The Sustainable Development Goals (SDGs) include 17 goals which were developed by the UN General Assembly in 2015 (U.N., 2015). They have 169 targets and are monitored by 230 indicators as a means for driving progress towards achieving the goals presented by the UN Statistical Commission through the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (IAEG-SDGs, 2016) to be achieved by 2030 (Bayoumi et al., 2022). Nutrition by ending hunger (SDG2) is a core dimension of the SDGs. Target 2.2: states that by 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age (de Onis et al., 2013). The reduction of child stunting is also the first of six goals in the Global Nutrition Targets for 2025 (WHO Resolution WHA65.6, 2012) and a key indicator in the second SDG of Zero Hunger (WHO, 2012).

Global estimates of stunting indicate that a considerable percent of children under five are stunted (1 in five), particularly in low income countries (LIC) and middle income countries (MIC) (UNICEF, 2019). Estimates of 149 billion stunted children indicate that these figures may have drastic effects on the economy of nations. In the Eastern Mediterranean region (EMR) the average weighted rate of stunting is 28% (Nasreddine et al., 2018) being the highest in LIC (Al-Jawaldeh et al., 2020). Stunting has devastating consequences on child development (Dewey & Begum, 2011). These children as adults may earn 20 per cent less than their non-stunted peers, (UNICEF, 2019) and stunting can reduce a country’s gross domestic product by up to 3 per cent (Victora et al., 2010). Stunting and child growth deficits are difficult to reverse, while cognitive deficits may be permanent after two years (Fink et al., 2016).

Arab nations living in conflict are struggling to maintain development. Their progress in SDGs as indicated by the indicators, is slow and many challenges face these countries as shown in the report for the Arab SDG index and dashboard in 2022 (Bayoumi et al., 2022). Improving children’s nutritional status is the foundation of sustainable and prosperous societies and paramount to achieving the 2030 “Sustainable Development Goals” (SDGs), including Goal 2 to improve nutrition and end all forms of malnutrition. Eliminating stunting supports the achievement of SDG targets on ending preventable childhood deaths and eliminating poverty, among others. In addition, improving children’s nutritional status is central to addressing three of the six World Health Assembly (WHA) targets for reducing stunting in children under five years of age by 40% by 2025 (de Onis et al., 2013).

Several factors underlie the problem of stunting. Consistent evidence suggests nonexclusive breastfeeding for the first 6 months, low household socio-economic status, premature birth, short birth length, and low maternal height and education are particularly important child stunting determinants in middle and low income countries (Danaei et al., 2016). Children from households with both unimproved latrines and untreated drinking water are also at increased risk (Torlesse et al., 2016) . However other factors than nutrition play a role in stunting. Community and societal factors—particularly, poor access to health care and living in areas of ongoing conflict and famines—have been repeatedly associated with child stunting (Argaw et al., 2019; Beal et al., 2018). Hence it is important to develop a more comprehensive and holistic overview of how to tackle the problem of malnutrition from a multidisciplinary, multidimensional approach.

The 17 SDGs approach the problems of human development from a more holistic overview. Hence the aim of this study is to identify SDG indicators inputs that crosscut with stunting in order to guide countries in the Arab region on how to manage and prevent stunting in children under five years of age.

Data about the SDGs in 22 countries of the Arab were compiled from the SDG global database. The countries were categorized by level income as per the World Bank classification. The 7 low income countries (LIC) included Djibouti, Comoros, Mauritania, Sudan, Somalia, Syrian Arab Republic and Yemen. The 9 middle income countries (MIC) included Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, State of Palestine and Tunisia. The six high income countries (HIC) of the gulf region included Bahrain, Kuwait, Qatar, Saudi Arabia, Sultanate of Oman and United Arab Emirates (UAE). Data for the State of Palestine source (https://www.pcbs.gov.ps/pcbs_2012/Publications.aspx). Other data source was obtained from the UNDP global database (Bayoumi et al., 2022). Stunting is measured by the percent prevalence of stunting in children under five years of age, whereby stunting is defined as below –2 SDs from the median height-for-age of the reference population using the WHO growth standards (WHO, 2006). Indices representing nutrition-related SDG indicators were compiled from global SDG data for the 22 Arab states of the Arab League. The relevant indicators for each of the 17 SDGs were compiled from the global database of UNDP included SDG1 (4), SDG2 (8), SDG3 (11), SDG4 (3), SDG5 (7), SDG6 (4), SDG7 (2), SDG8 (4), SDG9 (6), SDG10 (2), SDG11 (4), SDG12 (4), SDG13 (1), SDG14 (5), SDG15 (3), SDG16 (7), SDG17 (2) with a total of 77 indicators representing the targets of the 17 SDGs. They were correlated with stunting and income group through descriptive analysis. The source of data from 2022 Arab Region SDG Index and Dashboard Report and Cambridge University SDG report in 2022 (Bayoumi et al., 2022).

