Regional nutrition strategies to address the double burden in the Eastern Mediterranean

Dr Ayoub Al Jawaldeh has been the Regional Adviser for Nutrition in the WHO Regional Office for Eastern Mediterranean Region since 2009, leading the Regional Nutrition Strategy.

Introduction

The burden of disease associated with inadequate nutrition continues to grow in countries of the Eastern Mediterranean Region (EMR), comprising 22 countries and territories in the Middle East, North Africa, the Horn of Africa and Central Asia. Similar to many developing countries, the region suffers from problems of both undernutrition and overweight, obesity and diet-related non-communicable diseases (NCDs), which are all increasing. This ‘double burden’ of malnutrition negatively impacts EMR health systems. Several micronutrient deficiencies are still being reported from many countries in the region, particularly iron, iodine and vitamin A.

In response to these challenges, the World Health Organization (WHO) Regional Office in the EMR developed the first regional Nutrition Strategy (2010-2019) and Action Plan in coordination with other UN agencies and stakeholders to scale up nutrition¹. The overall goals of the regional strategy are to encourage countries to reposition nutrition as central to their development agenda; support them in establishing and implementing action on nutrition according to their national situation and resources; and provide a framework for prioritising nutrition actions in each country context. The plan has been updated to include recent initiatives such as the World Health Authority (WHA) global targets 2025 to improve maternal, infant and young child nutrition and the Sustainable Development Goals (SDGs)²; most states within the EMR have now developed or reviewed national action plans in line with these.

Nutrition situation for key indicators

According to the most recent estimates³, rates of stunting, wasting and underweight in children under five years of age (CU5) in the region are 28 per cent, 8.69 per cent and 18 per cent, respectively. Yemen, Pakistan, Afghanistan, Sudan and Djibouti have the highest burden of stunting (>30 per cent). Due to political unrest and food insecurity in these countries, as well as in Syria, Iraq and Libya, the total number of wasted CU5 is estimated at 9.1 million (7.3 per cent); out of which nearly half (3.1 million or 3.8 per cent) are severely wasted. Over half of pregnant women have anaemia in the Sudan (58.4 per cent), the Syrian Arab Republic (57.3 per cent) and Pakistan (51 per cent).

Of particular concern is the increasing trend in overweight and obesity among adults and children. Average prevalence of overweight and obesity in the region is 27 per cent and 24 per cent in adults and 16.5 per cent and 4.8 per cent in school-aged children respectively³. The highest levels of obesity were reported in Kuwait, Qatar, Bahrain and the United Arab Emirates (UAE). In 2016, an estimated 5.4 million CU5 (6.7 per cent) in EMR were overweight, an increase from 3.5 million in 1990. Half the region’s adult women and more than two out of five men are overweight or obese.

As in other regions, high rates of overweight and obesity are closely linked to physical inactivity and unhealthy diets. The EMR has the highest global prevalence of physical inactivity in adults (approximately one third), with data consistently showing higher levels of inactivity in women than men (compared with an overall global prevalence for both sexes of 23 per cent⁴. There have also been marked changes in the region’s dietary patterns consistent with global food consumption, shifting towards higher-energy diets dominated by increased intakes of fats and sugar.

Key priorities

The following key actions are taking place to support strategic priorities:

1. Maternal, infant and young child nutrition: interventions including infant and young child feeding (promotion of breastfeeding and complimentary feeding), food fortification and supplementation programmes, growth monitoring and nutrition surveillance and treatment of severe acute malnutrition (SAM).
2. NCD-diet related risk factors: promoting healthy diet through cost-effective interventions identified within the Regional Framework for Action to address NCDs, including: promoting breastfeeding and implementing the International Code of Marketing of Breast-milk Substitutes (‘the Code’); reducing salt intake at population level; developing food-based dietary guidelines; food labelling; product reformulation, including replacing trans fats with polyunsaturated fats and sugar reduction; and restricting marketing of unhealthy food to children.
3. Emergency nutrition: screening cases for SAM.

Progress and achievements to date

More than 17 countries have developed full or partial legal documents relating to the Code, but implementation remains a challenge. In 2017, development of food-based dietary guidelines was expanded in the region to include Afghanistan, Egypt, Islamic Republic of Iran, Lebanon, Oman, Qatar and Saudi Arabia. Salt reduction in bread is also progressing in Kuwait, Qatar, Oman, Iran, Bahrain, Morocco, Tunisia and Jordan. Elimination of trans fats is a priority for action in Iran, Saudi Arabia and Tunisia. Adding taxes to sugar-sweetened beverages to reduce sugar consumption is being implemented in Saudi Arabia, United Arab Emirates, Iran and Jordan.

Afghanistan Pakistan, Somalia, Sudan and Yemen have all become members of the Scaling Up Nutrition (SUN) Movement, providing a great opportunity to galvanise action to ensure country progress in efforts to reach SDG targets.

Challenges in implementation

The EMR is a very complex region and countries have different nutrition problems and challenges with different socioeconomic profiles. There is a double burden of malnutrition and at least 16 countries are experiencing internal conflicts and political instability, making the most vulnerable inaccessible to nutrition services that are in high demand. Many countries still face challenges in the formulation and implementation of nutrition strategies and action plans that are holistic in their approach to addressing nutrition issues, including Pakistan, Yemen, Sudan, Djibouti and Somalia.

Other challenges in the region include:

1. Weakness of clear political commitment to nutrition action and/or failure to turn the political commitment towards nutritional problems into tangible action;
2. The absence of a policy framework and institutional capacity to plan, implement and monitor nutrition programmes that respond to the multi-sector dimensions of nutrition problems;
3. Recurrent conflicts and natural disasters;
4. The disproportionate allocation of health budgets, often at the expense of preventive strategies such as nutrition;
5. The abandonment of traditional diets, which are often more nutritious, in favour of western diets that feature more refined foods, resulting in the reduction of dietary diversity; and
6. The absence of nutrition expertise in related sectors and inter-sector coordination.

The Regional Strategy has helped countries to set strategic priorities of key activities with clear outcomes and measurable deliverables and enabled states within the EMR to monitor progress towards meeting achievable global targets. Close follow-up and technical support from UN/NGOs is helping to scale up nutrition programmes and focus on cost-effective interventions. 

¹www.emro.who.int/nutrition/strategy/

²www.emro.who.int/nutrition/nutrition-events/scalingup-nutrition-consultation.html

³Lara Nasreddine, Jennifer J. Ayoub and Ayoub Al Jawaldeh, Review of the nutrition situation in the Eastern Mediterranean Region, Eastern Mediterranean Health Journal, Volume 24, issue 1, 2018. World Health Organization. Global status report on noncommunicable diseases 2014. Geneva: World Health

⁴World Health Organization. Global status report on noncommunicable diseases 2014. Geneva: World Health Organization.