The flow diagram of the study enrolment is presented in Fig. 1. A total of 316 females accepted to participate in the study but 126 were excluded after checking inclusion/exclusion criteria and thus 190 females aged 20–55 years were included. They had an average age of 35.2 ± 8.2 years, were mostly married (83.2%), housewife (72.6%), and educated lower than university levels (72.1%). According to the classification described in the Methods, 81 females (42.6%) were food secure, 77 (40.5%) were mild food insecure, 30 (15.8%) were moderately food insecure, and 2 (1.1%) were severely food insecure. Due to low number of individuals in the severely food insecure level, participants in moderate and severe food insecure levels were combined in the moderate/severe food insecure level.
Characteristics of the households in different food insecurity levels are presented in Table 1. There were significant differences between food insecurity levels in family head education, income, and family food expense (P < 0.001). Participants in different food insecurity levels did not differ in age and marital status but the educational level was significantly higher in women of food secure families (P < 0.001).
Table 1
Household characteristics based on food security levels1,2
| Secure (n = 81) | Mild insecure (n = 77) | Moderate/severe insecure (n = 32) | P3 |
Household size, n (%) 1–2 3–4 > 4 | 17 (21.0) 54 (66.7) 10 (12.3) | 14 (18.2) 52 (67.5) 11 (14.3) | 5 (15.6) 18 (56.3) 9 (28.1) | 0.330 |
Family head education, n (%) School College | 46 (56.8) 35 (43.2) | 63 (81.8) 14 (18.2) | 32 (100) 0 | < 0.001 |
Family income, rials/month | 15281 ± 7048 | 9870 ± 4915 | 6875 ± 3045 | < 0.001 |
Family income per capita, rials/month | 5540 ± 4710 | 3064 ± 1762 | 1884 ± 900 | < 0.001 |
Family food expense, rials/month | 3574 ± 1419 | 2695 ± 1474 | 2117 ± 1363 | < 0.001 |
Food expense per capita, rials/month | 1266 ± 811 | 818 ± 492 | 578 ± 365 | < 0.001 |
Participant’s age | 34.9 ± 8.5 | 35.6 ± 8.5 | 35.2 ± 6.7 | 0.845 |
Marital status Single Married | 12 (14.8) 69 (85.2) | 11 (14.3) 66 (85.7) | 9 (28.1) 23 (71.9) | 0.173 |
Participant’s education School College | 38 (46.9) 43 (53.1) | 68 (88.3) 9 (11.7) | 32 (100) 0 | < 0.001 |
1 Scores of food security levels are as follows: food secure (0–1), mild food-insecure (2–8), moderate/severe food-insecure (9–27). 2 Data are expressed as n (%) or means ± SD. 3 P value was determined by one-way analysis of variance for quantitative parameters and by chi-square for categorical variables. |
Distribution of cardiometabolic risk factors in different food insecurity levels is shown in Table 2. Weight, BMI, waist circumference, systolic and diastolic blood pressure, serum fasting glucose, triglycerides, total cholesterol, and LDL cholesterol increased while HDL cholesterol decreased across food insecurity levels (P < 0.001 to 0.009).
