Pishva Arzhang1
S. Haniye Abbasi2Peyman Sarsangi2Mahsa Malekahmadi3Mahlagha Nikbaf-Shandiz4Nick Bellissimo5
Leila Azadbakht2,6*†- 1Qods Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
- 2Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
- 3Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- 4Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- 5School of Nutrition, Toronto Metropolitan University, Toronto, ON, Canada
- 6Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
Background: Food security is a fundamental human right that must be upheld to preserve excellent general welfare, and mental, physical, and social health. However, according to the United Nations Food and Agriculture Organization (FAO) report in 2020, the level of food insecurity in the world is increasing.
Objective: Determining the prevalence of food insecurity in Iran will be beneficial for Iran and other low-middle-income countries.
Methods: We searched both English and Persian (Iranian) databases including PubMed, Scopus, Web of Science, Google Scholar, SID, Irandoc, Magiran, Civilica, and Iranian Medical Sciences Theses System from 01 January 1990 to 01 February 2022. Observational studies that reported the prevalence of household food insecurity among a healthy Iranian population and assessed food insecurity at the individual or household level using validated questionnaires were included.
Results: One hundred six studies and/or theses with a total of 152, 300 participants met the review criteria. Our analyses demonstrated that the prevalence of food insecurity among the healthy Iranian population was 55.9% (95% CI: 52.6–59.2%) and the highest prevalence of food insecurity was in the western regions with 64.8% (95% CI: 57.7–72.0%). Subgroup analyses showed that food insecurity among women at 51.3% (95% CI: 45.1–57.6%) and rural inhabitants at 66.1% (95% CI: 58.8–73.4%) was significantly higher than men at 47.8% (95% CI: 41.8–53.8%) and urban residents at 47.1% (95% CI: 44.1–50.0%), respectively. Among the age groups, the highest prevalence of food insecurity was in adults at 56.5% (95% CI: 51.7–61.2%).
Conclusion: The prevalence of food insecurity in a healthy Iranian population was higher than the global average. Women, rural residents, and residents of the western regions of Iran had a higher prevalence of food insecurity. These groups should be prioritized in programs to reduce the prevalence of food insecurity in Iran.
Systematic review registration: www.crd.york.ac.uk/PROSPERO, identifier: CRD42022328473.
Introduction
Household food security has been defined as all members having adequate access to safe food through socially acceptable means for active and healthy life (1). Limited or uncertain sources of adequate and safe nutritional foods or the limited or uncertain ability to acquire food lead to food insecurity (FI). FI is a public health challenge around the world and millions of households are struggling to maintain or achieve food security, which includes availability, access, utilization, and ability (2, 3). It is not considered a static state and is on a spectrum (3). According to the United Nations in 2021, there is a higher prevalence of FI since the beginning of the COVID-19 pandemic compared to before the pandemic (4). The prevalence of household FI in north Iran has been estimated to be ~50.8% in total with 43.2% mild FI, 6.5% moderate FI, and 1.1% severe FI (5), which may have increased in recent years due to the COVID-19 pandemic and other economic and social issues.
Various methods are used to evaluate FI, two of which are used the most: (1) estimation of food consumption and (2) estimation of the cost of food preparation (6). These methods have limitations due to the cost, participant burden, and the need for an expert interviewer. Recently, “experiential” or “perception-based” methods have been used to measure FI (7). Under these methods, individual experience of FI (i.e., access) is measured through a survey and summarized in a scale. The Household Food Security Survey Module (HFSSM) has been consistently validated as a reliable and significant perception-based measure of FI in the United States (8). In Iran, FI is mainly investigated by measuring the adequacy of energy and nutrients using food questionnaires or by estimating the poverty line from income and expenditure surveys (6). FI is a threat to the health and survival of individuals within communities and can have both short- and long-term effects (9). Several factors influence the prevalence of FI including population growth, industrialization of communities, growing migration from rural to urban areas, inadequate levels of education, wars and economic sanctions by governments, pandemics or endemic diseases, and weather changes (10–12). In addition, FI can include a wide range of health-related conditions from undernutrition to overnutrition. Undernutrition includes wasting, underweight, stunting, anemia, and other diseases associated with nutritional deficiencies. Overnutrition can lead to chronic conditions such as obesity, diabetes, fatty liver, hypertension, poor mental health, and metabolic syndrome (13–17). As a result, a large burden is faced by the economy and society (5).
