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Assessment of the nutritional status and food frequency pattern of
the preschooler children in Gaza under the Israeli's blockade.
نمط االسخهالك انغذائي نألطفال انفهسطينيين في انسن قبم و انحانت انخغذويت حقييم
.يححج انحصار اإلسزائيه انمذرسي في مذينت غزة
Dr. Samir M. Radi
Assistance Prof. PhD in Public Health & Nutrition
Director of Health Information Dept. MOH.
انمؤحمز انعهمي األول
دور انكهياث وانجامعاث في حنميت انمجخمع
Assessment of the nutritional status and food frequency pattern of
the preschooler children in Gaza under the Israeli's blockade.
Abstract
The goal of the study to assess the nutritional status and consumption pattern of
the preschool children and their families under blockade in Gaza. Objectives: to
estimate the dietary patterns and identify the child's feeding habits and health
related indicators. Methodology: A community based cross sectional study was
carried out including the total study sample of 733 preschoolers and their
families. A structured interview questionnaire was designed to collect required
data. Results: about 44.6% received exclusive breast feeding. About 86% of the
preschoolers take chips and biscuits snacks between meals. About 92% of
households rely on purchasing water for drinking use, and 85% of them
experience lack of gas for cooking. About 94.4% of studied households faced
difficulties in access to food products. A few (5.7%) of studied households
consumed meat daily and about one quarter 23.2% of them consumed both the
poultry and fish rarely. The prevalence of wasting, stunting and underweight
among the studied preschoolers was 3.5%, 15%, and 6% respectively.
Conclusion: improving nutritional status at international, national and
ministerial levels.
Key words: Malnutrition, Stunting, Wasting, Underweight, Dietary pattern,
Blockade.
2013
نألطفال انفهسطينيين في انسن قبم انمذرسي و نمط االسخهالك انغذائي انخغذيتانحانت حقييم
.يححج انحصار اإلسزائيه في مذينت غزة
انمهخص انعزبي:
ظ االسرالك في اىس قثو اىذرسي اىذراسح إىي ذقيي اىحاىح اىرغذيح ىألطفاه اىفيسطييي ذفد
ذ جع اىثيااخ اىطيتح طفالا 377تيغد اىعيح اىفعييح ىيثحث قذ غشج. في ذيح اىغذائي ألسز
قذ .رقيي اىظ اىغذائيىع طزيق قاتيح األ تاسرخذا اسرارج أعذخ خصيصاا ىذىل أيضا اسرارج
أا سثح . %44,,سثح اىزضاعح اىطثيعح خاله اىسد شر األىي اىعز أ خيصد اىذراسح إىي
% األسز 29أظزخ اىرائج أ %64األطفاه اىذي يراى اىشثس أ اىثسنيد تي اىجثاخ
ما أظزخ . % يعا قص أ عذ ذفز غاس اىطي68ذعرذ عيي شزاء يا اىشزب أ
ثة % األسز في اىعيح ماد ذاج صعتح في اىحصه عيي اىطعا أ اىس,2,4اىذراسح أ
%( يأمي 843أثثد اىثحث أ سثح قيييح ). األه اىزئيس ىذىل ما اىحصار قص اىاد اىغذائيح
% فقظ يأمي اىذجاج 1أظزخ اىرائج أ ما اىيح تشنو يي أ صف اىعيح يراى أسثعيا.
ى اىذجاج األساك %( يرا9749% يأمي األساك يياا حاىي رتع اىعيح )148تشنو يي
األطفاه تيغد سثح اإلصاتح تي% 18أظزخ رائج اىثحث أ سثح اىرقش تيغد قذ تشنو ادر.
تاءا % األطفاه في اىس قثو اىذرسي.441% تيا تيغد سثح اإلصاتح تقص اىس 748تاىشاه
سز اىفيسطييح ىألطفاه األاىغذائي عاىضسري عيي ذحسي عيي ا ذقذ رائج فقذ ذ اىرصيح
سري حيي إقيييسري االحرياجاختزفع اىحصار ذفيز عيي جيع اىسرياخ4 اىذىي
تزاج ذذخيي ذطيزيح في ذا اىجاه.
سء اىرغذيح4 ذقش4 شاه4 قص اىس4 اىظ اىغذائي4 اىحصار. :االفخخاحيتانكهماث
Introduction
Gaza Strip (GS) is a narrow piece of land lying on the coast of the
Mediterranean sea and its position is on the crossroads from Africa to Asia.