Table 2
Cardiometabolic risk factors and iron status markers in different food security levels1,2
| Secure (n = 81) | Mild insecure (n = 77) | Moderate/severe insecure (n = 32) | P3 |
Height (cm) | 160.9 ± 6.3 | 159.4 ± 5.3 | 158.5 ± 4.9 | 0.077 |
Weight (kg) | 65.3 ± 10.4 | 71.1 ± 12.1 | 83.1 ± 13.4 | < 0.001 |
Body mass index (kg/m2) | 25.2 ± 3.9 | 28.1 ± 5.1 | 33.1 ± 5.4 | < 0.001 |
Waist circumference (cm) | 85.0 ± 10.4 | 87.5 ± 11.9 | 97.5 ± 12.0 | < 0.001 |
Waist/hip ratio | 0.86 ± 0.06 | 0.87 ± 0.06 | 0.90 ± 0.06 | 0.009 |
Systolic blood pressure (mmHg) | 111.9 ± 11.6 | 116.4 ± 13.0 | 125.9 ± 14.0 | < 0.001 |
Diastolic blood pressure (mmHg) | 84.0 ± 9.5 | 88.5 ± 10.1 | 93.7 ± 11.3 | < 0.001 |
Fasting blood glucose (mg/dL) | 82.5 ± 12.0 | 87.7 ± 13.8 | 95.6 ± 21.8 | 0.001 |
Triglycerides (mg/dL) | 133.2 ± 53.2 | 137.9 ± 48.9 | 179.3 ± 48.9 | < 0.001 |
Total cholesterol (mg/dL) | 174.3 ± 28.5 | 184.8 ± 39.6 | 230.6 ± 43.5 | < 0.001 |
LDL cholesterol (mg/dL) | 113.2 ± 22.8 | 120.4 ± 35.7 | 160.6 ± 37.9 | < 0.001 |
HDL cholesterol (mg/dL) | 47.2 ± 7.6 | 44.5 ± 8.1 | 39.2 ± 7.0 | < 0.001 |
Metabolic syndrome score | 1.85 ± 0.83 | 2.41 ± 1.20 | 3.48 ± 0.95 | < 0.001 |
1 Scores of food security are as follows: food secure (0–1), mild food-insecure (2–8), moderate/severe food-insecure (9–27). 2 Data are presented as means ± SD. 3 P values were determined by one-way analysis of variance. |
Three major dietary patterns were detected in our study participants (Table 3). The first pattern contained mainly fruits, red meat, nuts, legumes, and non-starchy vegetables and little amounts of processed meats. We called it healthy pattern 1. The second pattern composed mainly from fish, chicken, low-fat dairy, and non-starchy vegetables but was low in processed meats, grains, and sugary foods. This was called healthy pattern 2. The third pattern contained potato, high-fat dairy, sugar-containing products, egg, processed meats, and grains. This pattern was called unhealthy pattern. Processed meats were especially low in healthy dietary patterns and grains were low in the healthy dietary pattern 2.
Table 3
Food groups and their factor loadings in the three extracted dietary patterns.
Food groups | Healthy dietary pattern 1 | Healthy dietary pattern 2 | Unhealthy pattern |
Fruits | 0.833 | 0.112 | -0.223 |
Red meat | 0.704 | | 0.286 |
Nuts | 0.612 | | |
Legumes | 0.537 | | -0.130 |
Processed meats | -0.464 | -0.358 | 0.436 |
Fish | | 0.821 | |
Chicken | -0.156 | 0.760 | 0.142 |
Low-fat dairy | | 0.588 | -0.158 |
Non-starchy vegetables | 0.405 | 0.497 | |
Grains | | -0.447 | 0.433 |
Potato | -0.128 | -0.114 | 0.571 |
High-fat dairy | 0.108 | 0.113 | 0.557 |
Sugary products | | -0.266 | 0.533 |
Egg | -0.152 | | 0.446 |
The association of cardiometabolic risk factors with tertiles of the dietary patterns is shown in Table 4. Weight, BMI, waist circumference, systolic and diastolic blood pressure, total cholesterol and LDL cholesterol had inverse association with healthy pattern 1. Similarly, these risk factors as well as fasting glucose had inverse relationship with healthy pattern 2. HDL cholesterol was only associated with the first dietary pattern. Among these risk factors, only weight, BMI, systolic and diastolic blood pressure, and HDL cholesterol had association with unhealthy pattern. Except HDL, other risk factors had positive association with this pattern. Triglycerides had no association with dietary patterns.