Several studies have been conducted to investigate the prevalence, causes, and types of FI around the world and in Iran. According to a meta-analysis from West Africa, the prevalence of FI in the rural population was ~60.91% and the highest prevalence was among large families, female-headed households, and low-income households with low education levels (10). Several systematic reviews and meta-analyses have been conducted in Iran (6, 11, 12). In a meta-analysis from 2017, the prevalence of FI was 49.2% based on studies that evaluated FI using questionnaires (12). Since the publication of the previous meta-analysis, many studies have been published evaluating the status of FI in Iran. Considering this, a new meta-analysis is warranted to provide updated results and summarize recent findings. Therefore, the objective of this systematic review and meta-analysis is to update the findings and conduct a more comprehensive review of the prevalence of FI with the consideration of multiple subgroups and other factors.
Method
This systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analysis statement (PRISMA) guideline (18). The protocol of the present study was registered on the PROSPERO website (www.crd.york.ac.uk/PROSPERO) (PROSPERO registration number = CRD42022328473).
Search strategy and information sources
International scientific databases including Web of Science, PubMed, Scopus, Google Scholar, and Iranian databases (HYPERLINKs: “https://www.sid.ir/fa/journal/,” “https://ganj.irandoc.ac.ir/,” “https://www.magiran.com/paperadvancedsearch,” “http://thesis.research.ac.ir/faces/home.jspx,” and “https://civilica.com/”) were searched from 01 January 1990 to 01 February 2022 to identify relevant studies. The detailed search strategy is shown in Supplementary Table 1.
Inclusion and exclusion criteria
Inclusion criteria were (a) observational studies (cross-sectional and cohort studies), (b) studies published between 1990 and 2022, (c) studies with a healthy Iranian population, (d) studies that reported the prevalence and/or at least one associated factor with household FI, and (e) studies that assessed FI at the individual or household level using validated questionnaires. Gray literature from credible sources was included. Exclusion criteria were intervention studies, abstract studies, studies performed on pregnant women, and populations with evidence of specific diseases.
Quality assessment
The Joanna Briggs Institute (JBI) quality assessment checklist was used to perform the quality assessment of the published articles (19). Two independent researchers (HA and PS) conducted a quality assessment for each of the included studies. Studies that received scores of ≥5 were categorized as low risk or good quality and studies with scores of ≤4 were categorized as high risk or poor quality.
Study selection and data extraction
Two independent reviewers (HA and PS) screened the studies based on the eligibility criteria. The abstracts and titles of the studies were reviewed, and the included full-text studies were evaluated. Any disagreements were addressed by a third reviewer's decision.
The following data were extracted from the included studies: the name of the first author, publication year, study design, province, geographical zone, urban/rural, gender, sample size, and prevalence of household food insecurity and relevant FI factors.
Data synthesis and statistical analysis
Pooled estimates for the magnitude of household food insecurity were calculated using a random effects model and metaprop module in Stata 14.2. The reason for using a random effects model was to attempt to account for the methodological differences within the included articles. A binomial distribution formula was used to estimate standard errors for each sample (20). The Egger's test and Trim and Fill test were used to evaluate publication bias. A funnel plot of symmetry visualized publication bias graphically. Evidence of statistically significant publication bias was considered a p-value < 0.05. Sensitivity analyses were performed by removing the studies that showed evidence of potential publication bias (21). The heterogeneity between studies was assessed using the I2 test (22). Subgroup analyses were conducted based on geographic region, age groups, type of questionnaire, quality of studies, location, and gender. Using meta-regression analysis, we examined the presence of any linear relationship between observed effect size and time. Evidence of a significant difference within the subgroups by the test of group difference was considered P < 0.05.
Results
A total of 6,164 articles and theses were retrieved from the initial database search. After the removal of duplicates, 3,468 studies remained to be screened. Title and abstracts were screened yielding 195 studies for full-text review. One hundred six studies (96 cross-sectional articles and 10 theses) published between 2010 and 2021 including a total of 152,300 participants were included after a full-text review and for data extraction. Study selection is presented in the PRISMA flowchart (Figure 1).
