Nutritional Deficiencies and Disorders

The traditional diet of North Africa reflects the geographic divisions of the area. Each country from the Senegal River to the Nile has a littoral and a desert region that are separated from each other by fertile plateaus and arid mountains. Commonly, the littoral food pattern has been based on cereals and fruit; the plateau diet, on cereals, olives, sheep's milk, and meat; and the desert diet, on dates and camel's milk.

The dietary patterns of Middle Eastern countries also reflect geographic and economic conditions. Except for Israel and Lebanon, where vegetables and fruits abound, cereals provide the major portion of both the caloric and protein intake in the average diet. Wheat is the most widely consumed cereal in all countries; maize is the chief staple in the delta region of Egypt and the Black Sea coast of Turkey; rice is also popular, but its high cost limits its consumption to producing areas (mainly Egypt) and the well-to-do; burghul (parboiled wheat sundried and crushed) is eaten in Turkey, Syria, and Lebanon as a substitute for rice. Lentils and other legumes are consumed widely.

Vegetables such as onions, tomatoes, eggplant, cucumbers, peppers, squash, and cabbages are universally popular but are consumed in inadequate amounts. Consumption of fruits shows wide seasonal variations, except for dates, raisins, grapes, and apricots, which can be preserved by drying. The difficulty of transporting and preserving fresh milk has led to the widespread use of fermented milk, yogurt, and, to a lesser extent, sheep and goat cheese.

Throughout the Middle East, meat is consumed at a low level, mainly because of its relatively high cost. Although the animal population in this region is among the highest in the world, livestock repre sent capital to the herdsmen that is not to be wasted by slaughter. Thus, meat contributes only about 2 percent of the total caloric intake, compared with 21 percent in the United States. Mutton is the principal meat consumed in Muslim countries, and to some extent beef and goat are also eaten. Like the nomads' herds, poultry and eggs provide a livelihood for villagers; they are sold and eaten mainly in towns. Fish as food has been important only among the inhabitants of the Black Sea area in Turkey, the delta lakes region in Egypt, and the marsh dwellers of southern Iraq.

Certain cultural and environmental features restrict diet in both the Middle East and North Africa. Both Muslims and Jews, for example, are enjoined from eating meat not slaughtered according to their religious codes, and this ritual slaughter adds to the cost. More generally, climatic conditions and the lack of efficient means of food preservation, refrigeration, and transport drastically restrict consumption of fruits, vegetables, milk products, fish, and meat. The scanty and irregular distribution of rainfall has been a constant factor retarding the development of agriculture. Although production has increased in all areas since the Second World War, the low purchasing power of the population, especially in rural areas, as well as the lack of transport and distribution facilities, has kept consumption of food low. The result of the foregoing is that a significant segment of the population is afflicted with nutritional diseases.

In Egypt, Iraq, and to a lesser extent in Syria, hypochromic microcytic anemia has been attributed to the prevalence of hookworm infestation in irrigated farm areas, but there is evidence that parasitic infestation also contributes to the high morbidity of nutritional anemia (May and Jarcho 1961).

One investigation in Algeria found that macrocytic nutritional anemia was common among various population groups in the capital, mainly inhabitants of the city slums or rural areas whose diets were unusually low in protein, fats, fresh fruits, and vegetables. Another survey (May 1967) revealed that a large percentage of children under 1 year of age in Tunisian cities showed signs of nutritional anemia. And in Morocco it was reported that women, especially those pregnant or lactating, showed gross evidence of iron deficiency anemia.

Kwashiorkor is not as common in the Middle East and North Africa as in sub-Sahara Africa, but it has been reported among the poorest classes in Egypt and Israel. In Morocco, Algeria, and Tunisia, it reportedly has been common following weaning of chil dren between 1 and 3 years of age (May and Jarcho 1961; May 1967).