Table 4
Cardiometabolic risk factors across tertiles of the three major dietary patterns1,2
| Healthy Pattern 1 | | Healthy Pattern 2 | | Unhealthy Pattern | |
| Tertile 1 | Tertile 2 | Tertile 3 | P3 | Tertile 1 | Tertile 2 | Tertile 3 | P | Tertile 1 | Tertile 2 | Tertile 3 | P |
Food insecurity score | 7.0 ± 5.1 | 3.1 ± 3.8 | 1.8 ± 2.7 | < 0.001 | 6.0 ± 4.8 | 4.5 ± 4.5 | 1.3 ± 2.7 | < 0.001 | 3.4 ± 4.3 | 3.0 ± 3.7 | 5.4 ± 5.2 | 0.007 |
Weight (kg) | 76.5 ± 14.3 | 67.0 ± 12.3 | 68.5 ± 10.8 | < 0.001 | 74.8 ± 14.6 | 71.9 ± 13.0 | 65.3 ± 9.7 | < 0.001 | 67.8 ± 10.2 | 68.4 ± 11.8 | 75.7 ± 15.5 | 0.001 |
BMI (kg/m2) | 30.4 ± 5.9 | 26.1 ± 5.0 | 26.6 ± 4.3 | < 0.001 | 29.6 ± 5.9 | 28.0 ± 5.6 | 25.5 ± 3.9 | < 0.001 | 26.5 ± 4.1 | 26.6 ± 5.0 | 30.0 ± 6.3 | < 0.001 |
WC (cm) | 89.4 ± 13.1 | 85.0 ± 11.8 | 90.0 ± 10.7 | 0.038 | 92.2 ± 12.6 | 87.9 ± 12.1 | 84.3 ± 10.3 | 0.001 | 88.0 ± 10.1 | 87.2 ± 12.1 | 89.2 ± 13.8 | 0.652 |
SBP (mmHg) | 121.8 ± 13.4 | 115.7 ± 12.3 | 111.1 ± 12.6 | < 0.001 | 119.5 ± 13.9 | 115.8 ± 13.6 | 113.4 ± 12.4 | 0.042 | 113.0 ± 12.1 | 113.5 ± 12.0 | 122.3 ± 14.4 | < 0.001 |
DBP (mmHg) | 90.6 ± 11.5 | 86.5 ± 10.3 | 85.5 ± 9.3 | 0.017 | 90.0 ± 10.8 | 89.6 ± 10.4 | 83.0 ± 9.3 | < 0.001 | 86.8 ± 9.8 | 84.6 ± 9.0 | 91.3 ± 11.9 | 0.002 |
FBG (mg/dL) | 90.7 ± 16.8 | 87.0 ± 15.5 | 83.9 ± 14.0 | 0.085 | 92.4 ± 17.9 | 86.5 ± 14.3 | 80.9 ± 11.1 | 0.001 | 84.3 ± 16.8 | 87.0 ± 14.2 | 89.7 ± 15.1 | 0.192 |
TG (mg/dL) | 144.1 ± 57.8 | 137.1 ± 54.1 | 149.3 ± 48.5 | 0.479 | 148.9 ± 55.3 | 148.9 ± 56.7 | 131.2 ± 44.9 | 0.160 | 140.9 ± 59.1 | 141.2 ± 46.9 | 148.4 ± 52.8 | 0.716 |
Total-C (mg/dL) | 201.3 ± 49.9 | 181.8 ± 36.9 | 185.3 ± 35.6 | 0.042 | 199.7 ± 45.6 | 191.4 ± 44.7 | 172.6 ± 23.8 | 0.003 | 189.1 ± 46.7 | 181.5 ± 31.8 | 195.0 ± 42.5 | 0.215 |
LDL-C (mg/dL) | 139.4 ± 43.5 | 119.6 ± 34.4 | 117.7 ± 25.8 | 0..003 | 134.9 ± 41.6 | 122.0 ± 37.0 | 115.5 ± 21.4 | 0.016 | 125.4 ± 37.6 | 118.4 ± 30.1 | 130.0 ± 38.0 | 0.265 |
HDL-C (mg/dL) | 40.0 ± 8.0 | 45.4 ± 7.8 | 47.7 ± 7.1 | < 0.001 | 43.9 ± 9.1 | 44.8 ± 8.3 | 45.4 ± 6.9 | 0.620 | 45.9 ± 7.9 | 45.8 ± 8.5 | 42.3 ± 7.9 | 0.033 |
MetS score | 2.78 ± 1.31 | 2.24 ± 1.02 | 2.22 ± 1.13 | 0.028 | 2.77 ± 1.26 | 2.42 ± 1.14 | 1.90 ± 0.90 | 0.001 | 2.30 ± 1.09 | 2.13 ± 1.00 | 2.74 ± 1.32 | 0.026 |
1 Healthy dietary pattern 1 included mainly fruits, red meat, nuts, legumes, and non-starchy vegetables. Healthy dietary pattern 2 included mainly fish, chicken, low-fat dairy, and non-starchy vegetables. Unhealthy dietary pattern included potato, high fat dairy, sugar-containing products, egg, processed meats, and refined grains. 2 Data are means ± SD. 3 P values were obtained by one-way ANOVA. Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; FBG, fasting blood glucose; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; MetS, metabolic syndrome; SBP, systolic blood pressure; TG, triglycerides; WC, waist circumference. |
