Overweight and obesity defined as an abnormal or excessive build-up of body fats that might harm one's health (1), are emerging public health concerns in Africa (2). The impact of overweight and obesity is even more significant when it occurs in children as it puts them at increased risk of both early and long-term breathing problems, musculoskeletal diseases, hypertension, diabetes, stroke, insulin resistance, some cancers, and adult obesity (3, 4). Also, obesity in childhood is linked to a higher risk of mental health issues, impairment, and even death (5).

Globally, there are about 41 million children under 5 years reported to be either overweight or obese as of 2018 (6). A growing body of evidence shows that the current majority of obese or overweight children are in developing countries, where the rate of increase is more than 30 percent higher than in industrialized countries (7). Overweight and obesity in children are on the rise, largely, due to significant changes in dietary and physical activity behavior (8). Thus, technological advancement has made it easier to perform daily physical activities; hence increasing sedentary lifestyles and reducing physical activities (9). In recent years, more children are also spending more time indoors and are likely to spend much time watching television or playing video games, which makes them less active and gain weight as a result (10). Moreover, dietary patterns have changed from traditional healthy diets largely composed of fruits and vegetables to energy-dense foods which are high in calories, fats and sugars (11). The World Health Organization recommends that to avoid the risk of excess body weight, infants should be breastfed exclusively during the first 6 months of their lives, should be breastfed continuously until at least 2 years of age, breast milk should be complemented with a variety of nutritious foods, salt or sugar should not be added to foods, food portions should contain at least 400 g or five portions of fruits and vegetables per day, and fat intake should be <30% of total energy intake (12).

Evidence shows that genetic or family characteristics are also factors associated with risk of overweight and obesity (13). Research indicates a possibility of a person inheriting about 40% of body type from parents (14). Additionally, emerging evidence suggests that socio-demographic factors, such as parental wealth status and place of residence have a significant impact on the likelihood of childhood overweight or obesity (15). Importantly, overweight or obesity resulting from socio-demographic factors are known to be modifiable compared to genetic factors (13). This idea of modifiable and non-modifiable risk factors associated with overweight and obesity is critical to developing appropriate interventions for reducing childhood overnutrition.

One of the regions in the world facing a high risk of overnutrition is North Africa. Studies show a rising trend in childhood overweight and obesity in North Africa, especially, in Egypt, with the prevalence higher than most countries in the Middle East and Sub-Saharan Africa (15, 16). A study among school-going children in Sohag, Egypt found that 17% of the participants were overweight and 15% were obese (3). Behera, a suburb of Egypt found as high as 18% of overweight and obesity among primary school children in 2019 (17). Although several community-based evidence shows a high prevalence of overweight and obesity among children under-5 years in Egypt, childhood overnutrition is under-studied in Egypt with most studies focusing on adults and adolescents (3, 17). In view of this significant gap, we examined the prevalence and correlates of overweight and obesity in Egypt. Findings from this study are critical to developing tailored interventions aimed at addressing overnutrition in the country and even beyond.

This study aimed to examine the prevalence and correlates of overweight and obesity among children under 5 years in Egypt. The findings revealed that the overall prevalence of overweight and obesity was approximately 17% which corresponds with previous community-based studies in Egypt which found an overnutrition prevalence rate ranging from 15 to 18% (3, 22). Our reported prevalence rate for Egypt is nearly twice the average rate for the world, which is estimated at 8.6%, indicating a serious childhood overnutrition problem in Egypt and the need for prompt actions to reduce this significant health burden (8).

The study also found several socio-demographic factors significantly associated with overweight and obesity among children under 5 years in Egypt. Notably, the childhood overnutrition indicators were significantly associated with children aged between 19 and 37 months, children with birthweights of 4.1 kg and above, children given large amounts of protein foods, and children belonging to rich mothers. The findings that children within the age bracket of 19–37 months had higher odds of developing childhood overweight or obesity is quite difficult to explain as there is a lack of literature on this topic (23). However, limited evidence shows that toddlers around that age bracket often engage in emotional eating behavior and often use food as a form of compensation or a soothing intervention when they feel upset which may put them at serious risk of being overweight or obese (24). Additionally, parenting styles and feeding practices may contribute to overweight or obesity among such infants (25–28). A systematic review has noted strong associations between indulgent or uninvolved parenting style and high childhood BMI whereas an authoritative parenting style was reported to be associated with a healthy BMI (28). Indulgent parenting style means parenting styles based on a combination of low demandingness, high responsiveness to a child's needs, and few rules; indulgent parenting style implies parenting styles associated with both low demandingness and low responsiveness; and authoritative parenting styles are parenting styles associated with a high level of demandingness, numerous rules, and high responsiveness to the needs of a child (28). Regarding feeding practices, the study further emphasized that authoritative feeding styles are associated with healthy BMIs whereas indulgent feeding styles are associated with a higher risk of overweight or obesity (28). Nevertheless, the systematic review and other available literature on parenting feeding practices were not decomposed according to age categories, and therefore, an in-depth exploration of the interplay of childhood age and parental feeding practices with overweight or obesity will be timely and important (25–28).

