Exploring the Impact of Crises on Food Security in Lebanon: Results from a National Cross-Sectional Study

: This study aims to explore the prevalence and correlates of food insecurity among Lebanese households since the ordeals of COVID-19, economic crisis, and Beirut port explosions. At the core of the study, a mobile application entitled Nutrition Assessment System (NAS) that simpliﬁed the data collection was used as toolkit and a technical test was carried out in all Lebanese governorates between November 2020 and March 2021. Findings show that food insecurity is an immediate problem for households in Beirut and in many governorates in Lebanon. Nine in every 16 households ate less than 2 meals per day and more than 70% of them skipped their meals to spare food. Even though half the population studied had a low food consumption score, 82.4% of the people were not relying on livelihood coping strategies. However, more than three out of ten of these households relied on at least three food-based coping strategies. In addition, as for the livelihoods, this assessment found that most Lebanese households reported a drop in income along with an expansion in debt incurrence in the last 24 months to be able to buy food. Improving food security in Lebanon requires effort not only on the part of the government, but through regional and international actions.


Introduction
Food insecurity can cause a deleterious impact on all age categories. According to the 2020 State of Food Security and Nutrition in the World (SOFI) report, to the global report on food security in 2020, and to the 2020 International Food Policy Research Institute report, the COVID-19 pandemic induced chronic hunger in an additional 83 million-132 million in 2020 compared to 2019 [1]. Furthermore, according to the Global Humanitarian Overview (GHO) 2021, and the fourth Progress Report for the Global Humanitarian Response Plan (GHRP) for COVID-19 it was estimated that 265 million people warranted humanitarian assistance in 2021 [1]. It was estimated that 54.5 million people were acutely food-insecure in the Eastern Mediterranean region (EMR) due to the compounding effect of COVID-19 [2]. Moreover, an increase in food insecurity was observed in the Middle Eastern countries, where hunger has quadrupled [2]. Six out of 12 Eastern Mediterranean countries, were using in 2020, assistances as cash-based transfers and short-term assistances including Algeria, Libya, Tunisia, Sudan, Palestine, and Lebanon [2]. Lebanon is a small country of 10,452 square kilometers and approximately 6,855,713 million people [3] subject to heightened demographic pressures, possessing limited crop land, renewable fresh water (approximately 770 m3 per capita per year) [3] groundwater which accounts for 50% of irrigation water and 80% of potable water [4].
After the famine between 1915 and 1918, the political dynamics and regional and national socio-economic conditions in Lebanon were continuously influencing the agricultural development in Lebanon. In 1920, the creation of Greater Lebanon motivated the government to implement food security imperatives. Thus, to ensure that Mount Lebanon would not suffer famine again, Akkar, the Beqaa Valley, and South Lebanon-all predominantly agricultural areas-were added to Mount Lebanon. Nevertheless, this addition faced political challenges. Between 1923and 1943, the French Mandate (1923-1943 implemented a rural development plan to gain support from rural landlords. During the rise of what became known as the "merchant republic" between 1943 and 1958, the inflow of regional capital and low-wage Palestinian refugee labor to Lebanon along with the oil boom that increased trade opportunities with the Arab Gulf states, little importance was given to take advantage of economic growth to depend economically on agriculture. In the late 1950s and early 1960s, the Chehabist reforms did not alter the system. Exportoriented agriculture and politically affiliated agro-industrial investments failed to induce any economic development. In 1975, due to the lack of rural opportunities that led to an increased migration toward Beirut and the growth of the city's poverty belt, the civil war began and ended after 15 years. Lebanon found itself, in 1990, divided into several political and territorial spaces lacking any initiative to support agriculture, and the sector relied on the intervention of international donors. In 2011, despite a lack of governmental support, the Lebanese agricultural sector adapted quickly in response to food security shocks and generated social stability and resilience in rural areas. Akkar and northern Beqaa Valley regions show the expansion of agricultural land. This local investment was based on initiative and opportunities from Lebanese people in assistant of Syrian refugee agricultural workers. Today, the financial crisis and the collapse of the Lebanese pound have aggravated the food security of vulnerable Lebanese and refugees as well [5]. Lebanon is highly reliant on food imports, as an example, more than 99% of all cereals and more than 65% of the food basket are imported [6]. Heavily indebted, Lebanon is also import dependent on the very foods that it consumes the most, such as bread and other cereals. The annual variability of production is quite pronounced, and the gap between total demand and production has continued to increase over the years [6]. Because of the extreme dependence on imports of food, agricultural and food trade balance in Lebanon is heavily in deficit. Up to 80% of the country's food needs are imported in any given year. Since 1990, the end of the civil war, governments have come and gone and policy has been shattered, not least with respect to food and nutrition security. These successive governments have adopted the behavior of borrowing, mostly from local banks [5]. Lebanon has faced multiple shocks over the past 12 months. The socioeconomic situation, political distress, the deterioration in the country's health system struggling under severe pressure because of COVID-19, the Beirut Port Explosions on 4 August which resulted in the loss of life of over 200 people, 6500 injured, 300,000 people homeless and the destruction of large parts of the city [7] altogether increased the number of households sinking into poverty, and aggravating the situation of already vulnerable communities. The financial crisis pressurized Lebanon's capacity to produce food and affected food security by increasing prices of raw materials, feed materials, pesticides, grains, and other agricultural products. Thus, the agricultural system has now fallen down, putting Lebanon's agricultural production capacity at risk. A loss of income-generating opportunities for many Lebanese was due to the pound's devaluation which has reached levels as high as 18,000 Lebanese pounds to USD 1.00. Both the impact of the financial crisis and COVID-19 confinement measures led to an inflation of 183% in the price of the food basket comprised of eight items of the Survival Minimum Expenditure Basket (SMEB) between October 2019 and December 2020 [8]. In the context of many challenges facing food security and agriculture in Lebanon including the Beirut port explosions, the financial and economic crisis, and the COVID-19 pandemic, and in an effort to better understand food insecurity and identify strategies for its prevention we must identify what characteristics and resources may keep families from experiencing it. Based on systems theory and findings from previous research, two research questions and two hypotheses have been formulated to guide this study. Each research question and hypothesis are summarized below.