In regression analysis, all of the examined risk factors had significant association with food insecurity in unadjusted model and after adjustments for age, marital status, and educational level (model 1) (Table 5). Addition of BMI to the covariates did not affect the associations except for blood pressure, particularly diastolic blood pressure which demonstrated a decreased β and increased P value (P = 0.051 for diastolic blood pressure). Both healthy dietary patterns had inverse association with food insecurity in unadjusted model (β = -0.422 and − 0.435, P < 0.001), model 1 (adjustment for age, marital status, and educational level) (β = -0.475 and − 0.341, P < 0.001), and model 2 (addition of BMI among the confounders) (β = -0.473 and − 0.253, P ≤ 0.003). Unhealthy pattern did not show a relationship unless when BMI was added to the confounders (model 2) which demonstrated a trend for an inverse relationship (β = -0.177, P = 0.053) (Table 5).
Table 5
Regression analysis assessing the association between levels of food insecurity and cardiometabolic risk factors as well as major dietary patterns1
| Unadjusted model | | Model 12 | | Model 23 |
| β | P | | β | P | | β | P |
Cardiometabolic risk factors | | | | | | | | |
Weight (kg) | 0.513 | < 0.001 | | 0.480 | < 0.001 | | | |
Body mass index (kg/m2) | 0.555 | < 0.001 | | 0.512 | < 0.001 | | | |
Waist circumference (cm) | 0.384 | < 0.001 | | 0.369 | < 0.001 | | | |
Waist/hip ratio | 0.230 | 0.002 | | 0.245 | 0.003 | | | |
Systolic blood pressure (mmHg) | 0.389 | < 0.001 | | 0.407 | < 0.001 | | 0.223 | 0.010 |
Diastolic blood pressure (mmHg) | 0.379 | < 0.001 | | 0.337 | < 0.001 | | 0.173 | 0.051 |
Fasting blood glucose (mg/dL) | 0.313 | < 0.001 | | 0.300 | 0.001 | | 0.322 | 0.001 |
Triglycerides (mg/dL) | 0.305 | < 0.001 | | 0.271 | 0.003 | | 0.284 | 0.006 |
Total cholesterol (mg/dL) | 0.471 | < 0.001 | | 0.422 | < 0.001 | | 0.325 | < 0.001 |
LDL cholesterol (mg/dL) | 0.444 | < 0.001 | | 0.451 | < 0.001 | | 0.384 | < 0.001 |
HDL cholesterol (mg/dL) | -0.369 | < 0.001 | | -0.450 | < 0.001 | | -0.408 | < 0.001 |
Metabolic syndrome score | 0.537 | < 0.001 | | 0.540 | < 0.001 | | 0.377 | < 0.001 |
Dietary patterns | | | | | | | | |
Healthy dietary pattern 1 | -0.422 | < 0.001 | | -0.475 | < 0.001 | | -0.473 | < 0.001 |
Healthy dietary pattern 2 | -0.435 | < 0.001 | | -0.341 | < 0.001 | | -0.253 | 0.003 |
Unhealthy dietary pattern | 0.054 | 0.462 | | -0.050 | 0.538 | | -0.177 | 0.053 |
1 The associations were examined by linear regression, except for metabolic syndrome, for which ordinal regression was used. 2 Model 1 was adjusted for age, marital status, and educational level. 3 Model 2 was additionally adjusted for BMI. |
Assessment of dietary intakes revealed that consumption of red meat, poultry, fish, dairy, fruits, and non-starchy vegetables decreased whereas processed meats increased as food insecurity increased (P ≤ 0.001) (Table 6). Consumption of potato also showed an increasing trend (P = 0.056). Grains, legumes, eggs, potato, nuts, and sugar-containing products did not show a significant association.