Figure 1. PRISMA flow diagram for study selection from: Page et al. (23). For more information, visit: http://www.prisma-statement.org/.
The characteristics of the included studies are shown in Table 1. Since some of the studies reported FI in different locations or genders, we considered them as separate studies. Of the included studies, 51 examined FI in urban areas, 41 in rural areas, and 14 in both areas. Included studies also investigated FI among men and women (n = 70), men (n= 20), and women (n= 35). In addition, studies were conducted on different age groups, including children (n = 14), adolescents (n = 6), adults (n = 45), and older adults (n = 9). Studies were conducted in several different locations including the central (n = 36), western (n = 34), southern (n = 16), northern (n = 7), and eastern (n = 11) parts of the country. Different questionnaires were used to assess FI including the United States Department of Agriculture 18-item Household Food Security Survey Module (USDA 18-item questionnaire) (n = 48), Household Food Insecurity Access Scale (HFIAS) (n = 32), US Department of Agriculture 6-item Household Food Security Survey Module (USDA 6-item) (n = 12), Radimer-Cornell (n = 6), Farsi Current Population Survey-Food Security Survey Module (FaCPS-FSSM) (n = 3), and the Coping Strategies Index (n = 3).
Table 1. Characteristics of the included studies in the systematic review and meta-analysis.
According to the meta-analysis, the total prevalence of FI in Iran was 55.9% (95% CI: 52.6–59.2%) (Figure 2). To determine heterogeneity, meta-regression and subgroup analyses were conducted.
Figure 2. Forest plot for the prevalence of food insecurity in Iran.
Subgroups and meta-regression analyses
The prevalence of FI in rural areas was 66.1% (95% CI: 58.8–73.4%) which was higher than the prevalence of FI in urban areas [47.1% (95% CI: 44.1–50.0%)] (Supplementary Figure 1). The prevalence of FI among women was higher [51.3% (95% CI: 45.1–57.6%) than the prevalence among men (47.8% (95% CI: 41.8–53.8%)] (Supplementary Figure 2). Pooled prevalence of FI was 44.7% (95% CI: 35.5–53.9%) in children, 40.6% (95% CI: 33.2–48.0%) in adolescents, 56.5% (95% CI: 51.7–61.2%) in adults, and 49.8 % (95% CI: 36.6–63.0%) in older adults.
Subgroup analyses by region revealed that the highest prevalence of FI was in the western part of the country [64.8% (95% CI: 57.7–72.0%)] and the lowest prevalence of FI was in the central part of the country [46.1% (95% CI: 43.1–49.2%)]. The prevalence of FI was also assessed according to questionnaires used in the studies. The prevalence of FI in studies that used USDA 18-item was 54.8% (95% CI: 49.0–60.6%), the HFIAS was 58.4% (95% CI: 49.8–67.1%), and the USDA 6-item was 48.2% (95% CI: 44.3–52.0 %). The highest prevalence of FI was 77.8 % (95% CI: 69.1–93.8%) in studies that used the Coping Strategies Index. Moreover, the prevalence was 53.4% (95% CI: 43.0–63.7%) in studies that used FaCPS-FSSM and 63.2% (95% CI: 38.2–88.1%) in studies that used Radimer-Cornell (Table 2). Meta-regression analyses using random effects models were conducted to analyze the change in the prevalence of FI over time; however, results indicated that there were no significant changes in FI over time (Figure 3).
Table 2. Food insecurity prevalence data by location, sex, region, age group, quality of studies, and assessment tool.
Figure 3. Association of the prevalence of food insecurity in households with years of data collection.
Quality assessment
The Joanna Briggs Institute (JBI) quality assessment checklist was used to assess the quality of the published articles (19). According to the checklist, 70 studies were categorized as high quality and 36 studies were categorized as low quality (Supplementary Table 2). Subgroup analysis revealed no evidence of a statistical difference between the two groups.
