Food Security Status of Pregnant Women in Yazd, Iran, 2014-2015
Afsaneh Rajizadeh; MSc¹, Maryam Tavakoli; BSc², Mahmoud Hajipour; PhD³, Maryam Rabiey-Faradonbeh; BSc¹, Amin Salehi-Abargouei; PhD^4,5, Ali Milani Bonab; PhD^5,6 & Azadeh Nadjarzadeh; PhD^*4,5
1 Student Research Committee, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
² Ageing Health Department, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
³ Epidemiology Department, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
⁴ Nutrition and Food Security Research Center, Department of Nutrition, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
⁵ Department of Nutrition, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
⁶ Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Bheshti University of Medical Sciences, Tehran, Iran.

 
Introduction

pregnancy is one of the most sensitive periods of life that affects the health of both mother and fetus. A healthy pregnancy is one of the important human rights (WHO, 2016). Due to some physiological changes such as an increase in blood volume, metabolism change, growth of the placenta and fetus, as well as mother's need for energy, protein, and micronutrients increases (Grieger and Clifton, 2014). According to the studies, malnutrition during pregnancy can lead to low-weight baby birth, stillbirth, and even mother's death (Black et al., 2013).
Studies have shown that mother's nutrition status during and even before pregnancy affects fetus health. According to David Barker’s hypothesis in 1986, many chronic diseases such as obesity, insulin resistance, cardiovascular diseases, and even immunological and psychological disorders are rooted in fetal life (Barker, 2004). According to this theory, inappropriate intrauterine environment and exposure to factors such as stress, medicine, infection, and malnutrition can affect the genetic design of the fetus and cause chronic diseases in adolescence (Eriksson, 2016). Therefore, for a successful pregnancy, mother's nutrition is very important (Nnam, 2015).
One of the important factors influencing mother’s nutrition is food security. Food security means people have access to adequate and healthy food at all times. It also entails making sure that people are able to access the food they need through socially acceptable ways (FAO, 1996). In fact, food security is one of the important indicators of the countries’ development (Ivers and Cullen, 2011, WHO, 2016). According to the official statistics of the international organizations, the highest prevalence of food insecurity in the world is related to the countries of South Asia (WHO, 2016). Meanwhile, despite the significant improvements in Iran's food security in recent decades, we are still far from the desirable status. Based on a Meta-analysis, the prevalence of food insecurity in Iranian households is 49%; this rate is 61% among women (Behzadifar et al., 2016). Food security has always been one of the most important international goals. Eradication of the poverty and reduction of the hunger are among the important global components of the Millennium Development Goals (MDGs) (WHO, 2013). Regarding that international food security status has not been improved considerably yet, in the new Sustainable Development Goals (SDGs) by 2030, Objectives 1, 2, 3, 6, and 12 are aimed at achieving food security (WHO, 2014)
Food security can affect mother’s health through different mechanisms. According to the studies, food insecurity is more common in people who are in inappropriate  socioeconomic status, which makes them eat cheap foods with often high calories (Laraia et al., 2010). On the other hand, poverty can affect the individuals' level of access to meat, dairy, and fruit. In addition, food insecurity is a stressful condition that can be involved in creating stress and depression for people (Laraia et al., 2010). Studies on pregnant women have shown that food insecurity causes pregnancy complications such as gestational diabetes, hypertension, and some chronic diseases (Laraia et al., 2015). Women who were in food insecure range had 1.6% higher risk of anemia in comparison with similar women, who were in food secure range  (Ghose et al., 2016)
 Food security is not a one-dimensional indicator; it measures the level of people’s access to food considering their economic and social status in a period of time. Food security can be a good indicator for assessing the pregnant women’s access to adequate food during their pregnancy (WHO, 2016). According to this issue that the study of food security status in pregnant women has only been carried out in Tehran, no complete picture of this indicator is available in different regions of the country with different levels of development (Hojaji et al., 2015). Therefore, this study was designed to provide evidence of food security in pregnant women in Yazd city, Iran. The results of this study can be used to develop and implement evidence-based interventions and policies in this area of the country.
Materials and Methods
Study design and participants: This cross-sectional study was conducted from June 2013 to April 2014. Pregnant women (n = 351) who refereed to Yazd health centers were selected using cluster sampling method to take part in the study. Twenty health centers were randomly selected and 20 pregnant women who met the inclusion criteria were selected from each center. Pregnant women aged 20-40 years old living in Yazd (stay in Yazd for at least 5 years) with gestational age of 24-28 weeks (6-7 months) and met the inclusion criteria entered the study. Since in some centers the number of eligible individuals was not enough, samples were selected from other health centers in the same region, and eventually 23 health centers were investigated in the sampling.
After the approval of this study in the research committee of public health school of the Shahid Sadoughi University of Medical Sciences in Yazd, the necessary requirements for sampling in health centers were obtained. Then, by referring to the health centers, women who had the inclusion criteria were selected. The pregnant women's participation was completely voluntarily and they were given detailed explanations about the study purpose. They were also asked to sign written informed consent forms. Samples were interviewed by trained experts according to food security questionnaire as well as socio-economic questionnaire. In addition, the weight and height of the participants were measured by a trained expert. Pre-pregnancy weight was also extracted from records at the health centers.