Table 6
Consumption of food groups (g/day) in different food insecurity levels1,2
| Secure (n = 81) | Mild insecure (n = 77) | Moderate/severe insecure (n = 32) | P value3 |
Grains | 391.7 ± 175.5 | 426.6 ± 128.4 | 433.0 ± 134.1 | 0.259 |
Legumes | 40.0 ± 27.7 | 35.2 ± 31.2 | 34.6 ± 26.3 | 0.511 |
Red meat | 21.9 ± 20.8 | 13.0 ± 12.3 | 6.4 ± 7.5 | < 0.001 |
Poultry | 5.6 ± 7.6 | 3.0 ± 3.7 | 1.7 ± 2.9 | 0.001 |
Fish | 14.5 ± 18.8 | 2.9 ± 3.3 | 0.93 ± 1.9 | < 0.001 |
Processed meats | 12.8 ± 19.6 | 36.8 ± 36.2 | 60.0 ± 43.2 | < 0.001 |
Eggs | 27.2 ± 16.2 | 26.1 ± 13.5 | 30.4 ± 16.0 | 0.392 |
Dairy | 294.8 ± 180.3 | 193.6 ± 115.0 | 169.1 ± 98.2 | < 0.001 |
Fruits | 440.0 ± 222.4 | 268.2 ± 226.3 | 119.2 ± 115.0 | < 0.001 |
Non-starchy vegetables | 404.8 ± 158.6 | 316.3 ± 141.2 | 294.6 ± 87.1 | < 0.001 |
Potato | 30.8 ± 23.9 | 36.8 ± 19.6 | 41.8 ± 21.7 | 0.056 |
Nuts | 7.4 ± 9.9 | 5.3 ± 9.6 | 3.8 ± 6.2 | 0.134 |
Sugary foods4 | 116.0 ± 168.0 | 140.2 ± 87.7 | 166.0 ± 75.6 | 0.170 |
1 Scores of food security are as follows: food secure (0–1), mild food-insecure (2–8), moderate/severe food-insecure (9–27). 2 Data are presented as means ± SD. 3 P value was determined by one-way analysis of variance. 4 sugary foods included sugar-sweetened beverages, cakes, biscuits, cookies, confections, candies, ice cream, etc. |
Among nutrients, carbohydrates (P = 0.016), fiber (P < 0.001), vitamin A (P < 0.001), vitamin C (P < 0.001), folic acid (P < 0.001), potassium (P < 0.001), calcium (P < 0.001), and magnesium (P < 0.001) decreased while fat (P < 0.001) and sodium (P < 0.001) increased as food security decreased (Table 7). Energy, protein, cholesterol, vitamin B12, iron, and zinc did not show significant association.
