Nutrition and Food Literacy in the MENA Region: Comparison
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Please note this is a comparison between Version 2 by Jason Zhu and Version 1 by Maha Hoteit.

Improving food and nutrition literacy is fundamental to tackling the Middle East and North Africa (MENA) region’s enormous challenges, including malnutrition and food insecurity. To direct initiatives, it is crucial to assess the region’s food and nutrition literacy. People in these countries mostly had inadequate food and/or nutrition literacy levels, especially in the skills rather than the cognitive domain. Food and/or nutrition literacy showed associations with food habits, food-label use, food-consumption patterns, school performance, food security, dietary diversity, and nutrient adequacy. The MENA countries developed no policies or programs to address food and nutrition literacy. 

  • food literacy
  • nutrition literacy
  • MENA
  • malnutrition

1. Introduction

1.1. Malnutrition and Food Insecurity Burden in the MENA Region

The triple burden of malnutrition and anemia along with the coexistence of food insecurity are tremendous challenges in the MENA region [1]. With ongoing conflicts, political instability, and the COVID-19 pandemic, the region is witnessing an unprecedented increase in food insecurity, a decline in dietary diversity [2], the adoption of unhealthy eating patterns, and changes in food literacy [3]. In addition, the ongoing conflict in Ukraine, since February 2022, is compounding the impacts of two long years of the COVID-19 pandemic on economies, food insecurity, poverty, and malnutrition in the MENA region [4]. It is expected that the number of people affected by hunger in the region will surpass 75 million by 2030 [5]. Recent estimates show that more than 7 million children in the region suffer from chronic malnutrition, manifested as stunting [6]. Besides, 3.7 million children have acute malnutrition, of which 1.6 million are severely wasted [6]. The average prevalence of overweight and obesity was 27% and 24% in adults and 16.5% and 4.8% in school-aged children, respectively [7]. Besides, anemia prevalence in the region ranged between 22.6% and 63% amongst pregnant women, 27% and 69.6% amongst women of reproductive age, and 23.8% and 83.5% amongst under-five children [8]. Added to these, MENA’s share of the world’s acutely food-insecure people was 20%, which is considered high for its 6% share of the population [9]. Hence, to overcome these challenges, the MENA countries should re-prioritize and reform inefficacious practices and food-related policies towards “high-return nutrition investment” that amplifies the availability of and the access to nutritious foods [10]. Furthermore, the reform of incompetent food-related practices and policies offers resources that can be used to ramp-up well-targeted educational, social, behavioral, nutritional, and health-related outcomes [11]. These outcomes are needed to transform and enhance the resilience of the region’s food systems, to increase the capacity to ensure safe, healthy, and sustainable diets [11]. To achieve Zero Hunger by 2030, it is crucial to transform Arab food systems to end hunger and malnutrition [11]. Thus, some various elements should be the focus of intervention. These include nutrition knowledge and attitudes, food and cooking skills, food environment, food preferences, and food literacy [12]. Being food literate is crucial to help people make healthy food choices that ensure nutritional needs are met [13]. “Food literacy is particularly important in the early years, when children are developing the eating patterns and skills that they will carry into adulthood and pass on to future generations” [13].

1.2. Existing Definitions of Food Literacy and Nutrition Literacy

The term “food literacy” has gained momentum in recent years, being evolved from the broader concept of health literacy [14]. Researchers will continue to debate the definition of food literacy for many years until it becomes a rich study area [14]. Food literacy is defined as the ability to make appropriate food decisions to support individual health and a sustainable food system, considering environmental, social, economic, cultural, and political contexts [15]. Food and nutrition knowledge, food skills, self-efficacy and confidence, food decisions, and multiple environmental factors, particularly the food system, are all food literacy attributes, according to the Food Literacy Framework for Healthy Eating [16]. Widener, P. and Karides, M. (2014) [17] further suggested the term “system food literacy”, implying that food literacy entails a thorough understanding of the food system and its social and economic issues. Besides, the components of functional (comprehend and understand information), interactive (share and exchange information and interact with others), and critical (evaluate and judge information) literacy presented by Nutbeam’s tripartite model [18] are reflected in worldwide food-literacy definitions.
Similar to food literacy, nutrition literacy is under the umbrella of health literacy [14]. It is considered “a health literacy applied to the field of nutrition” [14]. The nutritionally literate individual is one who can obtain, process, and understand basic nutrition information necessary for making appropriate nutrition decisions [19]; however, food literacy is incorporated into a broader spectrum of theoretical and practical knowledge and skills [20]. In other words, the skills incorporated in nutrition literacy are prerequisites for food-literacy competencies [20]. Nevertheless, they do not represent the whole spectrum of skills and competencies needed to perform well in making healthy and right food decisions [20]. Food and nutrition literacy are distinct but complementary concepts, as they are not debated as freestanding terms [20]. Food-literacy and nutrition-literacy definitions have not been originated by Arab reseauthorchers yet, indicating that these topics are undervalued in the region.