The SDGs and their relevant indicators which were selected in this study are presented in Table 1. Data was compiled in Microsoft Excel sheets for version of 2019 and descriptive analysis was used to present the data into line charts. Since these were secondary data and raw data was not accessible statistical analysis was not permissible and descriptive analysis of the rates and percentages was used as the basis of our qualitative analysis. Correlations were either positive or negative based on the directions of the associations with stunting. Correlations were either high (if above 0.6) or moderate (around 0.5) or low (if below 0.4). Correlations were used as a mean of descriptive analysis and not for statistical analysis. The degree of association was presented using line charts and trend lines to indicate the direction of the association. Countries with data for the relevant indicator ranged from 22 to 15.

The results from analysis of the global data on the indicators for SDGs 1 to 6 and 10 were grouped together to represent “People related indicators” while SDGs 7 to 9 and 11 to 17 were grouped as “Planet, Prosperity and Peace”. There were associations with at least one indicator for each of the 17 SDGs. Out of the 77 SDG indicators that were studied 47 (61%) i.e. almost two thirds showed some positive or negative correlation with stunting as shown in Table 1. The associations of the SDG indicators under study with stunting were demonstrated in Figures 1-7. Poverty rate (SDG1), mortality rates, universal health coverage, wellbeing (SDG3), quality education (SDG4), gender issues (SDG5), clean water, sanitation and hygiene (SDG6), affordable and clean energy (SDG7), science and technology (SDG9), climate action (SDG13) and peace and justice (SDG16) and

partnerships and government spending on health and education (SDG17) showed high correlations with stunting.

Figure 1 shows there is a positive relationship of stunting to poverty rate at $3.2 for working poor and poverty head count ratio at $3.2 (SDG1) in 13 of the 22 Arab countries. Figure 2 demonstrates the positive association of stunting with neonatal mortality rates, deaths from noncommunicable diseases (NCDs) and death from household and ambient air pollution and universal health coverage (SDG3) in 21 Arab States. Figure 3 demonstrates a reverse relationship of stunting with net primary enrollment rate and literacy rate, (SDG4) in 18 Arab States. Figure 4 shows there is a reverse relationship of stunting with percent demand for Family Planning Modern method (SDG5) and population using least basic drinking water services (SDG6) in the 22 Arab States. Figure 5 shows a reverse association of stunting to percent population using internet, Logistics Performance Index: Quality of trade and transport-related infrastructure (worst 1 - 5 best); and expenditure on research (SDG9) in the 22 Arab States. Figure 6 illustrates that there is a negative correlation between stunting with E-waste generated (kg/capita) and compliance with multilateral agreements (SDG12), CO₂ emissions (SDG13) in 22 Arab States. Figure 7 demonstrates a reverse association between stunting and corruption index (SDG16: peace and justice indicator) on the one hand, and government spending in health and education (SDG17) on the other hand, while obesity was positively associated with corruption index showing an increase in the HICs of the 21 Arab States (Palestine incomplete data).

There was a reverse relationship of stunting with access to electricity (SDG7), percent adjusted growth and labor freedom index (SDG8) in 22 Arab States. The highest positive correlation of stunting was shown with Poverty headcount ratio $3.2 and highest negative correlation was with corruption index.

