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Assessment of dietary changes and their health implications in countries facing the double burden of malnutrition: Egypt, 1980 to 2005

H. Hassan, W. Moussa and I. Ismail, National Nutrition Institute


Egypt lies in the northwest corner of Africa and has the largest population of the Arab countries - 68.6 million people - according to population estimates made in 2004 (CAPMAS, 2004). The total land area is approximately 1 million km2, only 6 percent of which is inhabited. Population density in the inhabited areas (primarily the Nile valley and delta) is therefore very high

Demography and urbanization

The Egyptian population is estimated to have increased from 40.5 million in 1980 to 68 million in 2003. The average annual growth rate during the period 1976 to 1986 was 2.75 percent, decreasing to 2.08 percent in 1986 to 1996, and then increasing slightly again to 2.3 percent (Figure 1).

Average population growth rates (percentage), 1897 to 2002

Sources: CAPMAS, 2004; EHDR, 2004.

The urban population has been growing rapidly since the early and mid-1980s, and now constitutes somewhat more than 40 percent of the total, with a decreasing growth rate that the most recent estimates put at 1.8 percent per annum (Figure 2). The declining growth rate of the urban sector may reflect the greater success of family planning efforts in urban than in rural areas. However, the urban population density has increased as a result of internal migration and the transformation of many villages into semi-urban areas (EHDR, 2004).

Urban population (as percentage of total), 1960 to 2002

Source: EHDR, 2004.


The government adopted an Arab socialist orientation during the period 1960 to 1970, which resulted in a fairly closed economy until 1974, when Egypt moved to an open market economy. The economy expanded rapidly during the 1990s, with gross national product (GNP) almost doubling between 1993 and 1997 and the rate of inflation decreasing to 3.6 percent (EDHS, 2000).

Gross domestic product (GDP) was 354 563.6 million Egyptian pounds (LE) in 2001/2002, increasing to 365 541.1 million LE in 2002/2003, with an annual growth rate of 3.1 percent. Over the last decade, there has been a gradual increase in annual per capita income, from 4 822.4 LE in 1998/1999, to 5 537.6 LE in 2000/2001 and 5 652.8 LE in2002/2003 (CAPMAS, 2004).

Indicators of quality of life in Egypt

Health indicators

Egypt was one of the first countries in the region to set up a comprehensive, nationwide health system with a relatively well-established network of health facilities in rural and urban areas. Nearly all of the Egyptian population has access to health care services. An illustrative indicator is the current complete immunization rate for children of 88 percent.

Childhood mortality rate. The 2003 Egypt Interim Demographic and Health Survey (EIDHS, 2003) estimates that childhood mortality is becoming increasingly concentrated in early infancy. For the five-year period before the survey, the under-five mortality rate was 46 per 1 000 births, and the infant mortality rate 38 per 1 000 births. More than 80 percent of early childhood deaths in Egypt were occurring in infants under the age of one year. Neonatal and post-neonatal mortality rates (23 and 15 per 1 000, respectively) show that three-fifths of infant deaths occur within the first month of life. Estimates of childhood mortality trends over the last 40 years (1964 to 2003) show a substantial decrease. Overall, the probability of dying before the age of five years has fallen by about 80 percent, from 243 deaths per 1 000 live births in the period 1964 to 1969, to 46 in the period 1998 to 2003 (Figure 3).

Trends in early childhood mortality rate, 1964 to 2003

Source: EIDHS, 2003.

Life expectancy. Life expectancy increased for males from 52.7 years in 1976 to 67.9 in 2003, and for females from 57.7 years in 1976 to 72.3 in 2003 (Figure 4). Life expectancy is anticipated to reach 73.9 and 78.7 years for males and females, respectively, in 2021 (CAPMAS, 2004).

Life expectancy at birth by gender, 1960 to 2021

Education and literacy

Enrolment in secondary education rose from 42 to 86 percent between 1960 and 2001. A similar trend also occurred in primary school enrolment, which increased from 68.6 to 91.4 percent during the same period. Literacy in the adult population (aged 15 years and over) grew from 25.8 percent in 1960 to 65.6 percent in 2001 - a significant increase that demonstrates the relative success of the government’s education policy to eliminate illiteracy; this is one of the major factors in Egypt’s transition into the "medium level of development" category.