Publication bias
Despite searching several databases, searching gray literature, and not having language limitations, the results of the funnel plot (Figure 4) and Egger's test (P < 0.000) revealed evidence of publication bias. The trim and fill method using random effects was used to adjust the pooled prevalence estimates for publication bias. After imputing 36 studies below the mean, the result indicated an adjusted prevalence of 74.6% (95% CI: 67.3–82.7%) among participants (Figure 5). Furthermore, there was a significant heterogeneity between subgroups based on the region (P-value < 0.000), gender (P-value = 0.017), type of FI questionnaire (P-value = 0.004), and location (P-value < 0.000).
Figure 4. Funnel plot of included studies.
Figure 5. Funnel plot for publication bias with trim and fill method.
Sensitivity analysis
Sensitivity analysis suggested that there were no changes in the mean prevalence after the removal of individual studies (Supplementary Figure 3).
Discussion
The present systematic review and meta-analysis evaluated the prevalence of FI in Iran examining 106 articles and theses among 152,300 participants from 2010 to 2021 with the consideration of gender, geographical areas, age groups, location, and type of questionnaires. According to the United Nations International Children's Emergency Fund (UNICEF), about 375.8 million people in Asian countries including Iran and the Pacific faced hunger in 2020, which increased by nearly 54 million people compared to 2019. Moreover, more than 1.1 billion people did not have access to adequate food in 2020 (129). Based on the present meta-analysis, the total prevalence of FI in Iran was 55.9% (95% CI: 52.6–59.2%), which is considered high. A previous meta-analysis evaluating FI in Iran also revealed a high prevalence of FI among different age categories (6, 11, 12). Differences in inclusion and exclusion criteria could be considered a potential reason for the contrasting findings. Additionally, this present study evaluated a greater amount of studies over several databases using a comprehensive search strategy.
In this study, subgroup analyses were performed based on identified factors to evaluate FI prevalence comprehensively. Subgroup analyses revealed that FI prevalence was significantly higher in Iranian women compared to men (51.3 vs. 47.8%, p < 0.000). In line with our findings, Diab-El-Harake et al. found a higher prevalence of FI in women living in Arab countries (130). In addition, a meta-analysis conducted by Jung et al. found that female-headed households were 75% (95 % CI: 49–96%) more likely to experience FI compared to male-headed households (131). Another meta-analysis in Ethiopia also found a higher FI prevalence in female-headed households (132). Furthermore, based on the 2019 State of FI report, the prevalence of FI was higher among women compared to men in every continent from 2016 to 2019 (133). Broussard (134) suggested that a higher prevalence of FI may be explained by differences in household income, social networks, and educational attainment. Furthermore, that gender differences in income accounted for more than 70% of the gender gap in FI, and lower educational attainment accounted for 5–45% of the gap. In addition, women may express more positive emotions when they are not necessarily experiencing favorable conditions, suggesting that cultural factors may influence the status of FI in women (135).
According to Sinclair et al., rural women had a higher prevalence of FI, which is in accordance with our subgroup analyses based on the region that indicated that the prevalence of FI was higher in rural areas [66.1% (95% CI: 58.8–73.4%)] compared to urban areas [47.1% (95% CI: 58.8–73.4%)] (136). Another study conducted by Sims et al. found that there was FI and malnutrition among Indian rural women (137). In addition, Sansón-Rosas et al. found high rates of FI in Colombian rural households (138). It is accepted that poverty is significantly linked to FI (139) and it is often considered the most common determinant of FI across the globe (139). Economic constraints may explain a higher prevalence of FI in rural areas (140). Many people who are from low-income households and are vulnerable to FI reside in rural areas and depend on agricultural activities to produce food; and in case of limited access to agricultural facilities and lands, they will face inadequate food availability (141).
In the present study, the highest prevalence of FI was among adults (56.5% [95% CI: 51.7–61.2%]) compared to different age groups. Sinclair et al. also found a higher prevalence of FI among people between the ages of 25–49 across the globe (136). A possible explanation for these findings may be that adults are often the head of the household and in the case of inadequate access to food, they may prioritize other members of the household. It also should be considered that fewer studies have been conducted among adolescents and older adults compared to those conducted on the adult population in Iran.