Overall all SDGs contributed in one or another towards overcoming the problem of malnutrition. The discussion below discusses some of the relevant indicators for the SDGs that contribute significantly to this problem and can be used in developing a comprehensive roadmap, monitoring progress in prevention and making the relevant improvements to promote the nutritional status of children.

There was an evident relationship between stunting with food production and supply indicators (Cereal Yield and Nitrogen Management Index) in the Arab countries. Wasting appeared to show similar relationships. Cereal yield tended to rise in the HIC on the right side of the X-axis coinciding with the lower rates of stunting and wasting. Cereal yield was flattened towards the left side of the axis and the gap between it and malnutrition was much wider in the LIC compared to the MIC in the middle part of the axis. The wider gap between cereal yield and stunting indicates the long standing degree of malnutrition in the LIC compared to the MIC. Yemen, Sudan and Djibouti are the worst off with very high rates of stunting and wasting. There were no significant differences in the nitrogen management index across the spectrum of countries (Figure 2). The long standing malnutrition causing these very high rates of stunting needs to be addressed by radical strategies beyond the mere provision of food supply (Roediger et al., 2020).

Ending poverty in all its forms everywhere (SDG1) is showing considerable progress in the fight against poverty. Since 1990, over 800 million people worldwide are affected 70% of whom are women, who still live in extreme poverty. The Sustainable Development agenda aims to eradicate extreme poverty by 2030. Target 1.1 urges the eradication of extreme poverty for all people everywhere by 2030 and is currently measured as people living on less than $1.25 a day. While target 1.2 aims at reducing at least by one-half the proportion of men, women and children of all ages living in poverty in all its dimensions by 2030 (22). Our study showed significant associations of malnutrition with extreme poverty i.e. poverty headcount ratio $1.9 (r0.7 for both stunting and wasting) and poverty headcount ratio $3.2, both indicators are associated with food insecurity. The level of income appears to be a delineating factor with the HIC performing better than the low income (LIC), while the middle income countries (MIC) lie on the border of LIC and are staggering to move towards the HIC. Figure 1 illustrates the relationship between indicators of ending poverty for SDG1 and stunting. The countries of the LIC were shown to be grouped on the far end left side of X-axis indicating that poverty was associated with stunting being higher in LIC followed by MIC on the far right side of the horizontal axis of the chart (Figure 1). Poverty headcount ratio $1.9 and working poor at $3.2/day were also correlated with stunting. Syria has recently shifted from a MIC to a LIC and appears to be shifted to the LIC on the left side of the X-axis. On the other hand State of Palestine and Tunisia appear to be shifting towards the right of the X-axis with the HIC, indicating a progress in its indicators for SDG1 and SDG2. On the other hand Oman is moving away from the HIC towards the MIC group, again a shift that warrants attention. With the falling oil prices, Oman’s high debt levels and the gradual implementation of austerity measures later in the forecast period may weigh on its economic growth in 2024-2026 (World Bank, 2006). The Ukraine crises may also impact Middle East and North African country’s (MENA) economy. At the top of our concerns are that MENA’s already fragile countries—like Syria, Lebanon and Yemen—where the Ukrainian crisis risks to dramatically jeopardize access to food. Syria imports roughly two-thirds of both its food and oil consumption, and most of its wheat is specifically from Russia. Lebanon imports from Ukraine and Russia over 90% of its grain and only has about a month of grain reserves. Yemen imports about 40% of its wheat from the two countries at war. People experiencing crisis or, even worse, acute food insecurity in Yemen, have climbed from 15 million to over 16 million in just 3 months, at the end of 2021. The war in Ukraine, (as it did in Bosnia-Serbia conflict) will only worsen this already bleak dynamic in Yemen. The compounding shock of the war in Ukraine can cause tragic outcomes in some MENA countries if humanitarian and development assistance are not scaled up in 2022”. This was quoted from World Bank blogs by Ferid Belhaj vice president of Mena World Bank (World Bank, 2022). This indicates that political events strongly influence Arab world food security and challenge the nutritional status of the children in this region.

