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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
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
rtio
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