Gaza Strip is a very crowded place with area of 378 Km2 and total population of
1.8 million (UNEP 2003). The diet of any young child must provide adequate
energy and nutrients for growth, building body nutrient stores, body
maintenance and repair and day to day activities. A poor diet of insufficient
energy and specific nutrients can have an adverse effect on both growth and
development and result in deficiency diseases (Thomson 1998). The causes of
child malnutrition are complex and multidimensional, and they range from
factors as broad in their impact as political instability and slow economic
growth to those as specific causes. The conceptual framework for the causes of
child malnutrition is adapted from the United Nations Children’s Fund’s in
1990. Children’s nutritional status depends on three necessary components
including food security, access to adequate health care and adequate feeding
practices (UNICEF 2004).
Malnutrition is a broad term commonly used as an alternative to undernutrition,
but technically it also refers to overnutrition (UNICEF 2009). Anew figures
show that, malnutrition contributes to 53% of the 9.7 million deaths of children
under five each year in developing countries and one child dies every six
seconds from malnutrition and related causes (UNICEF 2007). Micronutrient
deficiencies are widespread in developing countries with most common
deficiencies due to lack of iron, iodine and vitamin A (Kraemer 2007). There
are four components of nutritional assessment, including dietary assessment,
individual assessment, body composition and anthropometry assessment. The
individual assessment is including 24 hour dietary recall and food frequency
questionnaire (FFQ) (Oxford 2006).
Israeli blockade and restrictions on the free movement of people and goods in
the Gaza Strip and the unprecedented and prolonged closure of the Gaza Strip
since 2006 affected the different aspect of live including nutrition in Gaza.
Since the occupation of Palestine in 1967 until now, Israel exercised full
authority over the WB and GS and the events have shown that the political
relations with Israel remain the overriding factors that determine the level of
food security for the Palestinian people. Consequently, Palestinian economy is
strongly dependent on Israeli demand for goods and labor (FAO 2003).
This study was conducted to assess the nutritional status and consumption
pattern of the Palestinian preschool children aged 2–5 years in Gaza City and
their families under blockade. Our objectives were to estimate the dietary
behavior and identify the child's feeding habits to provide data on health related
indicators and child caring capacity.
Methods
This study was conducted during 2009, and the study setting was households in
Gaza City, comprising urban, rural and refugee camp. A community based cross
sectional study was carried out including the children aged 2-5 years.
The sampling methodology used in our study was the multistage stratified
cluster sampling technique with probability proportionate to size of population
in the first stage and a constant number of children per cluster at the second
stage. Based on sampling frame of Gaza City, it was divided into 12 primary
sampling units (PSU).
A sample of 7 PSU (Al-Shata'a refugee camp, Al-Moghraga, Al-Shekh Redwan,
Al-Shagaia, Al-Sabra, Al-Zitoon and Al-Twfah) were randomly selected from
each PSU, 110 children were selected giving a total study sample of 770
children. From a random starting point in each cluster, selection of households
was started and then search was made from door to door until required sample
size were selected. The number of participated children in this study was 733
preschoolers.
Data collection took a period of 6 months from January to June 2009. Two days
of training were conducted, and a pilot study on 30 preschoolers was carried out
incorporated the exercise for the validation and verification of the designed
questionnaires.
Pre-designed structured interview questionnaire was designed and checked for
completeness and accuracy to collect required data. Three research teams
conducted the interviews with the mothers of children and collected the required
data and measures in the amount of two days per week.
Food frequency questionnaire, where the data of household's food frequency
consumption were managed by computing the percentage of the daily, weekly,
monthly and rarely consumption for each different food item listed in the 8 food
groups.
Anthropometric measurements, where the following variables height, weight,
and were collected according to criteria of Jelliffe (Jelliffe et al 1989). (7)
Height
measurement the height of preschool child was measured to the nearest 0.1 cm.
Weight measurement the internationally field tested Tanita Baby/Adult Digital
Scale 1582, graduated to 0.1 kg was used for weight measurements.
Data entry, management and analysis were carried out using SPSS, version 16.0.
Epi-Info, version 2002, was used to calculate the nutritional indicators.
Statistical significance was established at P < 0.05. Frequency distributions
were generated for all variables and the univariate analysis applied.
RESULTS
The total sample was 733 children, 401 (55%) boys and 332 (45%) girls as
shown in (figure 1). The sample was collected from 7 districts in Gaza City:
these covered 3 types of locality. Mean age was 42.4 [standard deviation (SD)
10.2] months. About 8% of the sample had been low-birth-weight babies. Less
than half (43.7%) of the families had a crowding index of less than 3 members
per room, where more than half (56.2%) of the families had a crowding index of
three or more members per room. The mean SD of the crowding index was
3.29 1.52 members per room.
