Associations between food insecurity, eating behavior and dietary habits in an adolescent

population in Lebanon during the time of financial crises and recession

Rationale

Adolescence is a critical period in human development characterized by extensive and fast changes in

physical, psychological and social development. Nutrient requirements are significant and extremely

sensitive during this period, as dietary status effects puberty development, reproductive health, as well as

the risk of non-communicable diseases in adulthood. Since 2020 and till today, the world is facing with

global challenges ranging from conflicts to Covid-19 pandemic to climate shocks to economic instability,

which have reversed years of development gains and pushing food prices to all-time highs, exacerbating

food insecurity and inflation, as stated by the World bank (World Bank, 2022). Food insecurity, according

to Food and Agriculture Organization, is defined as lack of access to adequate and nutritious food at all

times (Food and Agriculture Organization, 1996). For adolescents, food insecurity remains an important

public health issue for them, with significant implications for their development (Masa et al., 2021). It has

a negative consequence on their optimal dietary intake (Belachew et al., 2013), and poor quality diet intake

during this phase may lead to malnutrition (Brinkman et al., 2010). Considering the importance of the food

insecurity concern in time of crisis, research conducted in recent years have explored that the level of food

insecurity was positively associated with unfavorable food intake for adolescents and they were at a higher

risk of poor dietary quality (Yeh, et al.,2021).

Concerning adolescent’s food choices during financial crisis, studies showed respectively that restrictive

eating behavior may be due to a lack of access to food (Kim et al., 2021), adolescents with low socio

economic status do not always have access to food enough because of lack of money and many people

living in the same household (Dapi, 2010) and increasing food prices or reducing family incomes may

influence family food purchasing and shopping basket (Arechavala et al., 2016). And regarding the

adolescents eating behavior and dietary pattern, many studies found that adolescents from low socio

economic status families reported significantly lower frequency of breakfast intake, that they consumed
significantly fewer meals per day (Costarelli et al., 2013), and the lack of money or poverty has been

influencing adolescent’s food habits with low socio economic status (Dapi et al., 2009). Furthermore,

inadequate nutrient intake was more frequently reported by the adolescents with low Socio Economic Status

(Dapi et al., 2011). A study published in Spain, found that there have been considerable changes in the

dietary habits in children in time of crisis (Shankar-Krishnan et al., 2021).

In Lebanon, a Mediterranean country, and since 2019, a compounded and unprecedented ongoing crisis has

been described as one of the three most severe crises globally since the mid-nineteenth century (World

Bank, 2021), with the repercussions of decreased purchasing power with an increased in unemployment

rates (Abi-Rached et al., 2020). According to a recent survey published by UNICEF in November 2021,

figures estimate that famine would affect 30% of children in Lebanon, and that more and more children are

going to bed hungry (UNICEF, 2021). Thus, between global economic insecurity, Lebanon's financial

crisis, and the nutrients required for optimal adolescent development and growth, it is important to

determine whether there are any associations between food insecurity, eating behavior, and dietary habits

in Lebanon's adolescent population. However, to the best of our knowledge, this will be the first study to

examine this association.

Literature review

Food insecurity is described as the disturbance of food intake or eating patterns because of low purchasing

power and other financial causes (Abi-Rached et al., 2020). It is not necessary that food insecurity (FI)

cause hunger, but hunger is always the cause of FI (Amarnani et al., 2017). FI may be permanent or

temporary, and it is influenced by many factors such as income, employment state, disability and knowledge

(Arechavala et al., 2016). It is important to be noticed that FI and hunger are related but have different

concepts. Hunger means a physical and personal sensation of discomfort, whereas FI is the lack of available

financial resources to get food at the household level (Belachew et al., 2013). Mainly, there are four

components of FI. The first component is food availability, if people having sufficient quantity of
appropriate food, it includes domestic production, food stocks and food aid. The second component is

accessibility, it is how people have physical and economic access to food, and it is described by the

purchasing power, income of population and transport and market infrastructure (Brinkman et al., 2010).

