A systematic review and meta-analysis of the prevalence of childhood undernutrition in North Africa

**Background:** Undernutrition among children under five remains a critical public health concern globally, contributing to approximately 45% of deaths in this age group. In North Africa, recent conflicts, food insecurity, and climate change have exacerbated the problem. Despite this, there are no ongoing region-wide nutrition monitoring and evaluation programs. This systematic review and meta-analysis aimed to determine the prevalence of stunting, wasting, and underweight among children under five in seven North African countries (Egypt, Sudan, Libya, Algeria, Tunisia, Morocco, and Western Sahara) and assess whether the region is on track to achieve Sustainable Development Goals (SDGs) 1, 2, and 3 by 2030.

**Methods:** The review followed PRISMA 2020 guidelines and was registered with PROSPERO (CRD42022311922). Five electronic databases (Ovid MEDLINE, Web of Science, Embase via Ovid, ProQuest, and CINAHL) were searched for peer-reviewed observational studies published between 1 January 2006 and 10 April 2022. The year 2006 was chosen as the baseline to align with the introduction of WHO Child Growth Standards. Studies were included if they involved children aged 0–59 months, were conducted in any of the seven North African countries, reported at least one anthropometric indicator of undernutrition (stunting, wasting, or underweight), and were published in English. The JBI critical appraisal tool was used to assess study quality. Meta-analysis was performed using the 'metaprop' command in STATA version 17. Due to significant heterogeneity (I² > 50%), a random-effects model was applied. Sensitivity analyses examined the effect of outliers, and funnel plots with Begg's tests assessed publication bias.

**Key Results:** From 1,592 initially identified articles, 27 cross-sectional studies met the inclusion criteria. Quality assessment rated 18 studies (66.7%) as high quality (score 7–9) and 9 studies (33.3%) as medium quality (score 4–6); none were rated poor. The overall random-effects pooled prevalence of stunting was 23.5% (95% CI not reported for overall; I² = 99.7%). Country-specific stunting prevalences were: Sudan 36% (95% CI: 33.8–38.2; p < 0.001), Egypt 23.7% (95% CI: 22.1–25.2; p < 0.001), Libya 23.1% (95% CI: 21.0–25.3; p < 0.001), Morocco 19.9% (95% CI: 17.8–22.0; p < 0.001), Algeria 10.7% (95% CI: 10.17–11.2; p < 0.001), and Tunisia 10.2% (95% CI: 9.1–11.3; p < 0.001). The overall pooled prevalence of wasting was 7.9% (95% CI: 6.5–9.3; p < 0.001; I² = 99.5%). Country-specific wasting prevalences were: Sudan 14.1% (95% CI: 11.4–16.7; p < 0.001), Egypt 7.5% (95% CI: 6.1–8.8; p < 0.001), Libya 5.9% (95% CI: 4.5–7.2; p < 0.001), Morocco 5.1% (95% CI: 2.1–8.2; p < 0.001), and Tunisia 2.9% (95% CI: 2.5–3.3; p < 0.001). The overall pooled prevalence of underweight was 12.9% (95% CI: 6.4–19.5; p < 0.001; I² = 100.0%). Country-specific underweight prevalences were: Sudan 24.6% (95% CI: 17.5–31.6; p < 0.001), Egypt 7% (95% CI: 5.1–9.0; p < 0.001), Morocco 6.1% (95% CI: 3.4–8.8; p < 0.001), and Libya 4.3% (95% CI: 3.8–4.9; p < 0.001). Funnel plots and Begg's tests indicated no significant publication bias for wasting or underweight, while stunting showed homogeneity. Meta-regression indicated that the proportion of undernutrition decreased with later publication year, but this relationship was not statistically significant (p = 0.0083).

**Clinical Implications:** The overall prevalence of stunting (23.5%) and underweight (12.9%) in North Africa exceeded global averages (approximately 20% and 12.6%, respectively), while wasting (7.9%) was higher than the global average of 6.7%. Sudan emerged as the most affected country across all three indicators, likely due to ongoing conflict, displacement, food insecurity, and water scarcity. Libya, Egypt, and Morocco also showed concerning rates. The findings suggest that the North African region is not on track to meet SDGs 1 (no poverty), 2 (zero hunger), and 3 (good health and well-being) by 2030. The authors recommend establishing ongoing nutrition monitoring and evaluation programs in these countries, implementing targeted policies to address undernutrition, and allocating resources from aid organizations. The study's strengths include its unique regional focus, use of uniform WHO growth standards, and exclusion of clinical settings to enhance generalizability. Limitations include the inability to assess trends due to inconsistent data collection, the exclusion of non-English studies, and the lack of analysis of factors influencing undernutrition epidemiology.