A metanalysis study showed that early childhood food insecurity is associated with poor developmental outcomes in HIC (Danaei et al., 2016), de Oliveira et al., 2020). Stunting also coexists with obesity and micronutrient deficiency states (hidden malnutrition) (Berger et al., 2007; Julia et al., 2004; Rachmi et al., 2016). Community awareness of the types of food that need to be introduced to children is another factor that influences malnutrition and stunting. A metanalysis showed that household food insecurity and suboptimal dietary diversity were significantly associated with child stunting in children 0 - 23 months in sub-Saharan poor African countries (Gassara & Chen, 2021). Moreover, stunting, wasting and undernourishment are interrelated through low diet diversity and suboptimal early feeding practices as a continuation of fetal programming from hidden starvation in prenatal life (Aguayo & Menon, 2016) which influence developmental outcomes of children (de Oliveira et al., 2020; Hashad, 2021; Horta et al., 2015). In Palestine, Gaza strip and Western Bank, food insecurity was associated with poor living conditions. Donations, are usually short-term with sporadic aids given to these communities to prevent wasting and may have a counter effect leading to dependency and thereby stunting on the long term, when these donations come to an end. Donations can be counterproductive if not used to teach these communities to sustain their income through capacity building in economic development (teaching trades or creating work opportunities that are secure and sustained (Rashad & Sharaf, 2018).

The SDG target 2.4 ensures sustainable food production systems and implement resilient agricultural practices that increase productivity and production, that help maintain ecosystems, that strengthen capacity for adaptation to climate change, extreme weather, drought, flooding and other disasters and that progressively improve land and soil quality. The Arab countries showed trends by income group in SDGs related to cereal yield, exports of hazardous pesticides and stunting but fewer associations of sustainable nitrogen management index with stunting. Hence mapping interactions between SDGs and malnutrition can be a useful strategy to guide policy in preventing stunting in these countries (Nilsson et al., 2016). Differences in-between Arab Member States indicate the risk of food security, on the long term in low and middle income states, can accentuate and impede progress towards eradicating malnutrition. Success stories from countries that have shown progress can be used to gear progress in other countries. Minimizing waste and quality management of resources are needed to sustain development in these targets. Interventions that encourage communities to sustain their yields of cereal and minimize waste and poor regulation of consumption can have a significant effect on the eradication of malnutrition (Ratcliffe et al., 2011).

Good health and well-being are reflected in the mortality rates of children and morbidity rates from Tuberculosis (TB) and non-communicable diseases (NCDs) in adults. These indicators were significantly associated with stunting and wasting. Reported cases of TB are highest in LIC and some MIC. While deaths from NCDs appear to be high and were associated with stunting and wasting probably related to the double burden of stunting and overweight or obesity in all income groups; unhealthy food intake and poor control of marketing practices that promote these foods. Stunting and wasting showed the highest association with mortality linked to exposure to ambient air pollution (AAP) and household air pollution (HAP). A meta-analysis identified up to a 13% and 90% increased risk of stunting in children exposed to increased levels of AAP and HAP respectively (Pun & Dowling, 2019). Universal health coverage (UHC) index of service coverage and subjective well-being are associated with reduction in malnutrition. Ensuring access to health care particularly preventive services such as growth monitoring, and continued breastfeeding for two years with nutrition education for adequate complementary feeding (Gassara & Chen, 2021) and avoidance of processed foods and fast foods with high grease and salt, beverages high in sugar (Relvas et al., 2019) are needed to prevent chronic and acute malnutrition which carry risks of micronutrient deficiency states and their consequent effects on cognitive development (Horta et al., 2015) and economic development (El Bilbeisi et al., 2022).

Early feeding practices by promoting breastfeeding can reduce morbidity from communicable and non-communicable disease and thereby reduce stunting. Tuberculosis (TB) remains strongly associated with acute and chronic malnutrition and is particularly higher in LIC followed by MIC and least in HIC. While death from noncommunicable diseases (NCDs) appears to be high in all countries irrespective of income group and is linked to obesity which appears to be rising even in LIC. There was also an apparent association between obesity with prevalence of diabetes mellitus. The HIC had the highest rates of obesity and were on the left side of the X-axis; LIC had the lowest rates and was on the left side of the x-axis. MICs were in-between. However all countries showed a steady high prevalence of death from NCDs rising more in the LIC. However DM appeared to be higher in the HIC than in the LIC and some MIC, probably because of low detection rates in LIC as shown by the tendency for lower universal health coverage rates in the LIC to the right side of the horizontal axis. Deaths from cardiovascular disease in the region have been shown to be particularly high in countries of the Eastern Mediterranean region (Abul-Fadl et al., 2018).