Moreover, it depends on political, economic and social factors and equitable disruption (Costarelli et al.,

2013). The third component is utilization, where it is described by the food quality and safety, nutritional

knowledge, paper preparation, clean water, sanitation and health care (Dapi et al., 2009). The fourth

component is stability, which depends on the maintenance of the three previous components over time and

on the absence of the risk of losing the supply due to economic, political or environmental factors (Dapi et

al., 2011). Poor dietary patterns are always associated with food insecurity, where food insecure people

cannot afford vegetables or fruits that are low in calories, less filling and more expensive (Coulthard et al.,

2021). During lockdowns and economic crises, food insecurity increases dramatically. In addition, the

employment across all sectors have been severely damaged due to the social distancing policies. Countries

with low-medium income and weak economy are exposed to the adverse effect of food insecurity (Brown

et al., 2021).

Between the ages of 12-18, the human body undergo a transition state from childhood to adolescence (Dush,

2020). This changing stage is lately considered a low-risk period, where people enjoy a good health

(Sparrow et al., 2021). Recently, this period was marked by critical health risks, mainly because the

unbalanced diet or the inappropriate eating habits may cause life time problems (Baceviciene et al., 2020).

These findings caused the development and implementation of different interventions that aimed to promote

healthy eating habits especially during this life stage (Rinninella et al., 2017). This critical transition period

requires a good monitoring to eating habits to prevent unhealthy eating behavior and food insecurity. To

make this monitoring valuable, we should understand the factors that are affecting the eating behaviors

during this stage (Fox et al., 2016).

When adolescent suffer from FI, they also have poor health and mental health. Many factors should be

studied to understand more the relation between adolescent and FI (Varadharajan et al., 2013). Parent and

parenting factors, household composition and family dynamics, psychological factors, health behaviors and
stress are all factors that should be investigated (Omiwole et al., 2019). Moreover, pre-school aged children

who suffer from FI demonstrate higher rated of behavioral problems and development delays (Chung et al.,

2018). However, school-aged children who live in food insecure household’s show higher rated of

depression, anxiety, and poor academic outcomes (Jáuregui-Lobera et al., 2018).

Although younger children take more attention and care to be shielded from hunger and are accessed to

different programs, adolescents are less likely to benefit from these programs and thus are more vulnerable

to FI (Huang et al., 2021). This may occur because younger children have more nutritional needs (Silverman

et al., 2015).

During the Covid 19 pandemic period in the UK, and due to the down economic situation, the rated of FI

increased dramatically (Mutisya et al., 2021). People who were exposed to FI in economically wealthy

countries has been interlinked with foods high in energy density (HED) consumption, over eating and lesser

intake of healthy food and snacks (Kaveh et al., 2021). People who are experiencing emotional states eat

more HED food such as chocolate, crisps and biscuits, to the fact that these foods are considered as a

comfort foods and have emotional regulation factors (Stabouli et al., 2021). Emotional eaters always suffer

from emotion dysregulation, and they need to overcome the negative effects and anxiety (Goldschmidt et

al., 2021).

During the crisis, FI concern should be highly considered, where population is negatively

socioeconomically affected (FAO, 2020). Reducing spending have a negative effect on education and

healthcare, reduce the amount of food consumed and dietary diversity (Kim et al., 2021). This also increase

the consumption of less expensive foods which are often lower in nutritional values (Masa et al., 2021).

