The aim of this study was to examine for the first time the connection between the levels of food insecurity and selected morbidities by describing the profiles of 362 households of the 4000 participating in the “National Food Security Project” (NFSP). These 362 families responded to a questionnaire specifically designed to determine the level of satisfaction of the households, the level of food insecurity (according to the six-item module of the Household Food Security Survey) and information about selected morbidities in these households. In particular, the respondents (usually one of the adults) answered whether someone in the family (regardless of whether adult or child) had one or more of the following conditions: anemia, hyperlipidemia, diabetes, heart disease or hypertension.
The results show that for every additional point in the food insecurity scale score the risk of hyperlipidemia, diabetes, heart disease and hypertension increases by 20, 16, 31 and 21%, respectively within the families who receive food support. These compare to much lower prevalence of these diseases/conditions in the general population in Israel. Among Jews in the study there is greater prevalence of morbidity than among Arabs. The biggest difference between Jews and Arabs was found in the probability of anemia, which is 3.6 times higher among Jews as compared with Arabs. This may be attributed to meat consumption habits of Arab families. There is also lower morbidity among the ultra-Orthodox as compared to other Jewish population groups. This may be explained by different lifestyle habits not related to nutrition habits, such as lower levels of stress and anxiety, and a more supportive community. It is also possible that the range of ages is lower in Ultra Orthodox households, and the respondent’s age component (which is part of the vector of explanatory variables in the regression) did not completely control for the full effect of age.
An additional significant finding is the difference in prevalence of diabetes which is much higher in families where heads of households were married as compared to single head of households. The finding may be partly explained by the nature of food purchasing for larger families, in that the necessity to purchase large food quantities on a limited budget often results in selection of cheaper foods of lower nutritional value, thus resulting in increased prevalence of diseases/conditions such as diabetes and hyperlipidemia, which are partly attributable to poor dietary habits. In addition, purchasing in bulk may reduce the degree to which the quality of the food.is checked.
These results can be seen, with the limitations of the comparisons, in other countries such as the USA.
There is no doubt regarding the importance of the programs but could they be improved, in order to give that population the right food with the right educational programs?
In the USA, programs for nutritional assistance -Supplemental Nutrition Assistance Program (SNAP), Special Nutrition Program for Women, Infants and Children (WIC), and National School Lunch Program (NSLP)-serve as the backbone of the nutrition safety net in the USA.
These programs have been successful in achieving many of their initial goals of improving food purchases, food intake, and/or nutritional status of low-income, vulnerable Americans. The only goal that was not achieved yet was the health benefit and obesity prevention, so as to prevent the resultant increased risk of chronic disease development .
A few studies done on the SNAP program found that the program did not address the problem of obesity and may even contribute to the problem .This may be as a result of the lack of regulation, until recently, regarding the type of food that could be purchased. As a result, often nutritionally poor foods were purchased, which in turn may have contributed to higher prevalence of diseases and conditions known to be related to poor dietary habits. In the last year, regulations have been introduced to define which foods may be purchased, with the emphasis on healthier nutritionally sound foods. Another problem that was found is the very low literacy level of the population receiving the program wherein low literacy is associated with poverty and economic disparities .
There have been many papers published investigating the correlation between food assistance programs and obesity and chronic disease. It appears that the correlation depends on age, gender and the specific food assistance program. For example, it was found that participants in the Supplemental Nutrition Assistance Program (SNAP) were more likely than nonparticipants (of equal or higher income) to be obese . However, this correlation appears to be gender-specific. Current and long-term participation in the food stamp program was significantly correlated with obesity in low-income women, but the association did not exist among men . Also the specific assistance program impacted on the correlation. In preschool children, research showed that children from lower-income families had higher incidences of obesity, hypertension, and dyslipidemias . And while participation in SNAP and the national school lunch program (NSLP) appeared to be correlated with certain cardiovascular risk factors, participation in the Special Nutrition Program for Women, Infants, and Children (WIC) may actually be beneficial in combating these cardiovascular risk factors . In research conducted in Peru, it was shown that children participating in the Glass of Milk program had a 65% lower risk of obesity than those not participating. For mothers, however, participants in the Community Kitchens program had twice the risk of obesity when compared to nonparticipants .
