Malnutrition and gender disparities in the Eastern Mediterranean Region: The need for action

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TL;DR

This paper examines the interplay between gender disparities and malnutrition in the Eastern Mediterranean Region (EMR), where 53% of women and 45% of men are obese, and undernutrition affects 19% of the population. Gender inequality—manifested through limited female mobility, discriminatory food allocation, and reduced access to healthcare—exacerbates both undernutrition and obesity, with women bearing a disproportionate burden. The authors call for gender-sensitive, multi-level policies and interventions to address the structural and social determinants driving malnutrition across the region's heterogeneous countries.

Full summary

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**Background:** The Eastern Mediterranean Region (EMR) faces a double burden of malnutrition, with undernutrition and obesity coexisting across its 22 countries. The region is highly heterogeneous: Gulf states are in an advanced nutrition transition with high obesity rates, countries like Egypt and Jordan are in an early phase with moderate obesity and undernutrition, nations such as Pakistan and Djibouti face a triple burden (undernutrition, micronutrient deficiencies, and rising obesity), and conflict-affected countries (Afghanistan, Somalia, Sudan, Syria, Yemen) experience complex emergencies with severe child and maternal malnutrition. Gender is identified as a key determinant of malnutrition, shaped by both biological sex differences and socially constructed gender roles. The EMR's Gender Development Index (GDI) is below the world average, with Qatar scoring highest and Yemen lowest. Women in the EMR have a life expectancy of 71 years versus 68 years for men, but are expected to live 1.7 of those 3 additional years in illness—a 'gender paradox' reflecting higher morbidity despite longer survival.

**Methods:** This perspective piece is derived from a larger WHO Regional Office report on gender and health in the EMR, which included available evidence from 2000 to 2019. The analysis is guided by Sen and Ostlin's conceptual framework, which distinguishes structural determinants (economic, social, political forces) from intermediary determinants (gender norms, power dynamics, differential exposures, and health system biases). The paper synthesizes published data on malnutrition prevalence, risk factors, and health outcomes, disaggregated by sex where available.

**Key Results:** The overall regional prevalence of undernutrition is 19%, with the highest levels of stunting, wasting, and underweight in Afghanistan, Djibouti, Pakistan, Somalia, Sudan, and Yemen. Micronutrient deficiencies affect approximately one in three EMR residents. Iron deficiency and anemia range from 20% to 47% among women of reproductive age (15–49 years), with the highest rates among Egyptian women (47%) and adolescents (47%). Vitamin D deficiency affects up to 83% of EMR residents, compared to less than 20% in Northern Europe. Being female is a significant predictor of Vitamin D deficiency, with rates reaching 96% in some countries, attributed to social and religious practices like skin covering and veiling. Overweight and obesity affect 47% of adults in the EMR (versus 39% globally), with a wider gender gap: 53% of women versus 45% of men are overweight or obese, compared to 40% versus 39% globally. The EMR is the second highest region globally for physical inactivity (35%), with women less active than men in most countries; inactivity ranges from 60% in Jordan to 95% in Egypt and 98% in Saudi Arabia. In conflict settings, gender norms lead women to reduce their own food intake in favor of male family members, while men may suffer malnutrition due to lack of cooking skills and access to food distribution. Maternal malnutrition is linked to low birth weight, growth retardation, and high infant morbidity and mortality. Iron deficiency contributes to 20% of maternal deaths and is a leading cause of adolescent disability-adjusted life years in low- and middle-income EMR countries.

**Clinical Implications:** The findings underscore the need for gender-sensitive nutrition policies that address both undernutrition and obesity simultaneously, even within the same households. Improving water and sanitation infrastructure, supporting exclusive breastfeeding, and ensuring culturally acceptable health services (including female health providers) are critical. The authors emphasize that addressing gender discrimination and power inequalities can improve women's nutritional status and that of their children, breaking the intergenerational cycle of malnutrition. A comprehensive, multi-level approach is needed to confront structural obstacles, including improving female education, mobility, and decision-making autonomy. The limited availability of age- and sex-disaggregated data and gender analyses is identified as a major gap that must be addressed to guide evidence-based policy.