Water and sanitation

More than eight out of ten Egyptian households have access to piped water, mainly within their dwellings. Urban households have almost universal access to safe drinking-water; 99 percent of them have piped water in their residences, and most of the remaining households obtain water from a public tap. In rural areas, access to safe water is less widespread, with 74 percent of rural households having access to piped water, 6 percent obtaining drinking-water from public taps and the remaining 20 percent obtaining drinking-water from covered wells (EIDHS, 2003).

Two out of five households have modern flush toilets, with significant differences according to residence. More than two-thirds (68 percent) of urban households have modern flush toilets, compared with only 13 percent of rural households. In Upper Egypt, 80 percent of households in the urban governorates have modern flush toilets, compared with 8 percent in rural areas (EIDHS, 2003).

Diet and dietary trends[3]

There are two main sources of national-level food consumption data for Egypt. The first of these is a series of national surveys conducted by the National Nutrition Institute (NNI). In the early 1980s, a national food consumption survey was conducted in urban and rural areas of six governorates - Cairo, Alexandria, Sharkia, Souhag, Fayoum and Beheira; this covered 6 300 households, representing 35 334 individuals (Aly et al., 1981). In 1995, an assessment of vitamin A status was conducted on children aged six months to six years. In 2000, another national survey was carried out to obtain up-to-date information on the national food consumption pattern; this covered 1 669 households, representing 9 134 individuals, which were randomly selected from the governorates that were studied in 1981 (Hassanyn, 2000). In 2004, a national survey was carried out to assess osteoporosis among adolescents and adults in Egypt (Hassan et al., 2004). Dietary data for these surveys were collected by the food frequency of households method, and 24-hour recall and sample weighing of individuals’ food intakes (Annexes 1 and 2). In the 1981 and 2000 surveys, 24-hour recall was used to calculate the mean daily per capita energy and protein intakes. For this case study, dietary data for the 1981 and 1995 surveys were derived from tables presented in the final reports, while those for the 2000 and 2004 surveys were reanalysed.

The second source of food consumption data is a series of surveys conducted by the Food Technology Research Institute, Agriculture Research Centre (FTRI/ARC) of the Ministry of Agriculture. These were first made in 1993/1994 (Khorshed, Ibrahim and Galal, 1995; Khorshed et al., 1998), with subsequent rounds in 1999 and 2001/2002 (ARC, 2001/2002; Ibrahim, Youssef and Galal, 2002). The FTRI/ARC surveys were designed to create a system for monitoring the food consumption of Egyptian populations. With the exception of Khorshed et al., 1998 - which is published in English and summarizes the first round of the FTRI/ARC surveys - the results of these surveys are available only in the form of final reports, and some are in Arabic only.

The NNI and FTRI/ARC surveys used different methods for analysing food intake data. In NNI surveys, data were converted into nutrient intake using Egypt’s Food Composition Table, which is maintained by NNI and was compiled in 1996. To analyse the adequacy of nutrient intake, the NNI surveys use the recommended dietary allowances (RDAs) from FAO, the World Health Organization and the United Nations University (FAO/WHO/UNU, 1985) for protein and energy, from WHO (1989) for iron and from FAO/WHO (1975) for vitamins A and C, except the 2004 survey data, for which the FAO/WHO (2002) recommendations were utilized for vitamins and minerals.

The FTRI/ARC surveys conducted since 1993 used a rotating sampling scheme. The first and largest round drew its sample from rural and urban areas in Cairo, Aswan, New Valley, Ismalia and Dakhalia governorates. Subsequent rounds utilized some overlapping and some different governorates, which were selected to include a large urban centre and governorates representing the Nile Delta and Upper Egypt. Data on adult women and on children aged two to six years were collected by the household food frequency method and quantitative 24-hour recall, with collection of detailed household recipes for prepared foods and the modelling survey methodology or that used in the United States National Nutrition Monitoring System surveys. Food intake data were converted to nutrient intakes using a modification of the United States Department of Agriculture’s (USDA) standard reference database (Food Intake and Analysis System, Version 2.3, University of Texas), which was adjusted to remove the influence of enrichment/fortification and to include more than 1 000 Egypt-specific recipes (Khorshed et al., 1998). Nutrient intake adequacy was expressed using the extant versions of the United States RDAs (published by the National Academy Press since 1989). The quality of the first round of these data was investigated with regard to completeness and underreporting (Harrison et al., 2000) and it was found that the degree of apparent underreporting was far lower than it was in surveys of adult American women conducted with a similar methodology.