1.
Research question one: What characteristics and correlates contribute to the food insecurity of Lebanese households?
It is hypothesized that relationships will be found between many characteristics including socio-economic and socio-demographic factors in addition to the economic crisis, the Beirut port explosions, and the COVID-19 pandemic with food insecurity among Lebanese households.

2.
Research questions two: What is the impact of all the previous listed factors on Lebanese households' food consumption and what are the food-based coping strategies and livelihood coping strategies followed by these households?
It is expected that households that frequently struggle from critical conditions are more at risk of food insecurity, eating unhealthy diets, and being able to eat.
To investigate these hypotheses and with the targets of Sustainable Development Goal 2 (SDG2), as well as support to the government of Lebanon and other partner efforts to eliminate food insecurity and malnutrition in the country, two strategic surveys on food security in Lebanon was conducted. The purpose of the two surveys was to meet three key objectives.
Main Objective: • To establish a comprehensive situational analysis of Lebanon's food and nutrition security situation amid the multiple shocks facing Lebanon; Specific Objectives: • To identify food and nutrition security goals or targets established in national plans and at regional frameworks to facilitate progress toward zero hunger; • To inform policy making and prioritization of interventions that would accelerate progress toward SDG target zero hunger; Moreover, to our knowledge, there is a limited number of online digital nutrition assessment tools that accurately measure the overall nutritional situation in terms of individual or household food security during crises and the need for such a tool has been highlighted in many publications and systematic reviews [9][10][11]. The combination among the field of information technology, information sciences and nutrition has led to the generation of the concept to nutrition informatics [12]. This branch has become a novel approach for public health nutrition practitioners to practice in this field and make a profit for the health care [12]. According to the international telecommunication union report, published in 2020, an estimated 90% of the population had access to a mobile-broadband network (3G or above) and 4.1 billion people used the Internet in 2019, indicating a 5.3% increase compared to 2018. In addition, in the Arab states, 91% of the population is covered by a 3G or higher net [13]. Today, many mobile applications, available on Google Play and Apple's online store are deliberated for the prevention and management of disease, particularly non-communicable diseases [14,15]. Rare are the mobile applications that assess food security which is one of the serious challenges and a topic of interest to academics, policy makers, practitioners, governments, and non-governmental organizations around the world and in the EMR. Thus, an innovative mobile application, entitled Nutrition Assessment System (NAS) was used to serve the above objectives.

