evidence. Annals of Nutr. Metabolism. 57: 193-‐203. Smith, MI, Yatsunenko T, et al. 2013. Gut Microbiomes of Malawian Twin Pairs Discordant for

Kwashiorkor. Science 339:548-‐554. Spears D. How much international variation in child height can sanitation explain? World Bank

policy research working paper, no WPS 6351 2013. http://go.worldbank.org/SZE5WUJBI0 (accessed November, 2013).

Solomons N.W. 2003. Environmental contamination and chronic inflammation influence human growth potential. Journal of Nutrition, 133: 1332-‐1338.

Swamy HV, Smith TK, MacDonald EJ, Karrow NA, Woodward B, Boermans HJ. 2003. Effects of feeding a blend of grains naturally contaminated with Fusarium mycotoxins on growth and immunological measurements of starter pigs, and the efficacy of a polymeric glucomannan mycotoxin adsorbent. Journal of animal science. 2003;81(11):2792-‐803. PubMed PMID:

Tawfik A, Hanna E and Freig S. 2014. Folate status in Egypt. Jou. Nursing and Health Sci. 3 (2): 32-‐26. Turner PC, Collinson AC, Cheung YB, Gong Y, Hall AJ, Prentice AM, Wild CP. 2007. Aflatoxin

exposure in utero causes growth faltering in Gambian infants. International journal of epidemiology. 2007;36(5):1119-‐25. doi: 10.1093/ije/dym122.

Turner PC, Wu QK, Piekkola S, Gratz S, Mykkanen H, El-‐Nezami H. 2008. Lactobacillus rhamnosus strain GG restores alkaline phosphatase activity in differentiating Caco-‐2 cells dosed with the potent mycotoxin deoxynivalenol. Food Chem Toxicol 46(6): 2118-‐2123.

Turner PC, Flannery B, Isitt C, Ali M, Pestka J. 2012. The role of biomarkers in evaluating human health concerns from fungal contaminants in food. Nutrition research reviews. 25(1): 162-‐79. doi: 10.1017/S095442241200008X.

Turner PC. 2013 The molecular epidemiology of chronic aflatoxin driven impaired child growth. Scientifica. 152879. doi: 10.1155/2013/152879.

Tzioumis E and Adair L. 2014. Childhood dual burden of under-‐and overnutrition in low-‐ and middle-‐income countries: A critical review. Food and Nutrition Bulletin. 35 (2): 230-‐43. UNICEF. 2013 EGYPT Nutrition L a n d s c a p e Analysis Report 2012, 116 pages Verme P, Milanovic B, Al-‐Shawarby S, El Tawila S, Gadallah M, and El-‐Majeed A. 2014.

Inside Inequality in the Arab Republic of Egypt: Facts and Perceptions across People, Time and Space. Washington, D.C.: World Bank.

Webb, P. 2015. Nutrition and the Sustainable Development Goals. SCN Bulletin, June 2015. Webb P, Luo H, and Gentilini U. 2015. Measuring Multiple Facets of Malnutrition Simultaneously: The Missing Link in Setting Nutrition Targets and Policymaking. Food Security. DOI: 10.1007/s12571-‐015-‐0450-‐0. WFP (World Food Programme). 2013. The Status of Poverty and Food Insecurity in Egypt: Analysis and Policy Recommendations. Cairo, Egypt: WFP.


32

Williams JH, Phillips TD, Jolly PE, Stiles JK, Jolly CM, Aggarwal D. 2004. Human aflatoxicosis in developing countries: a review of toxicology, exposure, potential health consequences, and interventions. The American Journal of Clinical Nutrition. 2004;80(5):1106-‐22. PubMed PMID: 15531656.

World Bank. 2010. Egypt: Nutrition at a Glance. Cairo, Egypt. WHO (World Health Organization). 2015. Global Database on Child Growth and Malnutrition:

Cut-‐off points and summary statistics. http://www.who.int/nutgrowthdb/about/introduction/en/index5.html 2014. Qatar STEPS Survey 2012 Fact Sheet. Accessed May 15, 2015,

http://www.who.int/chp/steps/Qatar_FactSheet_2012.pdf?ua=1. 2014b. Global Health Observatory Data Repository: Obesity (body mass index >= 30) (crude estimate). http://apps.who.int/gho/data/node.main.A900C?lang=en 2013. Egypt STEPS Survey 2011-‐12 Fact Sheet. Accessed May 15, 2015, http://www.who.int/chp/steps/2011-‐2012_Egypt_FactSheet.pdf?ua=1 2009. Jordan STEPS Survey 2007 Fact Sheet. Accessed May 15, 2015, http://www.who.int/chp/steps/2011-‐2012_Egypt_FactSheet.pdf?Ua=1. 2003. The Management of Nutrition in Major Emergencies. Geneva, Switzerland.

The Feed the Future Innovation Laboratory for Nutrition is a research and capacity building activity that supports USAID and national government agendas that create rigorous evidence for improved policies and programming at scale. The management entity for the Nutrition Innovation Lab is the Friedman School of Nutrition Science and Policy at Tufts University. It has multiple US academic partners in this work, including Harvard’s Chen School of Public Health, Johns Hopkins’ Bloomberg School of Public Health, Purdue University, and Tuskegee University, as well as many dozens of institutional partners around the world. For details please see: http://www.nutritioninnovationlab.org/


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