Because of important methodological differences between the surveys conducted by NNI and by FTRI/ARC, this case study presents each separately. However, both used internally consistent methodology so that trends over time in the data are reliable.

Trends in dietary energy and macronutrient intake

Data from NNI national surveys conducted in 1981 and 2000 show that the mean per capita calorie intake decreased from 3 057 kcal in 1981 to 2 460 kcal in 2000 (Aly et al., 1981; Hassanyn, 2000) (Figure 5).

Mean per capita calorie intake, 1981 and 2000

Sources: Aly et al., 1981; Hassanyn, 2000.

The changes in consumption patterns of Egyptian populations shown in the data from these two surveys can be explained by changes in socio-economic status, feeding habits, urbanization and globalization. The per capita consumption of cereals decreased from 1 980 kcal in 1981 to 1 266 kcal in 2000; cereals accounted for 61.2 percent of the total energy intake in 1981, and only 52 percent in 2000. Sugar’s share of total consumption also decreased, from 10.1 percent of total energy intake in 1981 to 7.7 percent in 2000. Over the same period, per capita consumption of items in the meat group increased from 163 kcal, representing 5.6 percent of total energy intake, to 298 kcal - 10.9 percent of total energy intake. The per capita consumption of items in the milk group increased from 74 kcal and 2.5 percent of total energy intake, to 177 kcal and 7.0 percent of total energy intake. This means that the percentage contribution of animal protein to total energy increased from 8.1 percent in 1981 to 19 percent in 2000 (Figure 6).

Percentage contributions of selected food groups to total energy intake, 1981 and 2000

Sources: Aly et al., 1981; Hassanyn, 2000.

Regarding the per capita consumption of protein, the protein intake from cereals decreased from 61.2 g/day and 54.9 percent of total protein intake in 1981, to 52 g/day and 48.2 percent of total protein intake in 2000. Per capita consumption of protein from meat increased from 16.3 g/day and 18.8 percent of total protein intake, to 25.5g/day and 26.8 percent of total protein intake (Figure 7).

Percentage contributions of selected food groups to total protein intake, 1981 and 2000

Sources: Aly et al., 1981; Hassanyn, 2000.

In order to compare the national dietary surveys conducted in 2000 and 2004, the dietary intakes of mothers were reanalysed to provide more comprehensive results. Table 1 and Figure 8 show the contributions of different food groups to the total energy intakes of mothers in 2000 and 2004. The total energy intake of mothers decreased from 2 602 kcal in 2000 to 1 995 kcal in 2004. The contribution of cereals to the total energy intake of mothers decreased from 1 349 to 1 066 kcal.

Contributions of selected food groups to the total energy and protein intakes of mothers, 2000 and 2004

Food group

Energy (mean kcal/day)

Protein (mean g/day)






1 349

1 066


















Fat and oils















Meat group





Milk group






2 602

1 995




2 442

1 944





1 090


1 090

Percentage contributions of selected food groups to the total energy intake of mothers, 2000 and 2004

Source: NNI surveys.

Dietary adequacy

Table 2 shows the mean and median intakes of energy and nutrients for mothers in the NNI 2000 and 2004 surveys. As well as a decrease in their mean energy intakes, mothers’ intakes of all macro- and micronutrients also decreased, especially those of plant protein, animal fat and calcium.

Mean intakes of macro- and micronutrients among mothers, 2000 and 2004


2000 (n = 835)

2004 (n = 1 090)

Mean ± SD


Mean ± SD


Energy (kcal)

2 602 ± 985.9

2 442.3

1 995 ± 670.9

1 943.5

Protein (g)

91.5 ± 31.3


73.5 ± 26.7


Animal source (g)

27.4 ± 20.6


24.2 ± 18.3


Plant source (g)

64.1 ± 23.8


49.3 ± 20.9


Fat (g)

70.6 ± 53.9


53.3 ± 25.1


Animal source (g)

32.5 ± 50.5


23.5 ± 20.9


Plant source (g)

38.1 ± 23.3


29.8 ± 17.3


Iron (mg)

27.8 ± 14.7


21.1 ± 9.8


Animal source (mg)

3.2 ± 4.8


2.8 ± 3.1


Plant source (mg)

24.6 ± 13.6


18.3 ± 9.4


Vitamin A (µg)