Almost all households (99.9%) had a access to water: 92.0% purchased their
drinking water from a truck with tanks of filtered water, only 4.0% of
households used tap water from the municipality for drinking use. The majority
(84.7%) of the households did not have gas available for cooking on a daily
basis. Accordingly, they used alternative methods: 28.4% used electricity,
41.4% used kerosene and 14.9% used wood.
The majority of households (94.4%) faced difficulties with access to food
products in the previous year; only 1.1% did not face any difficulties at all. The
predominant causes (97.3%) of difficulty in accessing food identified by the
mothers were the siege and the shortage of food products on the market,
followed by increases in food prices (94.0%) and loss of income (63.0%).
The household's food expenditure
The minority (0.9%) of studied households spent < 50 % to purchase food
products from their total income and one third (40%) of them spent 90% or
more to purchase food products from their total income.
Child's feeding habits
Table (1) clarifies that, the majority (86%) of studied children take chips and
biscuits snacks between meals, and about half (52.4%) of them take candies,
vegetables and 55.3% take fruits between meals. Also, about half (49.8%) of
them take juice and soft drink and 48.8% take cake and pastry. Sweet was the
most (56.5%) preferable meal among the studied children, and vegetable was
the least preferable meals among them. About third (33.6%) of the studied
Figure (1) Distribution of sample by sex
55%
45%Girls
Boys
children prefer meats, and fourth (25.1%) of them prefer fish. The majority
(87.7%) of studied sample took iron supplementation, 68.8% of them took
vitamins, and 49.1 and 14.1% of them took herbs and minerals respectively.
Table (1) Distribution of the study sample by child's eating habits
Child's eating habit No.
(n=733) %
Kinds of snacks/ day +
Chips
Biscuits
Candies
Juice, soft drink
Cake, pastry
Vegetables
Fruits
631
632
384
465
358
384
406
86.1
86.2
52.4
49.8
48.8
52.4
55.3
Preferred meal +
Sweet
Soup
Meat
Fishe
Fruit
Vegetable
414
135
246
184
298
117
56.5
18.4
33.6
25.1
40.7
16.0
Kind of tonics taken +
Iron
Vitamins
Minerals
Herbs
none
643
504
104
360
37
87.7
68.8
14.2
49.1
5.0
+ Categories are not mutually exclusive
The fortified foods at the household
The majority (91%) of studied households used adequately iodized salt for
cooking, and 46.6% of them were consuming food products fortified by iron
and some vitamins as well.
Household's food consumption pattern
Cereals, legumes and starches group
Table (2) illustrates that, all of (100%) the studied households consumed bread
every day as a staple food, while the majority (62%) of them consumed potato
every day and about one third (35.6%) of them consumed it weekly. The
majority (85.9%) of studied households consumed rice weekly and the minority
consumed it daily (8.6%) and monthly (4.2%). The studied households
consumed beans either on daily (44.2%) or weekly basis (41.6%). Intake of
macaroni was mainly monthly (58.3%) and other legumes was either on
weekly (41.3%) or monthly basis (45.2%).
Table (2) Distribution of food consumption pattern of cereals, legumes and starches
Cereals, legumes & starches Daily % Weekly % Monthly % Rarely %
Bread
Rice
macaroni
Potato
Bean
Falafel
Other legumes
100
8.6
1.8
62.5
44.2
46.0
2.2
-
85.9
32.7
35.6
41.6
40.5
41.3
-
4.2
58.3
1.6
7.9
7.4
45.2
-
1.2
7.2
0.3
6.3
6.1
11.3
Meat and milk group
Table (3) illustrates that, the minority (5.7%) of studied households consumed
meat daily and about half (54%) of them consumed it weekly. About third
(29.9%) of studied households consumed meat monthly and about tenth (10.4%)
of them consumed it rarely. The minority of studied households consumed
poultry 1% and fish 1.5% daily, where the majority (58.8%) of them consumed
the poultry weekly and 55.9% of them consumed the fish monthly. About one
quarter 23.2% of studied households consumed both the poultry and fish rarely.
Consumption of eggs was mainly daily (43.5%) or weekly (40.1%) and the
minority of them consumed it monthly 10.1% and rarely 6%. The milk was
consumed two thirds (60%) by the studied households daily, 19.8% weekly and
fifth (20.2%) of them monthly and rarely. About third of (30%) of studied
households consumed yogurt daily and the majority (42.7%) consumed it
weekly and nearly one fourth (27.3%) consumed it monthly and rarely. More
than third (38.5%) of studied households consumed cheese every day and about
one third (36%) consumed it monthly and rarely.