Methodology
Toolkit development The goal of the developed mobile application was to provide motivation for food security assessment by examining individual or household food security status, leading to an appropriate intervention. NAS is a cloud-based platform that uses the web-based and smart technology applications. This version of NAS was developed under Java Android studio IDE. The logo of this mobile application is shown in Figure 1a. This application was initially developed for the Android (Google, Mountain View, CA, USA) system, and it will eventually be adapted for the Apple (Cupertino, CA, USA) iOS. The software engineering methods for usability, accessibility, and availability were considered in the design and implementation phases. This assessment method was validated. The software was piloted tested on a sample of more than 2000 participants. The initiative, which runs over a 2month period, assisted in the validation and development of the application by creating standard operating procedures for running this mobile application to support and to serve the public health sector. The user provides his or her personal information to use the main functions of the application. Personal information includes age, gender, height, weight, number of family members, and children per household. Height and weight are necessary information for body mass index analysis. The provided information is saved in the database and managed as user information. In any later phase, a registered user can log in automatically through a selection of a study or question. When consenting to enter the survey 1, adapted from the "Food Security and Livelihoods Assessment of Lebanese Host Communities: Assessment Report" [16] published by the food and agriculture organization (FAO) in 2015 and translated to native Arabic, were available to be answered. In addition, the questions of the second survey were adapted from a valid questionnaire published by Sahyoun et al. [17,18]. For instance, if a user selects to provide data on the survey 2, the mobile application provides an introduction, socio-demographic questions and food security assessment questions that are appropriate for this study as shown in Figure 1b,c; subsequently, an assessment of his/her food security status starts.. When the user completes the questionnaire, this application quantifies the answers using an algorithm. Using the analyzed NAS scores, the application provides a data that was moved to Excel sheets for further analysis. The essence of this mobile application is to provide an easy and clear standard to grasp one's food insecurity level. As the questionnaire at the start of the application is based on the survey categories, it meaningfully compares the user's score with the standard. This mobile application is available and can be accessed upon request.

Survey 1: Assessment of the Impact of Prolonged Crises on Household Food Insecurity in Lebanon
Survey design and sampling Covering all governorates, the Lebanese households were interviewed using this mobile application which was able to capture 1133 participants. It was a cross-sectional survey conducted between November and December 2020. The sample representativeness was then optimized by a weighting procedure, according to the Central Administration of Statistics figures of the following variables: geographical dwelling region, gender, and education level. The survey collected quantitative data on the impacts of COVID-19 and the economic crisis on people's livelihoods, coping strategies, their food security situation, through the questionnaire "Food Security and Livelihoods national assessment" [16]. This questionnaire was about 30 min duration and was filled through NAS in a self-administered way, after an introduction explaining the context and objectives of the survey; answering the questionnaire was an implicit informed consent. The online questionnaire included in the mobile application was available in native Arabic, the native language in Lebanon.
Variables tested Several socio-demographic characteristics including gender, age, educational status, marital status, and number of family members were studied. Food Consumption Score (FCS), which is a proxy indicator used for food security analysis, was calculated using the frequency of consumption of different food groups consumed by a household during the 7 days before the survey [19]. The calculation formula of the score FCS is: (starches × 2) + (pulses × 3) + vegetables+ fruit+ (meat × 4) + (dairy products × 4) + (fats × 0.5) + (sugar × 0.5) [19]. Moreover, the Coping Strategy Index (CSI) had been tested using questions about household strategies to manage coping with a food shortfall that was associated with simple numeric score [20].