Sometimes the bad choice of food causes FI, where people decide on what to buy and what to eat, and this

decision depends on a complex set of factors that vary from person to another depending on culture, heritage

and upbringing (Moghames et al., 2016). Mainly this decision is affected by the economic status and food

cost. The socioeconomic status (SES) gradient depends on the affordability and availability of food

(Shankar-Krishnan et al., 2021). Low SES households reported that prices and income were the main

motivations in food purchasing decisions compared to those in the highest SES groups who prioritize
healthy food (UNICEF, 2021). The extent to which rising food costs induce food insecurity will be

determined by the proportion of the population that allocates a considerable portion of their income on food

(Yeh et al., 2021). As household income fell and relative prices of food increased, food purchases and

caloric consumption decreased (Wardle et al., 2001).

One may notice the difference between the definitions of three main terms related to FI: eating behaviors,

eating habits and dietary patterns. Eating behaviors are complex of physiologic, psychological, social and

genetic factors that influence meal timing, quantity of food intake, food preference and selection (World

Bank, 2021). Whereas, eating habits are the individual food preferences often related to culture, education,

socioeconomic background and health status. Dietary patterns are the quantities, proportions, variety, or

combination of different foods and the frequency with which they are habitually consumed (World Bank,

2022).

Food security and poverty are highly associated with each other’s, therefore, social innovation should focus

on dealing with both issues not only focusing on one, especially in the pandemics (Schmeer et al., 2017).

In rural China they followed the social innovation in food production and distribution to solve the food

insure and poverty (Huang et al., 2021). The global security of food supplies has been challenged due to

the changes happened to world’s economics and environmental changes (Ickes et al., 2020). The social

innovations included increasing the connectivity gap between smallholder farmers and urban markets,

improving waste prevention strategies and forming a community-supported agriculture model (Acb et al.,

2020).

Poverty and under nutrition are interconnected; poor dietary quality is linked with poor childhood growth

(Savage et al., 2007). The migration from rural to urban lead to large informal employment, which in return

ensures the food insecure state. Many strategies and policies have been prepared to counter under nutrition

in different countries but their implementation is still hard to be applied (Pereira et al., 2020).

Lebanon is a small country with low to middle income, and population of six million individuals and have

a long history of political and economic instabilities (WFP, 2022). Food prices were increased by more than

15 times from October 2019, and people’s purchasing ability decreased and the unemployment rates
increased (Jomaa et al., 2019). The relationship between food insecurity and health is a field that have

always gain the Lebanese people attention even before the COVID-19. However, after the pandemic the

economic and social inequality has increased, hence affecting the food system in the population (Kharroubi,

et al., 2021). Food insecurity (FI) and poverty may increase dramatically in the Lebanese societies with the

expansion of the financial crises and recession (Jomaa et al., 2019). Lebanon is highly reliant on food

imports, more than 99% of all cereals and more than 80% of the food basket are imported (UN News, 2020).

An inflation of 183% in the price of the food basket comprised of eight items of the Survival Minimum

Expenditure Basket between October 2019 and December 2020 (WFP, 2020b). Research have explored

that FI is an immediate problem for households in Beirut and in many governorates in Lebanon and nine in

every 16 households ate less than 2 meals per day and more than 70% of them skipped their meals to spare

food (Nabulsi et al., 2020). Even though half the population studied had a low food consumption score,

82.4% of the people were not relying on livelihood coping strategies (Hoteit, 2021).

The immune system capacity of the body may decrease due to malnutrition and moderate FI (Kharroubi et

al., 2021). The poor immunological response may increase the risk of infectious disease transmission. From

a biological perspective, people having FI, and especially adolescents, face nutritional deficiencies such as

anemia and lack in vitamins A and D, and antioxidant minerals (Robertson, et al., 2021). Moreover, people

suffering poverty with FI may not follow health-protection strategies and may have difficulty following

recommendations related to healthy diet and food system (Khonje et al., 2022). These people may come

from families where there is no working individual in it, they need to work to get financial resources to buy

food and have a balanced meal (Kotchick et al., 2021).

In the current circumstances in Lebanon, from the financial crises to the lockdowns, it is important to

determine whether there are any associations between food insecurity, eating behavior, and dietary habits

in Lebanon's adolescent population.