1.3. Food and Nutrition Literacy and Nutrition Outcomes

Promoting food and nutrition literacy is a determinant factor in leading to healthy food choices and the adoption of healthy diets by children and adolescents, in particular [28][21]. Plenty of evidence shows that adequate levels of food and nutrition literacy are positively associated with food selection, food preparation, eating habits, and diet quality [28][21]. For instance, a higher level of food and nutrition literacy has been associated with increased consumption of fruits and vegetables [29][22], preference for healthy food [30][23], and decreased consumption of prepacked or processed food [31][24]. Besides, having limited food skills was shown to be associated with increased consumption of ultra-processed foods [32][25]. Above these, inadequate food literacy had exacerbated food insecurity by impeding adequate food utilization [33][26]. Though evidence demonstrating the relationship between nutrition outcomes and food and nutrition literacy is still developing, the foregoing findings suggest that food- and nutrition-literacy-based interventions in the MENA region are extremely promising.

2. Food and/or Nutrition-Literacy Status in the MENA Countries

Taleb, S. and Itani, L. (2021) [39][27] assessed the nutrition literacy among 189 Lebanese adolescents aged 14–19 years old and the association of nutrition literacy with adolescents’ BMI status and food habits. Lebanese adolescents had adequate nutrition literacy on the nutrition and health, macronutrients, and food-groups literacy components of the NLAI scale; however, marginal nutrition literacy was observed for household-food measures and food-label reading [39][27]. In contrast, Natour, N. et al. (2021) [40][28] reported that about one quarter (29%) of Palestinian adult participants appeared to have adequate nutrition literacy. Tell et al. (2021) [41][29] further found that the mean of functional nutrition literacy (FNL) was 2.8 ± 0.5 (over 7), 3.3 ± 0.5 (over 8) for interactive nutrition literacy (INL), and 3.6 ± 0.5 (over 11) for critical nutrition literacy (CNL), indicating literacy insufficiency at all sublevels among Palestinian adults. The food and nutrition literacy has been widely addressed in Iran more than any other country in the MENA region. Ashoori, M. et al. (2021) [42][30] explored that Iranian senior-high-school students (17–18 years old) had inadequate levels of food and nutrition literacy, with a mean ± SD of the total food and nutrition literacy (FNL) score equal to 52.1 ± 10.96 (a score of 60 is considered acceptable) [42][30]. Among 803 Iranian student participants (10–12 years old), 68.8% of them had high food and nutrition scores in the cognitive domains (understanding food and nutrition information); nevertheless, at least one out of four students (25%) had low score values in the skill domain (including food label literacy, food choice literacy) [43][31]. Moreover, the study findings by Doustmohammadian et al. (2020) [44][32] reemphasized the latter, by showing that 25% of school-age Iranian students had low scores in the skill domain, and the majority (97.4%) scored moderate-to-high in the cognitive domain of the food and nutrition literacy. Similar findings were also reported in a 2019 published paper [47][33], which explored that even though most Iranian adolescents had adequate food and nutrition literacy, more than half (69%) had the highest score in the cognitive domain, while only few (15%) scored highly in the skills domain. Khorramrouz, F. et al. (2020) [33][26] demonstrated that 14% of 315 Iranian students had inadequate food and nutrition literacy, and only 23.2% had high food- and nutrition-literacy scores. Mehri et al. (2020) [45][34] also reported that most Iranian adolescents had poor food and nutrition literacy (62% of males and 58.1% of females). As well, the nutrition literacy score in elementary school teachers in Yasuj, Iran was 27.14 ± 3.2, revealing that 22.7% of participants were nutritionally illiterate [48][35]. Added to these, the mean ± SD of total nutrition literacy was 52.98 ± 7.15, an indication of inadequacy in literacy levels among Iranian young adolescents (13–15 years old) [49][36]. On the contrary, about half of Iranian medical students (48.1%) showed adequate nutrition literacy, and, interestingly, only 1% had poor nutrition-literacy scores [46][37]. Therefore, food literacy and nutrition literacy have