Table (3) Distribution of food consumption pattern of proteins and milk groups
Food item Daily % Weekly % Monthly % Rarely %
Meat & eggs Meat
Poultry
Fish
Egg
5.7
1.0
1.5
43.8
54.0
58.8
28.1
40.1
29.9
31.5
55.9
10.1
10.4
8.7
14.5
6.0
Milk & dairy products Milk
Yogurt
Cheese
60.0
30.0
38.5
19.8
42.7
25.5
6.8
13.9
17.9
13.4
13.4
18.1
Fruits and Vegetables group
Table (4) illustrates that, more than three quarters (79.9%) of studied
households consumed fresh vegetables and about half (51.4%) of them
consumed cooked vegetables every day. The minority (18.4%) of studied
households consumed fresh vegetables weekly, while cooked vegetables was
consumed by 43.9% of the studied households weekly. Intake of fresh fruits
and fruit's juice was daily consumed by 7.9% and 14.1% of the studied
households respectively.
Table (4) Distribution of food consumption pattern of vegetables and fruits groups
Food item Daily % Weekly % Monthly % Rarely%
Vegetables Fresh salad
Cooked vegetables
79.9
51.4
18.4
43.9
0.8
2.9
0.8
1.8
Fruits
Fresh fruits
Fruit juice
7.9
14.1
43.7
22.8
36.6
40.9
11.9
22.2
Fats, beverages and sweet group
Table (5) shows that, olive oil was consumed on a daily basis by 37.4% of
households, and the rest of its intake was distributed between weekly , monthly
or rarely. Other vegetable oils were the most commonly consumed on daily
basis (87.6%), while the butter and ghee were practiced commonly in weekly
basis (42.2%) in cooking processes. Tea was the drink used daily by nearly all
of households (93.9%), where other soft drinks were consumed on monthly
basis (40.7%). Sweet consumption was usually weekly 33.6% of households,
while honey intake was rare (72.4%).
Table (5) Distribution of food consumption pattern of oils, beverages and sweets
Food item Daily % Weekly% Monthly % Rarely%
Fats
Olive oil
Other vegetable oils
Butter & ghee
Tahini
37.4
87.6
10.4
12.0
19.2
10.5
42.2
48.2
18.4
0.5
18.3
19.4
25.0
1.4
29.2
20.5
Beverages
Tea
Soft drinks
93.9
5.2
3.4
18.7
1.0
40.7
1.8
35.5
Sweet
Jam and halvah
Honey
16.6
4.1
33.6
3.0
21.1
20.5
28.6
72.4
Identification of dietary patterns from FFQ
The investigation of sampling adequacy showed that the overall KMO= 0.822
and the probability associated with Bartlett’s test <0.0001 indicating that the
sample was adequate for factor analysis. The measure of sampling adequacy for
all items were over 0.5 supporting the inclusion of each item in the factor
analysis. During several steps a total of 8 items were eliminated, 7 items
(potato, fruits, fresh salad, olive oil, butter, soft drinks and honey) because the
communalities were low<0.5 and 1 item (macaroni) because it failed to meet a
minimum criteria of having a primary factor loading of 0.5 or above. None of
the variables demonstrated complex structure.
Six dietary patterns were identified through factor analysis based on eigenvalues
and the plot created by the Scree test and the percentage of variance explained
by each factor. However one component had only a single variable loading on
it (rice) and so was removed. The remaining 5 components accounted for
60.42% of the variability within the sample.
Table (6) shows the factor loading matrix for the 5 patterns. The first factor
which accounted for 16.22% of the total variance retained 5 items and was
labeled “protein and fruits” and this factor was characterized by meat poultry,
egg and fruits. All 5 items were positively associated with this factor. The
second factor explained 12.07% of the total variance and retained also 5 items
and since this factor was characterized by milk , dairy products, tahina sesame
and halawa sesame, it was labeled “milk/dairy products and sesame”. All 5
items were positively associated with this factor. The third factor which
accounted for 10.47% of the total variance, retained 2 factors and this factor
was labeled “foul and falafel” and was characterized by both bean and chick
pea which were positively associated with this factor.
The fourth factor explained 7.49 % of the total variance and retained 2 items
vegetable oils & tea and so was labeled “vegetable oils and tea”. The fifth
factor, which explained 7.37% of the total variance, retained 2 items and was
labeled “pulses and cooked vegetables” and was characterized by pulses and
cooked vegetables which were positively associated with this factor. The
internal consistency (Cronbach’s alpha) for each of the extracted factors was
0.74 for factor 1, 0.71 for factor 2, 0.81 for factor 3, 0.42 for factor 4 and 0.62
for factor 5. Two clusters were identified for each dietary pattern representing
high and low utilization of that dietary pattern.