517.3 ± 415.6


483.8 ± 380.2


Vitamin C (mg)

98.5 ± 102.9


92.8 ± 73.4


Calcium (mg)

626 ± 407


494.9 ± 292.3


Iodine (µg)

59.2 ± 33.3


51.1 ± 35.1


Data from ARC surveys conducted between 1995 and 2002 show the percentages of mothers and children aged two to five years who consumed less than 50 percent of the United States RDAs of selected macro- and micronutrients (Figures 9 and 10). The percentage of mothers with inadequate intakes of several nutrients decreased over time, but there are still notably high percentages of women with low intakes of vitamins A and C and calcium. The iron intake data shown here are not adjusted for bioavailability.

Percentages of mothers consuming < 50 percent of RDA of selected nutrients, 1995 to 2002

Source: ARC surveys.

Percentage of children consuming < 50 percent of RDA of selected nutrients, 1995 to 2002

Source: ARC surveys.

ARC used the truncated method of data analysis, whereby all the data that contain consumption of more than 100 percent of RDAs are removed. NNI did not use this method, and its findings regarding the percentages of mothers and children consuming at least 100 percent of the RDAs for selected macro- and micronutrients are shown in Figures 11 and 12.

Percentages of mothers consuming ³ 100 percent of the RDAs for macro- and micronutrients, 1995 and 2004

Iron requirements in 1995 and 2000 are based on WHO, 1989; and in 2004 on FAO/WHO, 2002.
Source: NNI surveys.

Percentages of children aged two to six years consuming ³ 100 percent of the RDAs for macro- and micronutrients, 1995 and 2000

Iron requirements in 1995 and 2000 are based on WHO, 1989; and in 2004 on FAO/WHO, 2002.
Source: NNI surveys.

The special case of iron should be given separate attention. In Egyptian dietary data, the intakes of iron appear to be relatively high and do not take bioavailability into account; however, the prevalence of anaemia is also high in vulnerable populations, and is even increasing. When bioavailability is considered, iron intakes become lower. Table 3 compares the iron intake and the available iron intake calculated from the data of the 1995 FTRI/ARC survey of women. Available iron was calculated using the method of Monsen et al., in which the proportion of iron absorbed is estimated from the amounts of meat, fish, poultry and ascorbic acid - all of which enhance iron absorption - in the diet. It is evident that although the average intake of iron meets or exceeds the RDA, the intake of absorbable iron is insufficient to meet average requirements. Iron bioavailability is compromised by relatively high amounts of fibre, phytate and other inhibitors in the diet, as well as by the even more significant lack of absorption enhancers.

Total and available iron intakes of Egyptian women, 1995


Total Fe (mg)

Available Fe (mg)


14.2 ± 6.8

1.2 ± 1.3


15.1 ± 6.3

1.2 ± 1.2


15.8 ± 5.3

1.0 ± 1.0

New Valley

20.2 ± 7.3

1.1 ± 1.5

RDA = 15 mg.
Requirement = 1.5 to 2.5 mg.
Source: Harrison, 2000. Calculated from Ministry of Agriculture/FTRI, 1995.

Food intakes in relation to population dietary guidelines

FAO/WHO (2002) provide guidance on population nutrient intake goals for fat, sugar, sodium, fruits and vegetables and fibre, among other foods. These goals include achieving a fat intake that accounts for between 15 and 30 percent of total dietary energy. Between 1995 and 2004, the percentage of total energy provided by fat showed a modest decrease in low-fat intake groups (those for whom fat accounts for < 15 percent of dietary energy) and no change in high-intake groups (for whom it accounts for > 30 percent of dietary energy). In 2004, about 20.5 percent of mothers and more than 30 percent of young children had fat intakes that accounted for more than 30 percent of total energy intake.

The FAO/WHO recommendation on sugar indicates that less than 10 percent of total dietary energy should be derived from free sugars. The intakes of free sugars in more than half of the mothers surveyed in Egypt accounted for less than 10 percent of their total energy intakes. Most of these women lived in urban governorates (Cairo and Alexandria). High sugar intakes, accounting for 10 to 20 percent or ³ 20 percent of total energy, were markedly more frequent in rural than urban areas and in Upper Egypt than in Middle and Lower Egypt; this is mostly owing to the habit of drinking heavily sweetened strong tea in rural areas (Hassanyn, 2000).