been inadequately addressed in the MENA countries, with the most data available in Iran. Moreover, where assessed, the data seem distressing, with critical deficits in skills rather than cognitive areas, such as food-label reading, food selection, and cooking. Nonetheless, food literacy and nutrition literacy were shown to be of better status in multiple countries outside the MENA region, even among adolescent participants. This was evident in recent studies conducted in China [74][38], Turkey [62[39][40][41],63,64], the U.S. [75][42], and Ghana [76][43], with all emphasizing adequate nutrition literacy in the sampled population, showing good competencies in most or even all food-literacy and nutrition-literacy components. Besides, good nutrition-literacy levels and basic food literacy were recorded in Greece [67][44] and Canada [77][45], respectively. The disparity between the MENA countries and other nations’ findings may be attributed by the latter’s investment in food and nutrition education. For instance, in the U.S., the percentage of schools providing nutrition education and instructions was 74.1% in 2014 [78][46]. Besides, it is encouraging to note that Nigeria has decided to increase investment in school food and nutrition [79][47]. Evidence suggests that people can change their behaviors to improve their nutrition outcomes, particularly when they are in supportive environments [80][48]. Thus, in a region such as the MENA that is plagued by numerous conflicts, the people, especially children and youth, need opportunities to develop nutrition and food literacy through food and nutrition education, standards, and policies. In addition to national governments, activists and advocates have a role to play in bringing about change. This is in line with the call for systemic change made by Agenda 2030 and the emphasis placed on food systems in the outcome documents of the Second International Conference on Nutrition (ICN2). Most of the reviewed studies in the MENA region included adolescent participants, with all reporting dismal literacy levels in this vulnerable age group. This observation is crucial because adolescence encompasses critical stages of development and rapid growth, mainly the pubertal growth stage, during which nutrient requirements increase [79][47]. Accordingly, nutrition-related problems have been observed among adolescents having inadequate levels of nutrition literacy [13]. Therefore, it is essential to promote healthy eating habits during this unique life stage, by having interventions be delivered continuously, with a specific emphasis on school-based food and nutrition education. Besides, the review presently reveals that skill-based literacy, mainly food-label use, is more problematic than cognitive-based literacy, with lower use of food labels among food/nutrition-illiterate participants [40,42,43,44,47][28][30][31][32][33]. Based on many pieces of evidence, food-label reading is one pivotal step to improving food choices and dietary habits [81][49]. One possible explanation for observing such findings in the MENA countries is that this concept and its application have neither been entered into school curricula and textbooks nor in education programs, to empower individuals in basing their food choices according to nutrition- and safety-related considerations. One recent study showed that Lebanese shoppers expressed poor nutrition-label-related knowledge, and more than half the population either read nutrition labels occasionally or did not look at the food label at all [82][50]. Emirati consumers reported looking mostly at the expiration date of the products rather than the information related to the food-storage and -handling instructions and the biotechnology as well, which are key components of being food literate [83][51]. Similarly, only 42% of Bahraini consumers read the food label, with the common practice being reading the basic label information related to production and expiry dates [84][52]. Food-literacy interventions focusing on consumer’ skills to read food labels should be prioritized in such regions, where nutrition inadequacy and malnutrition are not uncommon. Thereupon, Hoteit M. and colleagues (2022) [82][50] provided data on this topic, “the first steps in the Nutri-Score roadmap”, to serve as an initiative to motivate the national implementation of food-labeling approaches in Lebanon such as the Nutri-Score front-of-pack label.