A current study published by a Portuguese group show that when examined the impact of food insecurity on health and health-related issues they found that subjects with food insecurity reported worse quality of life score HRQoL and more physical disability when compared to subjects without food insecurity . A higher proportion of subjects with food insecurity were found to have diabetes and rheumatic diseases than those with food security. In fact, their results agree with those from other countries that found strong evidence that vulnerable people, who commonly live in food insecure conditions, have a higher risk of poor health . Studies have found that socioeconomically vulnerable groups experience higher mortality and morbidity rates for coronary heart disease , atherosclerosis, type 2 diabetes mellitus (34), and some cancers . The Portuguese study also revealed that a high proportion of subjects with food insecurity reported mental illness in the form of self-reported depression symptoms. The consequences of food insecurity in mental health, namely anxiety and depression symptoms, are well documented in the literature .
The possible correlation between food assistance programs and obesity and chronic diseases may have to do with the diet quality of the participants.
Among adults with obesity and diabetes, food insecurity is associated with lower overall dietary quality, increased consumption of unhealthy foods and lower consumption of healthy foods. These individuals are limited to cheaper, more calorie-dense and high-sugar foods that promote high blood sugar .
Data show that SNAP participants received a larger percentage of their calories from empty calories (solid fats, added sugars) when compared to nonparticipants . Overall, Healthy Eating Index− 2005 scores for SNAP participants were lower than those of nonparticipants . Participation in WIC and the NSLP, however, was correlated with increased nutrient quality without increased caloric intake . Policy revisions for all the food assistance programs now aim to improve diet quality. For SNAP, incentivizing the purchase of nutrient-dense items appears to be beneficial (https://brookdale.jdc.org.il/en/publication/food-security-israel-2003-implications-patterns-nutrition/). It has been suggested that limiting the choices of foods that SNAP participants receive would be beneficial, but the implementation is complicated (https://brookdale.jdc.org.il/en/publication/food-security-israel-2003-implications-patterns-nutrition/). Overall, it is understood that nutrition education must be implemented to improve diet quality of SNAP participants as is done in the Israeli programs.
In a study that was conducted among 279 lower income participants not enrolled in SNAP program, Harnack et al. (2016) wanted to evaluate whether prohibiting the purchase of less nutritious foods with SNAP benefits improves the nutritional quality of foods purchased and consumed. It was found that a food benefit program that pairs incentives for purchasing more fruits and vegetables with restrictions on the purchase of less nutritious foods may reduce energy intake and improve the nutritional quality of the diet of participants compared with a program that does not include incentives or restrictions.
The WIC program, with estimated expenditures of $6.8 billion annually and its authorized vendors, serves approximately 8.9 million infants, children, and pregnant/postpartum women each month. This population also faces the problem of an increased prevalence of obesity. In 2009 fruits and vegetables were added to the program to try to contain the obesity epidemic which is common among lower socioeconomic status women in the United States. This action resulted in lower prices of fruit and vegetables in small stores where those women tend to buy their food products . Improving the quality of foods in the food stores for the WIC program changed the purchase patterns to healthier ones. The food guidelines included more fruit and vegetables and whole grains . Changes to the food packages offered by WIC (such as fruit and vegetable vouchers) aim to improve diet quality . These policy changes may also affect vendor prices for fruits and vegetables, which further encourages their consumption . In Israel this was not part of the program.
Finally, new regulations for the NSLP aim to improve nutrient intake . Though a correlation between food assistance programs, such as SNAP and NSLP, and obesity appears to exist, evidence is not sufficient for such a correlation to be proven (https://brookdale.jdc.org.il/en/publication/food-security-israel-2003-implications-patterns-nutrition/).
Because of the results of these previous studies, this year these programs are aiming to address the obesity and resulting chronic disease problem and to change the quality of the food products and the environment and education to allow for better nutrition habits and status.
The methodology and the questionnaire did not provide morbidity data on each household member, and it is possible that less morbidity was correlated to a younger household composition (family with many young children) rather than other demographic characteristics.
The obesity information is lacking because the questionnaire did not directly examine this. Unlike questions on the other disease states which did not specifically relate to the respondent but rather to the incidence within the family, questions on weight and height are of necessity person-specific and may have met with an antagonistic response, because of perceived stigmatization. Therefore, questions on weight/height and obesity were not included. It is recognized that this issue is very important and future research of this nature will attempt to explore obesity prevalence in a non-intrusive manner.
There is adequate representation of Arab families in the sample (12%) as compared to 13% in the general population. However, about 30% of Arab families suffer from food insecurity, thus were in fact underrepresented in the sample. As the initial stages of the proposed new initiative were in the central areas of the country, and many Arab villages and towns are in the periphery, they were underrepresented. However, the number of Arab families included is large enough to allow for statistical comparisons.
In addition, there may be municipalities which, for various reasons, do not participate in the National Food Security Project and their health and socio-demographic characteristics may be different.