Table (6) Factor loadings for the dietary pattern identified by factor analysis
Dietary items
Dietary
pattern 1
Dietary
pattern 2
Dietary
pattern 3
Dietary
pattern 4
Dietary
pattern 5
Meat 0.749
Poultry 0.821
Egg 0.606
Fresh fruits 0.737
Fruit Juice 0.548
Milk 0.551
Yogurt 0.657
Cheese 0.557
Tahina sesame 0.558
Halawa sesame 0.634
Fuol medames 0.882
Falafel 0.839
Vegetable oils 0.765
Tea 0.767
Pulses 0.770
Cooked vegetables 0.686
Anthropometric indicators
Table (7) presents the distribution of studied sample by anthropometric
indicators of nutritional status. The table shows that, the prevalence of wasting
was 3.5%, the prevalence of stunting was 15%, and the prevalence of
underweight was 6.1%. The prevalence of overweight among the studied
preschool children was 2.9%, and the prevalence of tallness above normal was
2.2%.
Table (7) Distribution of the study sample by anthropometric indicators of nutritional status
Anthropometric indicators
No.
(n= 733) %
Weight for height wasting
normal
above normal
26
645
62
3.5
88.0
8.5
Height for age Stunting
normal
above normal
110
607
16
15.0
82.8
2.2
Weight for age underweight
normal
above normal
45
667
21
6.1
91.0
2.9
Determinants of nutritional status
Stunting
Table (8) presents the results of simple logistic regression analysis of factors
associated with stunting among studied preschool children. Stunting was
significantly associated with weight at birth. The prevalence of stunting was
higher (29.3%) among studied preschool children with low birth weight with
significant high risk more than double (OR = 2.59, P = 0.002) compared to the
children with normal birth weight (13.8%).
Other studied variables did not show significant effect on stunting although
higher risk was observed with these variables. Slightly risk effect on stunting
was observed among children who consumed low meats and fruits (dietary
pattern 1), foul and falafel (dietary pattern 3).
Table (8) Simple logistic regression analysis of factors associated with stunting
Variables Total
number
Prevalence of
stunting OR 95% CI P-value
No. %
Sex
Boys
Girls
401
332
57
53
14.2
16.0
1.14
0.76- 1.72
0.509
Age group (in months) 24-
48+
487
246
75
35
15.4
14.2
1.09
0.71- 1.69 0.675
Weight at Birth Normal BW
Low BW
675
58
93
17
13.8
29.3
2.59
1.41- 4.75
0.002*
Dietary pattern 1
Low
high
302
431
53
57
17.5
13.2
1.39
0.93- 2.09 0.163
Dietary pattern 2
Low
high
266
467
35
75
13.2
16.0
0.79
0.51- 1.22 0.349
Dietary pattern 3
Low
high
529
204
84
26
15.9
12.7
1.29
0.80- 2.07 0.488
Dietary pattern 4
Low
high
700
33
105
5
15.0
15.2
0.98
0.37- 2.61 0.937
Dietary pattern 5
Low
high
360
373
45
65
12.5
17.4
0.67
0.44- 1.02 0.108
(Ref.) Reference
P < 0.05 (significant)
Underweight
Table (9) presents the results of simple logistic regression analysis of factors
associated with underweight among studied preschool children. Underweight
was significantly associated with dietary pattern 5 (pulses and cooked
vegetables). The preschoolers with high pulses consumption and cooked
vegetables were at a lower risk of underweight than those who consumed low
pulses and cooked vegetables (OR = 0.49, P = 0.029). Other factors show no
significant effect on underweight.
Table (9): Simple logistic regression analysis of factors associated with underweight
Variables Total
number
Prevalence of
underweight OR 95% CI P-value
No. %
Sex
Boys
Girls
401
332
26
19
6.5
5.7
1.14
0.62- 2.10 0.699
Age group (in months) 24-
48+
487
246
31
14
6.4
5.7
1.12
0.58- 2.15
0.720
Weight at Birth Normal BW
Low BW
675
58
41
4
6.1
6.9
1.14
0.39- 3.31
0.802
Dietary pattern 1
Low
high
302
431
24
21
7.9
4.8
1.68
0.92- 3.08 0.105
Dietary pattern 2
Low
high
266
467
16
29
6.0
6.2
0.96
0.51- 1.81 0.908
Dietary pattern 3
Low
high
529
204
29
16
5.5
7.8
0.68
0.36- 1.28 0.107
Dietary pattern 4
Low
high
700
33
43
2
6.1
9.0
1.01
0.23- 4.38 0.987
Dietary pattern 5
Low
high
360
373
15
30
4.2
8.0
0.49
0.26- 0.94 0.029*
(Ref.) Reference
P < 0.05 (significant)
Wasting
Table (10) presents the results of simple logistic regression analysis of factors
associated with wasting among studied preschool children. Table reveals that ,
wasting was significantly associated with dietary pattern 1 (meats and fruits).