Another factor in the present study that made a significant difference in the prevalence of FI was the location of the participants' habitation as it was found that FI was higher in the western part of the country (64.8% [95% CI: 57.7–72.0%]) compared to the eastern (59.9% [95% CI: 49.9–69.8%]) and southern (59.2% [95% CI: 50.4–68.0%]) parts of the country. Mortazavi et al. conducted a cross-sectional study evaluating FI in the southern parts of Iran and in accordance with results from the present study, found a high prevalence of FI (58.8 %) (142). The current study found that the prevalence of FI in the northern parts of Iran was 56.8% (95% CI: 36.2–77.4%). A cross-sectional study conducted by Shakiba et al. also found a high prevalence of FI (50.8%) in northern Iran (84). Studies have shown that there are many risk factors for FI, including demographic characteristics and financial resources including age, economic status, employment, savings, educational level of the head of the household, single parenthood, and ethnicity (84, 142, 143). The impact of these risk factors on food security varies across populations, which reveals the potential influence of regional practices, policies, and nutrition programs (144, 145). However, to our knowledge, no study to date has examined the impact of regional influences in Iran. Future research is needed to validate the types of conclusions that can be drawn from this study.
Subgroup analyses were also conducted based on the type of questionnaire used to evaluate FI. Despite the fact that the questionnaires used in all of the studies were validated, there was evidence of a statistically significant difference between subgroups (p-value for heterogeneity: 0.003). However, the results for the prevalence of FI from the USDA 18-item (54.8% [95% CI: 49.0–60.6%]) and HFIAS (58.4% [95% CI: 49.8–67.1%]) were relatively similar, which were the questionnaires used in most of the studies. Other questionnaires were only used in a small number of included studies, which may explain the significant differences that were found in this study in the subgroup analysis for the type of questionnaire. Finally, the subgroup analysis for the results of the quality assessment did not reveal any evidence of a significant difference between high-quality and low-quality studies.
Strengths and limitation
To the best of our knowledge, the current meta-analysis included the highest number of studies to evaluate the prevalence of FI in Iran. The previous meta-analysis conducted by Behzadifar et al. (129) included 31 studies until 2015; therefore, the prevalence estimates reported in the present study represent the current findings. In addition, we performed subgroup analyses based on previously identified factors that may influence FI and found significant associations between the named factors and the prevalence of FI, which provided a strong comprehensive review of the relationships. However, this study had limitations worth considering when evaluating the findings. There was evidence of high heterogeneity between included studies. Furthermore, we did not assess the different levels of FI that may exist among the participants. Future studies and reviews may consider evaluating varying levels of FI as it may provide more information about FI status.
Conclusion
The findings of this systematic review and meta-analysis revealed that the prevalence of FI is high in Iran. The prevalence was higher among women, adults (aged), in rural areas and the western part of the country. It is an important finding that the prevalence of FI in Iran is influenced by age, gender, socioeconomic status, and habitation.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
LA and PA contributed to the study design, registered the study protocol, manuscript revision, and final version approval. NB edited the manuscript. SA, PS, MM, and MN-S contributed to the literature searches, title/abstract and full-text screening, extracted data, quality assessment, and manuscript drafting. PA contributed to the statistical analysis, ran the meta-analyses, and did data charting. All authors contributed to the article and approved the submitted version.
Funding
This study was supported by the Tehran University of Medical Sciences (Grant Number: IR.TUMS.MEDICINE.REC.1400.1423).
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnut.2022.1006543/full#supplementary-material
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Keywords: food insecurity, food security, Iran, prevalence, food supply
Citation: Arzhang P, Abbasi SH, Sarsangi P, Malekahmadi M, Nikbaf-Shandiz M, Bellissimo N and Azadbakht L (2022) Prevalence of household food insecurity among a healthy Iranian population: A systematic review and meta-analysis. Front. Nutr. 9:1006543. doi: 10.3389/fnut.2022.1006543
Received: 07 August 2022; Accepted: 05 October 2022;
Published: 15 November 2022.
Edited by:
Harsharn Gill, RMIT University, AustraliaReviewed by:
Huaqing Liu, Bengbu Medical College, ChinaHaiquan Xu, Institute of Food and Nutrition Development (CAAS), China
Copyright © 2022 Arzhang, Abbasi, Sarsangi, Malekahmadi, Nikbaf-Shandiz, Bellissimo and Azadbakht. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Leila Azadbakht, Azadbakhtleila@gmail.com
†ORCID: Leila Azadbakht orcid.org/0000-0002-5955-6818