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Hunger in the midst of Plenty: Responses to Food Insecurity in Israel

Dana Philip & Prof. Aron M. Troen

Nutrition and Brain Health Laboratory

Institute of Biochemistry Food & Nutrition Science

Robert H Smith Faculty of Agriculture Food & Environment

The Hebrew University of Jerusalem

aron.Troen@mail.huji.ac.il

TAU Food Safety & Security Summer Institute Course– July 3rd 2017

Food Security Definition

Food security exists

when all people, at all times,

have physical, social and economic access

to sufficient, safe and nutritious food which

meets their dietary needs and food preferences

for an active and healthy life.

FAO. Trade reforms and food security. Rome 2003.

The pillars of Food Security

Sustainability

Food Security

Ava

ilab

ility

Acc

ess

Uti

lizat

ion

Stab

ility

Availability: The “supply side” of food security. Determined by: food production, stock levels and net trade. Global/national level.

Access: Physical, social and economic access. Economic access is determined by: incomes, expenditure, markets and prices. Often household level.

Utilization: good care and feeding practices, food preparation, diversity of the diet and intra-household distribution of food. This determines the nutritional status of individuals.

FAO. An Introduction to the Basic Concepts of Food Security. EC - FAO Food Security Programme, 2008.

Food insecurity in Israel – Access Not Availability

3619 kcal/capita/day

109.7 gr/capita/day

509.2 gr/capita/day

140.5 gr/capita/day

549.2 gr/capita/day

Supply of nutritional energy (calories) and nutrients per capita per day. Central Bureau of Statistics, 2014. Food supply balance sheet. Central Bureau of Statistics, 2014.

Is poverty relative or absolute?

Prevalence and Risk Factors

Endweld M et al. Food Security 2011 The Course of the Survey and Main Findings. Jerusalem: National Insurance Institute, 2012.

12,000 households surveyed

18.8% food insecure 8.6% severely food insecure

755,000 children - more than a third of the children in Israel

Need for income support Unemployment

More than 4 children Single parent

Arabs and Orthodox Jews Lower levels of education

Disability

Socioeconomic and demographic factors associated with food

insecurity:

Food Insecurity is Highly Correlated with Poverty Measures

Endweld M et al. Food Security 2011 The Course of the Survey and Main Findings. Jerusalem: National Insurance Institute, 2012.

Food insecurity rate ------ Severe food insecurity rate ------

Household income per person (NIS)

Prevalence of Food Insecurity in Israel 2014 – Bituach Leumi

http://taubcenter.org.il/wp-content/files_mf/pictureofthenation2017.pdf

Household expenditure on food as % of income

Lower Income is Associated with Less Fruit and Vegetables Consumption

“With the decline in income, households … are likely to find it challenging to consume sufficient amounts of milk and dairy products, and especially fruit and vegetables, which are the basis for a healthy Mediterranean diet.”

Chernichovsky D, Regev E. Patterns of expenditure on food in Israel. Policy Papers Series: Taub Center for Social Policy Studies in Israel, 2014.

The “Double Burden” of Food Insecurity

Food Insecurity

Malnutrition

Overnutrition Undernutrition

Micronutrient

deficiencies

Chronic illnesses

Overnutrition + Undernutrition

NGOs Play an Important Role in National Policy

Until 2015, Israeli government left food security to the third (private) sector.

New national plan:

• Regulate third sector activity with partial funding.

• Use existing logistic infrastructure (Leket Israel and Latet)

Leket Israel • The largest food bank in

Israel.

• Treats food insecurity as a logistical problem. Reduces food loss and waste.

• An umbrella organization, distributing food to 180 partnering food agencies nationwide.

Philip D et al. The "Leket Israel" model of food rescue and distribution: A case study of food insecurity alleviation in Israel. Manuscript submitted for publication. Photos: Leket Israel.

Food distribution in Kg by food group

(%)

2015 Jan-June

(Kg) (%)

2014

(kg)

year/

food groups

1% 50,782 1% 150,037 Dairy

4% 375,976 6% 648,131 CHO rich foods

2% 158,102 3% 305,283 Protein rich foods

91% 7,746,491 88% 10,169,917 Fruit and Vegetables

1% 111,468 3% 301,440 Sweets

0% 7,669 0% 17,171 Fat rich foods

0% 19,223 0% 24,926 Spice and misc.