The prevalence of wasting was statistically higher (5.6%) among preschool
children who consumed low meats and fruits (dietary pattern 1) with an
increased risk of about 3 times (OR = 2.79, P = 0.024) than those who
consumed high meats and fruits (2%). Other factors apparently affected
wasting but not significantly.
Table (10): Simple logistic regression analysis of factors associated with wasting
Variables (n=733)
Prevalence of
wasting OR 95% CI P-
value No. %
Sex
Boys
Girls
401
332
13
13
3.2
3.9
1.21
0.55- 2.66
0.624
Age group (in months) 24-
48+
487
246
19
7
3.9
2.8
1.38
0.57- 3.34
0.467
Weight at Birth Normal BW
Low BW
675
58
25
1
3.7
1.7
0.45
0.06- 3.42
0.446
Dietary pattern 1
Low
high
302
431
17
9
5.6
2.0
2.79
1.23- 6.36 0.024*
Dietary pattern 2
Low
high
266
467
9
17
3.4
3.6
0.92
0.40- 2.11 0.935
Dietary pattern 3
Low
high
529
204
22
4
4.2
2.0
2.17
0.73- 6.37 0.268
Dietary pattern 4
Low
high
700
33
25
1
3.6
3.0
1.18
0.15- 9.02 0.869
Dietary pattern 5
Low
high
360
373
8
18
2.2
4.8
0.44
0.19- 1.04 0.114
(Ref.) Reference
P < 0.05 (significant)
DISCUSSION
The studied sample was 733 preschoolers, out of them 401 boys and 332 girls.
About 8% of the studied sample were with low birth weight. The results in this
study revealed that, the habit of giving chips and biscuits was practiced by about
86% of the mothers of preschoolers which is higher figure than that of
(Shaaban1990)
and (El-Wasseef 1994) studies conducted in Egypt which
reported 73.8% and 77.2% respectively. Comparing the results of the present
study with these studies indicate the dramatic change that happened in the
Palestinian preschooler's food consumption pattern mainly the consumption of
the commercial products on daily basis.
The present study revealed that, all the studied households have water supply
and sewage system, although the minority (4%) of studied households in Gaza
city used the tap water for drinking use and the majority (92%) relied on
purchasing water from mobile filtered tanks, and 3.3% of the households had
filter machine at home. These findings were supported by the recent reports of
(FAO 2010) and (WHO 2009). FAO & WHO reported that, 80 percent of
drinking water is not safe for human consumption (FAO 2010).
Access to sufficient fuel for food preparation is a critical issue to consider in
emergency situation and fuel shortage are often a major constraint in Gaza Strip
(WHO 2002). In the present study the findings revealed that, the most (84.7%)
of studied households were experiencing shortage and lack of gas for food
preparation on daily basis, where the Israeli occupation supplied it to Palestinian
people. The sorts of fuel used for cooking by studied households were 15.3%
gas, 28.4% electricity, 41.4% kerosene and 14.9% used wood for food
preparation. The findings in the present study are in agreement with the results
of survey conducted by United Nation Population Fund (UNPF 2009).
Most of the households in the present study confronted difficulties accessing
food during the year preceding the survey. The most often cited prevailing
causes of difficulties were the ongoing siege of Gaza and shortage of food
commodities, followed by high price of food products and the loss of income
source. These findings did not differ from those of previous studies [WHO
2007, WHO 1996] and are in agreement with a recent report of the UN
Development Program (Kim et al. 2008).
Household's food expenditure findings in the present study revealed that, three
quarters (73.3%) of the studied households spend 70% or more from the total
income on food, and 8% of them spend less than 50%. PCBS reported that, the
households in Gaza Strip spend 35.8% of their income on food (PCBS 2006).
The World Bank reported that, the poor in the Arab region are most vulnerable
to food-price shocks, spending anywhere from 35 to 65 percent of their income
on food. Considering the figures of World Bank, over and a above the impact of
ongoing siege and deterioration of the living condition in Gaza Strip could
explain the results of the present study (World Bank 2009).
Households food consumption pattern
For many years nutritionists have assumed that all nutrients can be obtained
from a diet containing a variety of foods drawn from a variety of sources
(Kraemer 2007).
The WB and GS are not self sufficient in food and have a unique situation since
they rely on commercial imports through Israel to supply domestic and basics
demand.
