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