Table 7
Daily nutrient intakes in different food security levels1,2
| Secure (n = 81) | Mild insecure (n = 77) | Moderate/severe insecure (n = 32) | P value3 |
Energy (kcal) | 2197 ± 537 | 2156 ± 540 | 2231 ± 488 | 0.799 |
Carbohydrate (g) | 348.9 ± 93.2 | 316.8 ± 80.3 | 299.0 ± 54.6 | 0.016 |
Protein (g) | 65.4 ± 16.3 | 61.1 ± 13.9 | 63.3 ± 15.7 | 0.298 |
Fat (g) | 60.0 ± 20.2 | 71.6 ± 33.7 | 86.9 ± 34.8 | < 0.001 |
Cholesterol (g) | 199.5 ± 78.8 | 200.2 ± 83.6 | 240.0 ± 99.1 | 0.077 |
Fiber (g) | 27.0 ± 8.9 | 20.2 ± 7.9 | 16.9 ± 5.1 | < 0.001 |
Vitamin A (µg RE) | 707.4 ± 405.9 | 516.6 ± 300.3 | 418.5 ± 276.0 | < 0.001 |
Vitamin C (mg) | 319.6 ± 149.5 | 196.8 ± 123.2 | 149.7 ± 90.7 | < 0.001 |
Folic acid (µg) | 328.9 ± 117.8 | 239.8 ± 95.9 | 221.5 ± 84.6 | < 0.001 |
Vitamin B12 (µg) | 5.1 ± 4.8 | 3.9 ± 3.5 | 5.5 ± 6.5 | 0.213 |
Sodium (mg) | 747 ± 343 | 1162 ± 742 | 1411 ± 843 | < 0.001 |
Potassium (mg) | 4148 ± 1391 | 3054 ± 1130 | 2735 ± 809 | < 0.001 |
Calcium (mg) | 745.7 ± 269.6 | 582.5 ± 172.5 | 575.0 ± 190.0 | < 0.001 |
Magnesium (mg) | 278.9 ± 75.3 | 224.2 ± 62.4 | 212.5 ± 53.5 | < 0.001 |
Iron (mg) | 15.1 ± 4.2 | 14.3 ± 3.6 | 14.3 ± 3.1 | 0.476 |
Zinc (mg) | 6.9 ± 1.8 | 6.3 ± 1.9 | 6.8 ± 1.9 | 0.176 |
1 Scores of food security are as follows: food secure (0–1), mild food-insecure (2–8), moderate/severe food-insecure (9–27). 2 Data are presented as means ± SD. 3 P value was determined by one-way analysis of variance. |
Frequency of main meals and snacks (P < 0.05) decreased along with decreasing food security levels but the association for dinner was not significant (Table 8). On the contrary, the frequency of fast and fired foods increased as food security decreased (P ≤ 0.001). Food secure participants used boiling as the main technique of cooking while frying was the main method of cooking among food insecure participants (P = 0.001). Although in each category of food insecurity, more women were straining rice than doing it as a pilaf, 96.9% of women in moderate/severe food insecurity level strained rice while 63.0% and 71.4% of women in food secure and mild insecure levels strained it, respectively (P = 0.001). Compared to food secure families more women in food insecure category drunk tea with meals (56.2% vs. 25.9%) (P = 0.001).
Table 8
Eating habits in different food security levels1,2
| Secure (n = 81) | Mild insecure (n = 77) | Moderate/severe insecure (n = 32) | P value3 |
Breakfast frequency (n/week) | 5.9 ± 2.0 | 5.3 ± 2.1 | 3.4 ± 2.5 | 0.001 |
Lunch frequency (n/week) | 6.8 ± 0.7 | 7.0 ± 0.1 | 6.7 ± 0.9 | 0.041 |
Dinner frequency (n/week) | 6.1 ± 1.6 | 6.0 ± 1.5 | 5.8 ± 1.4 | 0.645 |
Meal frequency (n/day) | 2.7 ± 0.4 | 2.6 ± 0.4 | 2.3 ± 0.5 | < 0.001 |
Snack frequency (n/day) | 1.9 ± 1.0 | 1.6 ± 1.1 | 1.2 ± 0.6 | 0.005 |
Fried foods (n/week) | 2.8 ± 1.7 | 3.5 ± 1.7 | 4.1 ± 2.1 | 0.001 |
Fast foods (n/week) | 1.7 ± 1.4 | 2.8 ± 2.5 | 5.2 ± 3.9 | < 0.001 |
Main cooking method Boiling Frying | 48 (59.3) 33 (40.7) | 23 (29.9) 54 (70.1) | 10 (31.2) 22 (68.8) | 0.001 |
Method of cooking rice Pilaf Strain | 30 (37.0) 51 (63.0) | 22 (28.6) 55 (71.4) | 1 (3.1) 31 (96.9) | 0.005 |
Tea with meals Yes No | 21 (25.9) 60 (74.1) | 41 (53.3) 36 (46.7) | 18 (56.2) 14 (43.8) | 0.001 |
1 Scores of food security are as follows: food secure (0–1), mild food-insecure (2–8), moderate/severe food-insecure (9–27). 2 Data are presented as means ± SD. 3 P value was determined by one-way analysis of variance or chi-square (for the last 3 items). |