Cereals, pulses and starches group: Local production of wheat and pulses
covered only 4% and 2% respectively of consumption in the Palestinian
territories, as 96% of the consumed wheat and 98% of the consumed pulses are
imported through Israeli ports of entry (FAO 2007).
Bread is considered the most important source of calories and proteins in
regular Palestinian diet. Bread intake has a unique form, 100% of the
households consumed it on daily basis. Although, most of the households like to
eat rice and macaroni, the majority of them consumed rice weekly while
macaroni on monthly basis and other legumes such as flafal and foul medams
was either on weekly or monthly basis. Most of the households (62.5%) in the
present study consumed meals containing potatoes every day, because children
and adults like it as shown in (Table 2).
These results were approximately similar to that reported in the study of
Abdeen. Results of Abdeen's survey confirmed that diet of the population in
Gaza City lacks of sufficient diversity, although the majority (97%) of homes
consumed bread on daily basis and 57% of them consumed other cereal
products (Abdeen 2009).
Meat and milk group: About Half of the studied households consumed meat
(54%) and 58.8% poultry on weekly basis, while about half (55.9%) of them
consumed fish every month. Consumption of eggs was mainly daily (43.5%) or
weekly (40.1%) and the milk was consumed by two thirds (60%) by the studied
households on daily basis as shown in (Table 3).
Findings of the present study are in agreement with that of UNDP which
reported that, dietary patterns in Kuwait, Lebanon, Morocco and the Occupied
Palestinian Territory are similar, with one noticeable difference among the
Palestinians. They consumed the least amounts of fish and meat, eating the
former less than once a week. In general, fish and meat are the least frequently
consumed food items among the Palestinian households (UNDP 2009).
WHO reported that, the imposition by Israel of a much reduced limit for fishing
activities in Gaza Strip which seriously hampers fishing field (WHO 2009).
FAO reported that, all qualitative case studies emphasized that households rely
on eggs for proteins that they cannot afford to get through higher priced foods.
Red meat prices, increased significantly reaching an average of 45 NIS per kilo.
This price is highly discouraging for poor people who tend to revert to buying
frozen meat and meat-flavored stock cubes (FAO 2007).
Fruits and vegetables: Findings in the present study revealed that, more than
three quarters (79.9%) of studied households consumed fresh vegetables and
half of them consumed cooked vegetables every day. While, fresh fruits and
fruits juice consumption was 7.9% and 14.1% on daily basis respectively as
shown in (Table 4).
Integrated Regional Information Networks (IRIN) reported that, the amount of
affordable fresh fruit and protein on the Gaza market has been significantly
reduced due to the closures (IRIN 2009).
Low daily intake of fruits is recorded by all of the studied households, may be
due to the shortage of fruits in Gaza, which go in line with its high price related
to loss and scarcity in the Gaza's markets. By taking in consideration that most
of fruits consumed in Gaza Strip are imported and fetched from Israel, while the
vegetables are available locally, this may could explain the high intake of
vegetable and the low intake of fruits every day.
Olive oil was consumed on daily basis by more than third (37.4%) of the
studied households and the rest of its intake distributed between weekly,
monthly or rarely. Daily intake of tea is recorded by nearly all of the studied
households (93.9%), as shown in (Table 5).
Anthropometric indicators
Three consecutive main surveys document the nutritional status of preschool
children in Palestine (PCBS 1996), (USAID 2003) and (PCBS 2004).
Underweight the overall prevalence of underweight among the preschoolers in
the present study was 6.1% (Table 7), where the prevalence was a higher among
the boys (6.5%) than among the girls (5.7%).
PCBS reported that the prevalence of underweight in Gaza Strip dropped from
3.9% in 1996 to 2.5% in 2000 (PCBS 2000). Also, PCBS reported that
underweight in children is also relatively low standing at 4% in 2004, which
represents a rise since the year 2000 but is unchanged when compared to the
1996 (PCBS 2004). Where WHO reported that, the prevalence of underweight
in Palestine was 3% in 2006 (WHO 2009).
Also, UNICEF reported that, the prevalence of underweight in oPt was 5%
among the children under 5 years in 2005, while it was 7% in Syrian, 5.6%
Libya 7% Iraq, and 6% in Egypt. The prevalence of underweight in the present
study was the worst prevalence reported in Gaza strip since several decades as
shown in figure (2) (UNICEF 2007).