100% 8,469,711 100% 11,616,905 Total

Philip D et al. The "Leket Israel" model of food rescue and distribution: A case study of food insecurity alleviation in Israel. Manuscript submitted for publication.

Unknown Data

?

The Effect on Target Population Index

A B

Philip D et al. The "Leket Israel" model of food rescue and distribution: A case study of food insecurity alleviation in Israel. Manuscript submitted for publication.

Unanswered Questions

• What are the needs of the recipients?

• Do recipients eat the food?

• Does it improve their nutritional status?

• Does it improve their subjective sense of food security?

• Does it improve their health?

• Are there any factors which influence these outcomes?

Life Consequences

Disability, age, income, marital status, number

of children, etc

Outcomes

Nutrition

Health

Coping strategies

Food aid, reduction of food quality and

quantity

Household food insecurity

Resource allocation

Working Hypothesis

Leket Israel makes a unique contribution to the food security, nutritional and health status of the beneficiaries who receive food distributed

through Leket Israel's partner agencies.

Additional Hypotheses

• Expected high prevalence among study population of – low income

– high number of people (especially children) living in the household

– poor health and non-communicable diseases

– food insecurity

– low diet quality including nutritional deficiencies

• Expected effects of the number of people living in the household and of income on nutritional, health and food security outcomes.

Specific Aims

• Characterize recipient population in terms of diet,

health, and food security.

• Assess recipient population’s dietary needs.

• Measure Leket’s contribution to the food baskets

and individual diet. Explore factors influencing

food basket quality.

• Find other factors influencing diet, health, and

food security.

Aims: Feasibility phase

• The specific aims of this project:

Test feasibility and optimize methodology for a full-scale, ongoing and definitive research on the recipients.

Design and Methodology

Survey, cross-sectional study

Convenient sampled NPOS and clients

+cash incentive

Inclusion/exclusion criteria

NPOs and clients

Recruitment goals: n=100 (feasibility

phase)

Telephone interview Languages: Hebrew,

Amharic, Russian and Arabic .

The questionnaire is comprised of:

verbal confirmation of consent

a demographic questionnaire

a food security questionnaire

a food frequency questionnaire (FFQ)

self-reported anthropometric measurements and health (MABAT)

questions relating to individual knowledge and attitudes about

nutrition (MABAT)

Questionnaires - FFQ

Shahar RD et al. Development of a semi-quantitative Food Frequency Questionnaire (FFQ) to assess dietary intake of multiethnic populations. Eur J Epidemiol 2003.

Questionnaires – Food Security

Endweld M et al. Food Security 2011 The Course of the Survey and Main Findings. Jerusalem: National Insurance Institute, 2012.

Statistical Analysis

Main outcomes :

• Micronutrient consumption (FFQ)

• Fruit and vegetables consumption (FFQ)

• Nutrition quality score of FFQ

• Self-reported health outcomes and food security level

Fixed factors :

• Food basket content of micronutrients

• Food basket content of fruit and vegetables

• Food basket quality score

• Leket Israel’s portion of macro and micronutrient content

• Leket Israel effect on fruit and vegetables content

Preliminary Results

Methods

• Population Sample – Food baskets recipients from non-profit organizations (NPOs)

receiving fruits and vegetables from Leket Israel. – Excluded if do not speak Hebrew, English or Arabic. – A variety of NPOs included to reflect geographic, sectorial and

diversity of food distribution method

• Questionnaire

– A semi-quantitative Food Frequency Questionnaire (FFQ) including 126 items, validated for Israeli population.

– Household Food Security Survey Module (18 Questions) coded according to Bituah Leumi’s description.

– Demographics, self-reported anthropometric measurements and health status.

Variables

Primary outcomes: Diet quality and quantity, Nutrient intake, Food security level, BMI, health status.

Derived outcomes: Nutrient Density Score, healthy food portions in diet.

Fixed factors: Healthy food portions in baskets and baskets’ Nutrient Density Score.

Covariates: Gender, age, number of people in the household, income, ethnicity, employment, marital status, country of birth, Interest in nutrition and health.