Almost half the survey sample (48.2 percent) reported excess intakes of animal fat (accounting for ³ 10 percent of total energy). On the other hand, almost three-quarters of mothers consumed less than 300mg/day of cholesterol in their diets, which matches the FAO/WHO population nutrient goal recommended (Hassanyn, 2000).

Infant feeding practices

Infant feeding patterns have important impacts on the health of children. According to the Egypt Demographic and Health Surveys (EDHS) of 1992 and 1995, almost all Egyptian children (about 92 percent) are breastfed for some period, and there was no significant change in this figure between the two studies. Among the children who are breastfed, the percentage of those for whom breastfeeding begins within the first day after birth increased. Exclusive breastfeeding of children up to six months of age also increased between 1992 and 1995, as did the number of children over six months of age who received complementary foods (Figure 13). These positive trends imply that nutrition education programmes for mothers have been well received. The complementary foods that are given along with breastmilk to infants of six to 24 months usually include cereals, cow’s milk and products, eggs, meat, vegetables and fruits.

Breastfeeding status of children less than 24 months, 1992 and 1995

Sources: EDHS, 1992 and 1995

Intra-household food distribution

In Egypt, the prevalence of malnutrition among certain sectors of the population raises concern about intra-household food distribution. A survey studied the intra-household food distribution of 1 470 Egyptian families in three governorates - Cairo, Qualyobia and Beheria - which represent an urban, a semi-urban and a rural community, respectively. The survey included 5 431 target individuals: fathers, mothers, preschool children (aged two to six years), schoolchildren (aged six to 12 years), and male/female adolescents (aged 12 to 19 years). Dietary assessment was carried out on each target individual (using 24-hour recall and the sample weighing method), and a special method of assessing intra-household food distribution was adopted. In this method, the target individual’s intakes of energy, protein and selected nutrients (iron, vitamins A and C and calcium) were recorded as percentage shares of the respective total household intake, and then compared with the recommended share for the target individual.

The results showed that fathers’ share was almost equal to that recommended; mothers’ was much higher than that recommended, especially in urban areas; and preschool and schoolchildren had lower than recommended energy intakes. Fathers consumed more than the recommended shares of iron, vitamin C and calcium, and the recommended share of vitamin A. All other target individuals except mothers consumed less than the recommended shares of calcium. These results were more pronounced in rural than urban communities. (Shaheen and Tawfik, 2000).

Household food security

Khorshed, Ibrahim and Galal (1995) implemented a national food consumption survey in 1994, including 6 000 households in five governorates - Cairo, Ismailia, Dhakahlia, Aswan and New Valley. One of the objectives of this survey was to identify food-insecure households, which were defined as those spending more than three-quarters of their income on food. Food-secure households were defined as those spending less than half of their income on food.

Results of the study revealed that the prevalence of food-insecure households ranged from 4.7 percent in Ismailia to 21.6 percent in Dhakahlia, with New Valley registering a prevalence of 8 percent and Aswan a relatively high 18.6 percent.

Effects of food prices and decreased food subsidies on consumption

Consumers have been affected by increases in food prices resulting from the removal of food subsidies. Galal (2002) reports that when subsidies were removed between 1990 and 1994, food prices increased sharply and at a higher rate than general inflation - three- to tenfold while wages less than doubled. Household food consumption dropped dramatically by about 20 percent during this period. A study by Ibrahim and Eid (1996) to predict the effect of removing food subsidies and applying free market prices concluded that free market prices for cereals, legumes, oils and sugar would increase the cost of energy for the population and reduce the consumption of animal protein, particularly in vulnerable groups.

Hussein et al., (1989) conducted a study of families’ behaviour in response to increasing food prices. A sample of 350 households in Cairo, Assuit, Beheira and industrial areas was selected. Results revealed that the rise in income could not cope with that in food costs. Less expensive foods were substituted, and the frequency of meat consumption in particular declined.

In 1994, Khorshed, Ibrahim and Galal (1995) found that 60 percent of surveyed households had changed their pattern of consumption over the previous year, owing to rising food prices. The range went from 35 percent of households in Cairo to more than 85 percent in Aswan and New Valley. About 21 percent of households indicated that they would spend additional income on improving their dietary quality by purchasing more meat, fruit and vegetables.

[2] This section was investigated by A. El-Hady Abbas, S. Khairy and M. Shehata.
[3] This section was investigated by A. Tawfik, M. Mattar and D. Shehab.

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