Hidden Hunger: Micronutrient Deficiencies in the West Bank and Gaza

The poor nutritional status of the Palestinian population is worrying, with a high prevalence of micronutrient deficiencies among groups for whom good nutrition is particularly important, such as children under five years old and pregnant and postnatal women. 

There are many reasons why: In the West Bank and Gaza, heightened food insecurity contributes to an insufficient intake of micronutrients, and poor households especially have limited access to micronutrient-rich foods, such as red meat, fresh vegetables, and milk. 

Other factors, such as the physical barriers that limit access to health services, as well as prolonged periods of insecurity, prevent many initiatives that have been taken to address micronutrient deficiencies from having much effect. The resulting, persistently high prevalence of micronutrient deficiency is likely to have grave consequences for human health and economic development if no action is taken. 

Micronutrient deficiencies are caused by poor dietary intake and/or poor absorption of micronutrients, an increased need for micronutrients (due to childhood growth or chronic disease), the presence of parasitic, bacterial, and viral infections, and other environmental risk factors. In women and children, micronutrient deficiencies are associated with increased morbidity and mortality. They lead not only to serious health outcomes, but also to lower educational outcomes and lower productivity at work. 

Micronutrient deficiencies a public health threat

Anemia is when the body lacks enough healthy red blood cells to carry oxygen to tissues. It can be caused by a lack of iron and other micronutrients. In Gaza, anemia is a severe public health problem. Over half of pregnant women and over half of children aged 6–23 months were anemic, according to Ministry of Health (MOH) and national nutrition surveys conducted in 2018 and 2020. In the West Bank, anemia is a moderate public health problem, with more than a quarter of pregnant women and more than a quarter of children aged 6–23 months anemic. 

High proportions of the Palestinian population are also deficient in vitamins A, D, and E, which play key roles in vision, bone health, and immune function. 

Data from the most recent national survey conducted by the MOH in 2013—the most reliable and comprehensive source of data on micronutrient status to date—showed about 72% of children (6–59 months old) and 47% to 58% of pregnant women (depending on the trimester of pregnancy) suffered from low plasma vitamin A. About 54% to 68% of children (6–59 months old) and 99% of pregnant women (18–43 years old) in their second and third trimesters had low vitamin D. About 65% of children (6–59 months old) and 16% to 42% of pregnant women (depending on the trimester of pregnancy) had low vitamin E.

Despite a decade of efforts by the MOH, this problem still exists. The MOH asked the World Bank for help to identify the factors hindering improvement in micronutrient levels and to find practical, innovative solutions, adapted to the local context. Two detailed assessments were conducted by the World Bank between 2019 and 2021 (1) to identify the bottlenecks in anemia prevention and control programs and (2) to examine the feasibility of an edible oil fortification program. 

These two multi-sectoral assessments were conducted to answer key questions, such as food consumption, supply chain systems, consumer behavior, market distribution, and service delivery systems. The findings from the assessments illustrate the large numbers of Palestinians with persistent micronutrient deficiencies. The actions proposed by the World Bank team can improve the coverage and quality of interventions in the West Bank and Gaza Strip. 

Toward better nutrition

Current anemia prevention and control services target the most vulnerable, including pregnant women and those who are breastfeeding, as well as children aged under five years old. However, existing interventions, such as iron and folic acid supplementation for pregnant women and a universal flour fortification program, do not seem to increase blood micronutrient levels.

Current anemia prevention and control services target the most vulnerable, including pregnant women and those who are breastfeeding, as well as children aged under five years old. However, existing interventions, such as iron and folic acid supplementation for pregnant women and a universal flour fortification program, do not seem to increase blood micronutrient levels. 

Opportunities for effective interventions exist but need more technical and financial support. To improve outcomes, the stock management of iron supplements needs to be revised, quality of care in nutrition counseling strengthened, and public awareness raised about the importance of adequate micronutrient intake. Monitoring and evaluation systems also need to be introduced for service delivery and fortification enforcement. 

For example, interactive information sessions for pregnant women and other caregivers of children, three years old and younger, could be leveraged to give participants advice on preventing anemia and the importance of compliance with the practices recommended for good health. 

An edible oil, fortified with vitamins A, D, and E, could be a platform for increasing the intake of these vitamins in the general population. Technical and financial support should be provided to strengthen the work of local laboratories, conduct spot checks of samples, and establish or revise technical regulations. More capacity is also needed for monitoring vitamin content at points of entry, such as in repacking factories and retail shops in markets, and for equipping repackaging factories with the premix needed to fortify edible oils with the vitamins. 

More information about the assessments results and recommendations can be found in “Micronutrient Deficiencies in the Palestinian Territories: Identifying the Bottlenecks of Anemia Prevention and Control and Assessing the Feasibility of an Oil Fortification Program”.