Nutrient Density Score

Nutrient Adequacy Score

Average Daily Values for 16 nutrients per 100g of edible food:

∑ { Nutrientᵢ / DVᵢ } X 100 / 16

Energy Density

Amount of Energy (kcals) per 100g of edible food

Nutrient Density Score

(Nutrient Adequacy Score / Energy Density) x 100

Darmon N, Darmon M, Maillot M, Drewnowski A. A Nutrient Density Standard for Vegetables and Fruits: Nutrients per Calorie and Nutrients per Unit Cost. J. Am. Diet. Assoc. 2005;105:1881-1887

Healthy Basic Food Basket

Number of healthy food portions in food baskets

as described by Taub center, with regards to choice of items and portion sizes for each food group.

Food items choice

Food group Included Excluded

Whole grains Bread, pasta, potatoes, rice – all from whole grains

Cereals, pastries, crackers, refined grains

Fruits and Vegetables Raw and cooked vegetables, common fruits

Fruit juice and dried fruits

Protein-rich foods Milk, yogurt, cheese, meat, poultry, fish, eggs, pulses

Sweetened dairy products, ice-cream, cream, peanuts, salted grains and nuts, high-fat meat

Fat Oil, nuts, avocado, tahini Margarine, butter, products high in saturated and trans fatty acids

Portion Sizes Whole grains 30gr for bread and 78 gr for

potatoes

Vegetables 1/2 cup of vegetable (USDA database)

Fruits A medium size fruit (USDA database)

Dairy 300mg of Calcium

Meat 76gr of lean meat. An egg or 1/2 cup legumes are considered as 30 gr out of 76 of meat portion.

Fat 10gr of fat

Recommended number of portions

Gender Age Whole grains

Vegetables Fruits Dairy Meat Fat

Children 2-3 6 3 2 1 3 1

4-6 7 3 2 1 3 1

7-10 8 4 3 1 3 1.5

11-14 10 5 4 2 4 3

Men 15-18 11 5 4 2 4 3

19-24 11 5 4 1 4 3

25-50 11 5 1 2 4 3

>51 9 4 3 2 3 3

Women 11-24 9 4 3 2 3 3

25-50 9 4 3 2 3 3

>51 7 4 3 2 2 3

Results

Flowchart

N turned to by NPO staff = unknown

N singed consent = 150

N started interview = ?

N finished interview = 105

N with FFQ results = 100

N with Energy value < 4000 kcal = 91

~20/180 NPOs selected for participation

Demographics Proportion (%)

Gender (female) 76

Marital status

Unmarried 4

Married 57

Divorced/ separated

28

Widowed 11

Employment

Disability 24

Salaried/ self-employed

34

Pensioner 17

Unemployed 13

Housewife 12

Proportion (%)

Mean SD

Age 51.3 14.6

Income 4552 2440

Number of people in household

4.3 2.5

Children <21 in household (yes)

68

Interest in nutrition and health

To a very large extent

41.2

To a large extent 39.2

To a small extent

15.5

Not at all 4.1

Demographics

Ethnicity

Jewish 77

Muslim Arab 10

Christian Arab 2

Druze 9

Other 2

Food Security and Health Food security

N (proportion %)

N=91 Food secure 16 (17.6) Food insecure without hunger 34 (37.6) Food insecure with moderate hunger 36 (39.6) Food insecure with sever hunger 5 (5.5)

Health

General health

N=91 Very good 15 (16.5) Good 36 (39.6) Not so good 24 (26.4) Not good at all 16 (17.6)

Food Security and Health Non-communicable diseases

N=91 Anemia 34 (37.4) Osteoporosis 10 (11) High cholesterol 29 (31.9) Triglycerides 21 (23.1) High blood pressure 36 (39.6) Diabetes 8 (8.8) Stroke 1 (1.1) Cancer 5 (5.5)

Body Mass Index (BMI)

N=87

Underweight (<18.5) 8 (9.2) Normal weight (18.5-24.9) 30 (34.5) Over-weight (25-29.9) 21 (24.1) Obesity (>30) 28 (32.2)