Indicators of quality education (SDG4) showed significant negative associations with stunting and wasting and varied by country income group. Awareness campaigns cannot be effective and sustainable without achieving high levels of literacy and education since social media and internet technology are becoming leading strategies to achieve for achieving behavioral change. Improving the quality and level of education has been shown by many studies to impact the nutritional status of children. However in many instances, it may increase unhealthy food intake and lead to overweight and obesity due to the counter effect of marketing on education and strong impact it may have on affluent societies. Bardosono et al. (2007) also observed that inappropriate maternal nutritional knowledge and low paternal education were related to stunting in urban poor children 6 - 59 months. Media literacy and proper use of technology should be a mandatory subject starting from primary education. However traditional teaching remains the norm and adaptation of school curricula to meet the changing needs of the environment of technology needs to be reinforced in developing and underdeveloped countries by upgrading curricular content. A comprehensive implementation plan on maternal, infant and young child nutrition was addressed by the World Health Assembly in 2012 in this respect (WHO, 2012). Increasing caregiver education, especially maternal education, was shown to be strongly associated with declines in child stunting in numerous studies (SDG5). Reducing inequalities (SDG10) can influence differences in Gini index between countries (Danaei et al., 2016; Roediger et al., 2020).

We found strong associations between clean water and sanitation with decreases in stunting and wasting. A cross-sectional survey demonstrated that children 0 - 23 months living in a household with untreated drinking water had much higher odds of stunting if the household used an unimproved latrine (Torlesse et al., 2016).

SDG9 for promoting Industry, Innovation and Infrastructure was also closely associated with stunting. There were negative correlations between industrial and innovative infrastructure which were low or absent in the LIC and some MIC and more prominent in the HIC on the right side of the axis, indicating that stunting was linked to communities that do not have access to innovation, research and opportunities for developing their human resources. Even opportunities to be linked to more developed countries that offer higher education and research opportunities were limited in these countries.

The indices of reducing inequalities (SDG10) correlated with stunting and were inconsistent in the LICs. This could be explained mostly by high negative correlations of stunting with indices of sustainable cities (SDG11) in particular water sources (pipes) which showed variations not only in LIC but also in MIC. These countries also have challenges in SDG12 for regulation of consumption mostly municipal solid waste and the production-based nitrogen emissions (kg/capita) as shown with the negative correlation with compliance with multilateral environmental agreements which was a particular challenge more in the MIC as shown in the charts. Regulation of consumption by reducing waste and regulating the supply can have a great effect on reducing inequalities and boosting sustainable cities without affecting the climate (SDG13). We found that CO₂ emissions were correlated with stunting, indicating the need for instigating action in these countries with high rates of stunting, as this may in one way or the other be related to stunting (Pun & Dowling, 2019).

We also found some relevant associations between stunting with SDG14 but not SDG15. These were related to negative association with protection of water resources related to biodiversity. It may indicate that in less developed countries, because resources are scarce, biodiversity may be at risk, as these populations use up any resources to meet their needs for survival, which again fires back to increase stunting and poor health and development as they deplete the biodiversity of resources. However there were significant correlations of several of the peace and justice indicators (SDG16) and Government spending on health and education (% of GDP) (SDG17) with stunting as they were also related to income group. All the LIC were grouped on the left side of the horizontal axis. The LIC coincided with countries were political instability and violence and wars continue. Although Libya is a MIC yet it was still on the left of the axis with the LIC.