Measurements: Anthropometric measurements were performed according to standard guidelines. The participants' height was measured using a height-measuring device with a precision of 0.5cm and their weight was measured in light clothes and without shoes by the Seca scale with an accuracy of 100 g.
The standardized questionnaire of Household Food Insecurity Access Scale (HFIAS) was used to assess the food security. Validity and reliability of this questionnaire was confirmed for Iranian society in a previous study (Mohammadi et al., 2012). The questionnaire consists of eight items, which indicate the severity, occurrence, and frequency of the food insecurity in the past month. Based on the responses and ideas obtained from the questionnaire, samples were divided into 4 groups: food security (0-1 points), food insecurity without hunger (2-7 points), food insecurity with moderate hunger, and food insecurity with sever hunger (8-14 points). In the present study, due to the low number of people in some groups, food insecurity without hunger and food insecurity with moderate hunger were merged to make the marginal food insecure group. Food insecurity with moderate and severe hungers were also joined together and made the food insecure group. Subsequently, participants were divided into three groups of marginal (mild) food insecurity, severe food insecurity, and food security.
A standardized questionnaire, previously used in the comprehensive study of household consumption pattern and nutritional status of the country, was utilized in order to conduct a more precise assessment about the socio-economic status (Hojaji et al., 2015). The questions indirectly assessed the economic and social status of individuals. The questions included: employment status, household size, number of rooms, insurance coverage, receiving donations from charities, living costs/expenditures, home area per capita, loan cost and possession of living facilities such as gas, refrigerator, car, mobile phone, vacuum cleaner, LCD TV , radio, internet, computer, dishwasher, washing machine, and freezer (Mohammadi et al., 2012).
Data analysis: To analyze the data, SPSS 22 was used. The Kolmogorov-Smirnov test was also run to assess the data distribution. Central index, dispersion, number, and percentage were used for comparison of frequency distributions of qualitative variables. Logistic regression was further applied to analyze the data. In the logistic model, significance level was set at 0.3 to select the important variables that entered into the multivariate logistic regression model. Furthermore, the variables considered as significant by the significance level of 0.05 were investigated using backward method.
To analyze the socioeconomic status index/indicator (SES), based on the variables in the questionnaire, the "component analysis" or "focus index" analysis was used. According to this index, people were categorized into three groups with low, moderate, and high status. Finally, ethnic and socio-economic variables were found to be significant for the severe insecurity model. For the mild insecurity model, the socioeconomic level remained in the model and the achieved odds ratios were compared at three levels.
Ethical considerations: This study was conducted under Helsinki II ethical principles after approval by the Shahid Sadoughi University of Medical Sciences.
Results
The mean age of the participants was 27.84 ± 5.46 years and their mean score of food security was 4.40 ± 3.45. According to the grouping of the total score of HFIAS questionnaire, 160 people (45.6%) were in the food security, 137 (39%) in the marginal food insecurity, 45 (12.8%) in the moderate food insecurity, and 9 (2. 6%) were in the severe food insecurity range. As it can be seen in Table 1, the frequency rates of the moderate and severe food insecurity groups were merged to make the severe food insecurity with frequency of 54 individuals (15.4%(. Frequency distribution of participants based on different demographic variables in different food security levels is shown in Table 1
The results of single-variable regression between the desired variables with mild and severe food insecurity levels are separately shown in Table 2. According to the results, a significant relationship was observed between the socioeconomic status and severe and mild food insecurity (P ≥ 0.001 (as well as ethnicity and sever food insecurity (P ≥ 0.006). The



relationship between food insecurity and ethnicity revealed that the probability of food insecurity among non-Persian groups was 2.4 times more than the probability of food insecurity in Persian groups [CI: 1.64 - 20.83]. Probability of mild food insecurity in people with low socioeconomic status was 2.4 times higher than others [CI: 4.61 - 43.15]. In addition, probability of the food insecurity in people with moderate socioeconomic level was 1.6 times higher than those at high level [CI: 0.94 - 2.91].
For controlling the confounding variables by backward method, the multivariate logistic regression was conducted for the variables with the significance level of less than 0.3 and only the food security group remained in the model. The odds of severe and moderate food insecurity in the age group above 35 years was 47% higher than that of the age groups of below 35 years (P = 0.40). However, this odds ratio was not statistically significant.
The logistic regression analysis was used to compare the under-weight and the obese individuals with the normal-weight individuals in terms of food security status. This dependent variable was derived from a three-component variable (skinny, natural, and obese). The results of this analysis are represented in Table 2. Food insecurity rate in the low and moderate SES was 13 and 8 times higher than those with high SES, respectively. As it can be seen, Table 3 also shows the relationship between food security status with ethnicity and the economic situation.