Consistent with previous studies (29, 30), we found that children who weighed 4.1 kg or higher at birth were more likely to experience childhood overweight or obesity. In line with our findings, a study in Sweden has indicated that males and females with birth weights above three standard deviation scores had higher risks of obesity, ranging from 2.46 to 1.85, respectively (30). In contrast, biological evidence shows that children with low birth weight have a higher concentration of plasma leptin which increases their obesity risks (31). Several previous studies have also indicated that low birth weights are associated with higher BMI z-scores and higher odds of obesity (32, 33). Casey et al. (33) for instance, reported an increase in obesity in a cohort of low-birth-weight preterm infants and reported a proportional increase in obesity from 2.3% at the age of 3 years to 6.1% prevalence by the age of 5 years. Together, these findings demonstrate an interesting paradox in terms of associations between birth weights and risks of overweight or obesity which may be attributed to differences in samples and confounding variables, such as variations in residence. To adequately understand the impact of birth weights on risks of overweight or obesity, it will be important to employ a longitudinal approach whereby the same cohort of infants will be studied over time. Nevertheless, our study contributes to the growing evidence on associations between high birth weights and risks of being overweight or obese in subsequent years of a child's life.

With regards to food consumption, children who consumed protein foods such as meat and eggs had a greater risk of overweight and obesity. This finding is in line with several previous studies (3, 34). A plausible reason for this outcome is that a high intake of protein foods is likely to lead to excess storage of body fats which eventually leads to a higher risk of overweight or obesity (24, 26). It needs to be however acknowledged that the assessment of food intake in the DHS data were limited to “yes” and “no” responses, hence this finding should be taken with caution. Consistent with previous studies (27, 28, 35), we also found that children belonging to wealthy mothers had a higher risk of overweight and obesity. This is probably because children in rich households may be exposed to high-calorie foods and sedentary lifestyles which puts them at risk of overweight and obesity (36, 37).

While taking due caution in making policy suggestions based on findings from this cross-sectional data, our findings which are based on over 40,000 under-five children provide a comprehensive and important “wake-up” call to policymakers and health advocates about the need to pay close attention to childhood overnutrition in Egypt. Particularly, interventions aiming to reduce childhood undernutrition need to be cautious of the possibilities of causing overnutrition after the implementation of food intake interventions. Additionally, our findings indicate that the growing overnutrition problem in Egypt (North Africa) can be effectively reduced if attention is paid to modifiable risk factors, such as sedentariness and overfeeding of toddlers with high protein foods, especially, by wealthy mothers (12). Supportive interventions are important in shaping people's choices, especially, in choosing healthier foods for their children and engaging in regular physical activity (12). At the individual level, parents can limit the provision of foods high in proteins to toddlers and increase the consumption of fruit and vegetables (38, 39). We believe that these factors are critical in promoting optimal health for children aged under 5 years in Egypt and even beyond.

Recent studies on overweight and obesity in Africa have indicated a potential double burden of undernutrition and overnutrition in the continent (40, 41). However, the previous studies have been largely focused on adult populations in Sub-Saharan Africa with limited studies focusing on children in North Africa, although anecdotal evidence shows that many North African countries have a potentially high prevalence of childhood overnutrition. Using Egypt as a case study, we have successfully reported the prevalence of overweight and obesity among children under-5 years and the risk factors associated with these overnutrition indicators. The potential burden of childhood overnutrition in Africa has received much attention in recent years. Modifiable risk factors may be important contributors to overnutrition, and this study is one of the early research projects examining this emerging problem for early interventions. Findings from this study provide useful calls for researchers, health promoters, and policymakers to consider seriously the emerging problem of childhood overnutrition in Egypt and North Africa.

We conclude that overnutrition (overweight and obesity) is highly prevalent among children under 5 years in Egypt. Approximately one in every six children (17%) included in our sample were either overweight or obese. We also found that a child's age (19–37 months), birth weight (>4 kg), protein consumption levels, and mothers' wealth status were significantly associated with the likelihood of overweight and obesity among children under-5 years in Egypt. This is a significant public health concern as overweight or obesity increases risk of numerous health issues, such as cardiovascular diseases, musculoskeletal diseases, diabetes, stroke, and some cancers (12). These findings adequately address the objectives of this study and indicate the need for early and urgent strategies to mitigate childhood overnutrition in Egypt.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at: http://dhsprogram.com/data/available-datasets.cf.

Ethical approval was not sought for this study since our analysis was based on publicly available data. However, the DHS reports that both written and verbal informed consent were obtained from all participants. Before the commencement of the survey, ethical clearance was sought and all ethical guidelines governing the use of human subjects were strictly adhered to and methods were carried out in accordance with the relevant guidelines and regulations by the Declaration of Helsinki.

IA conceived the study, reviewed the analyses, and supervised the entire study. EO conducted the multilevel analysis. EO and IA drafted and critically reviewed the manuscript. All authors read and approved the final manuscript.