Food Security and Health

Individual Nutrients Mean Median SD % of subjects to reach

recommendations Energy (kcal) 1959 1885 673 Protein (gr) 80 78 31 86 Dietary Fiber (gr) 22.78 22.61 8.20 44 Calcium (mg) 773.49 688.37 405.76 18.7 Iron (mg) 11.39 11.23 3.85 50.5 Magnesium (mg) 301.14 284.66 106.85 34.1 Vitamin A RAE (mcg) 1065.46 889.76 759.65 60.4 Vitamin E (mg) 8.52 8.76 3.38 3.3 Vitamin D (IU) 114.02 96.76 85.26 0 Vitamin C (mg) 166.43 141.11 103.45 82.4 Thiamin (mg) 1.24 1.13 0.46 51.6 Riboflavin (mg) 2.02 1.80 0.89 85.7 Niacin (mg) 18.05 16.63 6.39 72.5 Pantothenic acid (mg) 6.09 5.59 2.32 60.4 Vitamin B6 (mg) 1.81 1.64 0.70 67 Folate (mcg) 317.06 298.34 119.45 24.2 Vitamin B12 (mcg) 5.46 3.60 4.82 78 Healthy portions 14.08 14.23 5.76 Fruit & Veg portions 7.56 7.10 4.16 Nutrient Density Score 6.2 5.92 1.65

Selected cases by Energy<4000 kcal. N=91. Recommendations are Recommended Daily Allowance (RDA) for nutrients, Estimated Energy Requirements (EER) for Energy, Healthy Index for food portions.

Food basket nutrients

Median % of baskets to reach recommended portions (family needs)

Energy (Kcal) 13526 Protein (gr) 428 10

Dietary fiber (gr) 251 11

Calcium (mg) 3930 0

Iron (mg) 111 23

Magnesium (mg) 227 4

Thiamin (mg) 11 7

Riboflavin (mg) 9 18

Niacin (mg) 99 15

Pantothenic Acid (mg) 36 16

Vitamin A RAE (mcg) 16030 47

Vitamin E (mg) 60 2

Vitamin C (mg) 1467 45

Vitamin D (IU) 4 0

Vitamin B6 (mg) 16 19

Folate (mcg) 3634 20 Vitamin B12 (mcg) 6 13 Healthy portions 205 Fruit &veg portions 81 Nutrient Density Score 0.1

Recommendations are Recommended Daily Allowance (RDA) for nutrients, Estimated Energy Requirement (EER) for Energy, Healthy Index for food portions.

Leket contribution to food baskets Total NPO Leket Israel

Leket Israel % of total

Energy (kcal) 17390.81 14827.37 2563.44 14.74

Protein (gr) 548.00 458.23 89.77 16.38

Dietary fiber (gr) 313.16 159.63 153.53 49.03

Pantothenic Acid (mg) 91.55 68.19 23.36 25.52

Calcium (mg) 4536.91 2042.56 2494.35 54.98

Iron (mg) 162.64 123.76 38.88 23.91

Magnesium (mg) 3036.29 1954.39 1081.90 35.63

Thiamin (mg) 11.91 8.05 3.86 32.39

Riboflavin (mg) 23.26 19.73 3.53 15.19

Niacin (mg) 207.67 169.44 38.23 18.41

Vitamin A RAE (mcg) 39629.56 22396.42 17233.14 43.49

Vitamin E (mg) 99.86 73.83 26.03 26.06

Vitamin C (mg) 1727.71 579.53 1148.18 66.46

Vitamin D (IU) 19.48 17.88 1.60 8.20

Vitamin B6 (mg) 21.66 13.80 7.86 36.27

Folate (mcg) 7318.06 5294.25 2023.81 27.65

Vitamin B12 (mcg) 109.72 109.18 0.54 0.50

Healthy portions 323.69 199.19 124.50 38.46

Fruit &veg portions 137.18 15.14 122.04 88.96

Leket contribution to food baskets

Nu

mb

er

of

po

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ns

Healthy portions in food baskets are correlated with individual diet quality

• The number of healthy portions in basket and number of

people living in the household significantly predict individual Nutrient Density Score by linear regression (F(2,88)=3.738, p=0.028), with an R2 of 0.078.

• When age, gender, marital status, and country of birth were added to the model, healthy portions in basket did not significantly predict the individual Nutrient Density Score.

Discussion – Internal Validity

• Chance • Bias • Confounding • Measurement error

• Selection bias • Reporting bias • Over and underestimation • Sample Size? • NPO / LEKET effects? • Limitations

Thank You for Your Attention