3. Correlates of Food and/or Nutrition Literacy in the MENA Countries

TIt his reviewas been found associations between food and/or nutrition literacy and critical factors and correlates. The nutrition literacy of Lebanese adolescents was associated with their food habits; nevertheless, an unusual finding is that participants with higher nutrition literacy scores had poorer food habits (higher fat intake, higher sweets intake, and lower intake of fruits and vegetables) as compared to other participants with low nutrition-literacy scores [39][27]. Related to this, Taleb, S. and Itani, L. debated that nutrition literacy alone, if not coupled with essential behavior capabilities and environmental support, may not guarantee behavior change [39][27]. What is also worth mentioning is that the body mass index (BMI) of Lebanese adolescents did not correlate with their nutrition literacy [39][27]. However, higher nutrition-literacy levels among Palestinian adults predicted better use of the food labels as well as checking the health benefits on the label and, in consequence, higher consumption of low-calorie products [40][28]. In addition, the food and nutrition literacy were correlated with the use of food labels and looking, in particular, over the ingredients part of the label [41][29]. Adding cheese and mayonnaise to meals was less common in participants with adequate critical food and nutrition literacy [41][29]. Participants with better FNL seemed to rely on health professionals and scientific books rather than unreliable online sources to seek nutrition information [41][29]. Ashoori, M. et al. [42][30] found that high food and nutrition literacy scores predicted better school performance among high school students. Participants who had a family member having a nutrition-related disease scored higher on the food-label-reading skill of the food and nutrition literacy [42][30]. Better food and nutrition literacy anticipated everyday intake of breakfast, lunch, and dinner compared to those who used to skip meals [43][31]. Participants having higher food- and nutrition-literacy scores reported lower consumption of sausages, hamburgers, and sweets [43][31]. Further, food and nutrition literacy were a barrier to dietary diversity and nutrient adequacy in school-age children in Iran [43][31]. A low level of functional food and nutrition literacy (FFNL) was significantly associated with a lower intake of fruits and meat products [43][31]. Likewise, inadequate food-label literacy predicted significantly lower consumption of dairy and meat products [43][31]. It was also found that poor food and nutrition literacy was significantly associated with a low level of nutrition adequacy ratio (NAR) of protein, calcium, vitamin B3, vitamin B6, and vitamin B9 and the probability of a lower-level mean adequacy ratio (MAR) [44][32]. Adolescents who were in contact with healthcare providers had better food- and nutrition-literacy scores [45][34]. Moreover, an increase in total nutrition literacy (T-NL), INL, and CNL enhance diet quality [49][36]. An increase in FNL was associated with lower sugar intake and better energy balance in male participants [49][36]. Further, higher education level was also a significant correlate with the nutrition literacy [48][35]. Nutritional literacy had a significant correlation with the field of study, residence, and body mass index (p < 0.05) [46][37]. Food and nutrition literacy and food insecurity have also been associated, and food-insecure participants were about three times more likely to have low food and nutrition literacy scores compared to the food-secure participants (OR = 2.86, 95% CI 1.35, 6.05; p = 0.006) [33][26]. The review findings of food literacy and nutrition literacy correlate with those reported by studies outside the MENA boundaries, with significant associations with a myriad of nutrition outcomes. Costarelli, V. et al. (2021) [67][44] debated that better parental nutrition literacy was significantly associated with the feeding practices of their children, including healthy-eating guidance and monitoring practices. Moreover, better food literacy was found to have a negative association with fast food consumption and alcohol abuse among secondary students (16–21 years old) in Portugal [68][53]. The relationship between food literacy and food security has been also addressed in Australia, showing that food-insecure participants were 1.4 times less likely to base their food choices on looking over the nutrition information panel [85][54]. Furthermore, food-label use was higher among Turkish adolescents having adequate nutrition literacy, who also experienced lower consumption of fast food and reliance on reliable sources to search for and access nutrition information [64][41], which were also emphasized by the findings reported by Ayer, Ç. and Ergin, A. (2021) [62][39] and Koca, B. and Arkan, G. (2020) [63][40]. Besides, there was a significant positive relationship between food literacy and students’ dietary behavior in Ghana [76][43]. Moreover, multiple studies reported a positive association between food literacy and adolescents’ dietary intake; adolescents with greater food knowledge and frequent food preparation behaviors had healthier dietary practices [13]. Taken together, improving communities’ food and nutrition literacy could refigure the nutrition situation in many countries, pushing them closer to or even attaining Goal 2 of the 2030 Agenda of Sustainable Development, which is to end all forms of malnutrition.

4. Existing Food Literacy and Nutrition Literacy Policies and Programs

The published literature reveals that the MENA countries have not adopted any food-literacy or nutrition-literacy policies and programs yet, despite the need and the evident effectiveness of the existing ones. On the other hand, many countries have taken the initiative to formulate and adopt school-based programs and policies to promote food and nutrition knowledge and skills among children, and in certain circumstances, those of their parents and other community members. According to Hawkes and colleagues [80][48], there are four mechanisms by which a policy can influence food preferences and support healthy-eating patterns: (1) policy provides an enabling environment for healthy-preference learning; (2) policy overcomes barriers to the expression of healthy preferences; (3) policy encourages people to reassess existing unhealthy preferences; and (4) policy stimulates a food-system response.

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