Xerophthalmia or night blindness due to vitamin A deficiency is common in the Middle East and North Africa. Lack of vitamin A also lowers resistance to infection. For example, keratoconjunctivitis occurring in a child deficient in vitamin A increases that child's susceptibility to chronic trachoma. Also, in Libya bacterial infections rise during the autumn date harvest when flies proliferate; combined with vitamin A deficiency, an eye infection may lead to serious complications - rupture of the cornea and prolapse of the iris - and blindness (Kanter 1967). Night blindness has been reported in Iran and among sedentary communities of the northern Sahara in North Africa (May and Jarcho 1961; May 1967; Benenson 1975).

Pellagra, by contrast, has been reported only in the Black Sea area of Turkey and the delta of Egypt where maize is the staple grain, and in North Africa during periods of wheat or barley shortage when consumption of corn has become necessary.

Scurvy is rare in the Middle East and North Africa, where citrus fruits are usually available, except in Erzerum in northeastern Turkey, which is isolated from food supply lines during winter months.

Rickets, on the other hand, has been observed in large towns of Iran, Syria, and Egypt where infants were swaddled and therefore not exposed to the sun. In North Africa rickets was reported in the sunless slums of coastal cities in Morocco, Algeria, and Tunisia and among sedentary communities in the northern Sahara. Southern nomads appeared to escape this disease as well as scurvy and xerophthalmia perhaps because of greater exposure to sunlight and higher milk consumption. Erzerum in northeastern Turkey has reported seasonal incidence of rickets as well as scurvy during long, severe, sunless winters (May and Jarcho 1961; May 1967; Benenson 1975).

General Observations on Nutrition Although malnutrition (overreliance on starch in the diet, with little fat or protein) has been observed, undernutrition (calorie as well as protein-deficient diet) has been far more common in the Middle East and North Africa. In most countries, the population rise has consistently exceeded the increase in cultivated land. The most dramatic example is Egypt, where population is increasing by about a million people each year.

In extensively irrigated countries like Egypt and Iraq, and to a lesser extent Syria, there is a synergistic interaction between inadequate diet and parasitic infestation, particularly hookworm, causing severe anemia and threatening retardation of the physical and mental development of children. Investigators also have suggested that an interaction between poor diet and schistosomiasis may cause pellagra.

In North African countries and the states of the Arabian Peninsula, protein and vitamin deficiencies are reported predominantly among women and children, and are not common among men. This observation is valid as well for other countries in the region that share the patriarchal custom of serving the father and older sons of the family first, leaving what remains for women and children, which may not include meat, fruits, and vegetables.

In North Africa where the child between 1 and 3 years old is weaned abruptly and then given a diet of carbohydrates familiar in family fare, the young may not be able to tolerate the change, which may then cause dyspepsia, infantile diarrhea, lowered resistance to infectious diseases, and kwashiorkor. Nomadic tribespeople of the Sahara south of the Atlas mountains, however, wean the infant over a 6-month period, introducing it gradually first to camel's milk and then to cereals.

On the positive side, the high consumption of whole wheat and other cereal products may explain the comparative absence of vitamin B complex deficiencies. Also, traditional dishes that combine cereals with legumes such as beans, chickpeas, and lentils have been demonstrated to be a good source of protein.

In addition, there are some naturally occurring foods that compensate the inhabitants of unproductive areas for the lack of more common foods. In Iraq, for example, an herb called khoubbaz (Malus ro-tundifolia), which is eaten raw by both rural and nomadic peoples, has been found to have a high ascorbic acid content. And in Libya's Fezzan, two naturally occurring foods have been found to be rich in beta-carotene and riboflavin. One, danga, is prepared from an alga growing on salt lakes; the other, duda, consists of small crustaceans from the salt lakes. Both are kneaded, formed into small cakes, dried in the sun, and later mixed with barley, millet flour, or dates, and eaten as a main dish in a meal. Lastly, dates, an important food among nomadic and seminomadic peoples, are ideal for desert dwellers in that they have a high sugar content, are relatively resistant to contamination with pathological bacteria, and show long-keeping qualities.

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