3.9 4
5
3
6.1
0
1
2
3
4
5
6
7
PCBS- 1996 PCBS- 2004 UNICEF-2005 WHO- 2006 Present study-
2010
Figure (2) Pattern of underweight % among preschoolers in GS over years
Stunting the overall prevalence of stunting among the preschoolers in the
present study was 15% (Table 8), and the prevalence was higher among the girls
(16%) than among the boys (14.2%). PCBS (PCBS 1996) reported that the
prevalence of stunting among preschoolers was 8% in Gaza Strip, where
USAID (USAID 2003) found that the prevalence was 12.7% and PCBS survey
(PCBS 2004) revealed that 11% of children under 5 years in Gaza Strip were
stunted. WHO reported that, the prevalence of stunting in oPt in 2006 was 10%,
while in Iraq 27.5%, Egypt 30.7% in 2008 and Libyan Arab Jamahiriya in 21%
in 2007 (WHO 2009). The result of the present study demonstrated clearly the
higher expected prevalence of stunting than the earlier studies done in Gaza
Strip, and not surprisingly, to be the highest among the Gazan's children since
several decades, and it is expected that to be the highest since the occupation of
Gaza Strip in 1967 as shown in figure (3).
8
15
12.7
11
10 10
5
7
9
11
13
15
17
PCBS-1996 USAID-2003 PCBS-2004 UNICEF-2005 WHO-2006 Present study-
2010
%
stunting
Figure (3) Patterns of stunting among preschoolers in GS over years
Wasting the overall prevalence of wasting among preschoolers in this study
was 3.5% (Table 9), and the prevalence was slightly higher among the girls
(3.9%) than among the boys (3.2%). PCBS reported that, the prevalence of
wasting was 3.8% in Gaza Strip, then decreased since 2004 to reach 1.4%
(PCBS 1996). USAID reported in GS that the prevalence of wasting was 3.9 in
2003. (USAID 2003) Also, UNICEF recorded in 2005 that, the prevalence of
wasting in oPt was 3% among the children under 5 years, while it was 7% in
Syrian, 5.6% Libyan, 7% Iraq, and 6% in Egypt. WHO reported that, the
prevalence of wasting in Palestine was 1% in 2006 (WHO, Executive Board
2009). The prevalence of wasting demonstrates markedly higher prevalence
than the previous studies carried out in GS with exception of figure reported by
(PCBS 1996) and (USAID 2003) as shown in figure (4).
3.5
3
1
1.4
3.93.8
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
PCBS-1996 USAID-2003 PCBS-2004 UNICEF-2005 WHO-2006 Present study-
2010
%
Wasting
Figure (4) Patterns of stunting and wasting among preschoolers in GS over years
CONCLUSION AND RECOMMENDATIONS
This study provides information about nutritional status of Gazan's preschool
children, through the assessment of preschooler and their households dietary
consumption pattern, and factors affecting them.
From findings of the present study, it may be concluded that:
Most (94.4%) of the studied households confronted difficulties to food access
during the year preceding the survey, and the main commonly cause was the
blockade and shortage of food products in the markets and they are spending
more than half of their total income on food products. About Half of the studied
households consumed meat and poultry on weekly basis, while about half of
them consumed fish every month.
The result of the present study demonstrated clearly the higher expected
prevalence of malnutrition indices than the earlier studies done in Gaza Strip,
and not surprisingly, stunting to be the highest among the Gazan's children since
several decades, and it is expected that to be the highest since the occupation of
Gaza Strip in 1967.
From the results of this study, the following recommendations are suggested:
1. In general, this critical situation which is unlikely to change until the
root causes related to the political sphere of blockade and food insecurity
are tackled, therefore it demands an immediate response from both
national and international actors.
2. Nutritional intervention programs to establish a strategies are useful
for designing nutritional intervention programs include adoption of the
most successful food fortification methods, and establish rehabilitation
centers for management of malnutrition cases in MOH.
3. Improvement of the existing programs in health system activate the
IMCI program, maximize the utilization of health nutritional data and
information from MOH, UNRWA, and NGOs with unification of the
health information system.
4. Additional proposed researches further researches should be focused on
vulnerable groups, including dietary studies, food security and child
caring capacity in future.
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LIST OF ABBREVIATIONS
Abbreviations Word
AQU Al-Quds University
FAFO Institute for Applied International Studies
FFQ Food frequency questionnaire
GS Gaza Strip
IRIN Integrated Regional Information Networks
JHU Johns Hopkins University
MOH Ministry of Health
oPt occupied Palestinian territory
PCBS Palestinian Central Bureau of Statistics
PNA Palestinian National Authority
UNRWA UNITED NATIONS RELIEF AND WORK AGENCY
USAID United States Agency for International Development
WB West Bank
WBGS West Bank and Gaza Strip
WFP World Food Programme of the United Nations
WHO World Health Organization