Corruption index showed reverse associations with stunting and level of income of the country and was much higher in the MIC and HIC than LIC. The higher corruption index in HIC could be explained by higher bribes demanded from larger oil corporations as shown by Hashad dissertation in 2021 (Hashad, 2021). Their findings coincided with other research workers who showed that bribes increase with company growth (Nguyen, 2016; Nguyen, 2020). Stunting can also co-exist with overweight and obesity in more developed countries (Rachmi et al., 2016). In Egypt economic growth was associated with increased childhood overweight and obesity in Egypt (Rashad & Sharaf, 2018). Moreover Supplemental Nutrition Assistance Program is expected to reduce food insecurity but has a rebound effect once the assistance is stopped (Ratcliffe et al., 2011).

Impressive lessons can be learnt from countries where political will, leaders and champions of peace and will have changed the nation. These were seen when Nelson Mandala inspired his nation in South Africa (World economic forum, 2022) and also in India, by the Ghandi Peace Foundation (1980) whose values and leadership led the country to its present status, despite the major challenges of poverty. In Arab countries where the Islamic teaching prevail, peace and justice are mentioned in the Quran repeatedly. Corruption is associated with poverty and malnutrition. In the Quran the term “fasad” (corruption) and its derivatives have been used approximately 50 times and they appear in 22 chapters of the Quran. Similarly, according to al-Asfahanr, the word “salah” (which is usually used as the antonym for “fasad”) and its derivatives have been used in the Quran approximately 150 times (Jomaa, 2008). This somewhat extensive use of these terms indicates the great emphasis of the Quran on promoting peace and justice (SDG17) through reform, integrity, transparency, avoiding conflicts, wars and social insecurity “Fetna”. Promoting Peace is rooted in the Islamic values and is guided by the Islamic law “Sharîa” to ensure ownership, impact and legitimacy of measures. However, although Islamic law is implemented to some degree in most MENA countries and strongly influences their legal codes, there is little evidence available of how Sharîa law guides the prevention of means that lead to conflict mediated by corruption and injustice. Traditional Sharia Courts, complaint mechanisms or other Islamic institutions could potentially provide entry points for anti-corruption initiatives, to prevent conflicts and ensure peace to meet basic human rights and international legal standards (Chene, 2007). This can strongly influence prevention of malnutrition by ensuring health, food security and all the above mentioned SDGs for economic development.

Limitations: The main limitation in this study was that we were dealing with secondary data and not raw data from the countries for the indicators under study. However we have used the data derived from the report prepared for Arab nations that was more or less weighted to represent the 22 Arab nations under study. Another limitation is that we did not examine all the 269 indicators of the 17 SDGs. However this can be expanded in other studies. However number of indicators used may have been distracting. But since the focus of our study was to expand our understanding of factors influencing malnutrition we needed to include a minimum number of relevant indicators that represented all the 17 SDGs. Another challenge was missing data for indicators from some countries. These were mostly for poverty in which high income countries did not report, also in countries living in conflict as Palestine, Syria and Yemen or having economic or political instability as Somalia and Djibouti. We tried to include indicators that had a minimum of missed data.

In conclusion in this analytical study we identified several SDG indicators that were cross-cutting or related to malnutrition and stunting. These indicators were either directly or indirectly related to the nutritional status of under-fives. These include the “People” related indicators (SDG 1, 2, 3, 4, 5, 6 and 10) and the indicators on reducing inequities (SDG11) and regulating consumption (SDG12) and peace and justice (SDG16) as well as those encouraging government spending on health and education (SDG17). This entails that ending poverty, hunger and inequalities while promoting health and wellbeing, quality education, access to clean water and sanitation as well as gender equity are drivers for preventing malnutrition. Indicators linked to values and faith as peace and justice are of profound importance to political stability and strengthening the physical and administrative infrastructure of these countries. This can play a significant role in empowering people to become better nations with hope towards a prosperous and peaceful future and eradicating poor feeding and nutritional practices and their consequences.

The content, views and recommendations in this article do not represent World Health Organization and are solely the responsibility of the authors.

The authors declare no conflicts of interest regarding the publication of this paper.

Abul-Fadl, A. M. A., & Al-Jawaldeh, A. (2022). A Comprehensive Roadmap for Reversing Under-Five Malnutrition on the Arab States Based on the Sustainable Development Goals. Open Journal of Social Sciences, 10, 341-358. https://doi.org/10.4236/jss.2022.1010022