Survey 2. Assessment of the Impact of Prologned Crises on Household Food Insecurity in Areas Affected by the Beirut Port Explosions
Study Sampling and Design This cross-sectional study was conducted between December 2020 and March 2021 using a representative random sampling of Lebanese households from Beirut province. A minimal sample size of 384 households was needed to allow for adequate power for statistical analyses to be carried out according to the Epi info sample size calculation with a total Beirut population size of 450,413 residents according to the population estimates of 2019, based on the Ministry of Public Health data, a 50% expected frequency and a 5% confidence limits [21]. This number was, then, multiplied by 2 to reach a representative sample of 768 households that takes cluster effect and refusals into account. A simple random selection sampling was then performed to this targeted number of households to account for all regions in Beirut and start data collection based on the number of residents obtained for each region. Even though the calculated number was a sample of 768 households, we collected more households, and we reached a total number of 1388 households. The "Arab Food Security Scales" [17,18] questionnaire was used to collect data. It was about 7 min duration and was filled through NAS in a self-administered way, after an introduction explaining the context and objectives of the survey; answering the questionnaire was an implicit informed consent. The online questionnaire included in the mobile application was also available in Arabic, the native language in Lebanon. Using this questionnaire, food insecurity in respondents using the scale Arab Family Food Security Scale (AFFS) and Food Insecurity Experience Scale (FIES) [17,18] was assessed accordingly.

Ethical Aspects
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of the Lebanese university (protocol code #CUER 22-2020 and date of approval was on 13 May 2020). Anonymity of respondents was guaranteed throughout the process of data collection and analysis. Informed consent was obtained from all subjects involved in the study.

Statistical Tests
Data were converted from NAS database to Excel spreadsheet; they were then analyzed using SPSS version 26.0. A descriptive analysis was first conducted to evaluate sample characteristics. The sample size being higher than 1000, parametric tests were used in the bivariate analysis: means were compared using Student test and percentages using the Chi-squared test. A p-value lower than 0.05 was considered significant. A multivariate analysis was also conducted: using a binomial logistic regression, independent variables were included to explain the variability of the major dependent variable. A backward stepwise likelihood ratio method was also used. Moreover, two models were derived to optimize the probability of food insecurity. The study targeted individuals above 14 years of age. Of the Lebanese respondents, and after weighting, it included 52.4% females, 19.2% university education and 73.3% school education, while 49.8% were married, and 47.1% were single (Table 1). The mean age of participants was 32 years (SD = 12). For work status, 29.3% do not work (housewives and retired, mainly), 21.6% were university students, 10.8% were licensed from work and 38.4% were active workers (Table 1). Among current workers, 60% were healthcare workers. The current household income was inexistent for 20.1% of participants, less than USD 1000 for 45.8%, USD 1000-2000 for 26.8%, and more than USD 2000 for 6.9%. A total of 29% were current regular smokers (Table 1). Although most households in all governorates have between 4 and 6 members, the highest number of children per family was observed only in Akkar (Appendix A). As for the financial situation, more than 40% of households in Akkar, 39% of households in Beqaa, more than 20% of households in North Lebanon, South Lebanon and Baalbek-El Hermel have no monthly income (p < 0.001) (Appendix A). Most households in all governorates have a monthly income of less than USD 1000 (Appendix A). As for chronic diseases, 20% of respondents declared having at least one diagnosed chronic disease, where 8.5% suffer from hypertension, 4.5% from diabetes, 3.9% from anemia, 3.9% from hypercholesterolemia, 1.6% from cancer, 4.2% from chronic lung disease (asthma/chronic obstructive pulmonary disease), 6.9% from obesity, 4.9% from depression and 8.0% from anxiety and depression (Data not shown). Women (22.2%) were reporting more chronic diseases compared to men (17.2%) (p = 0.035) (Data not shown).

Impact of COVID-19 on Economic Situation
To investigate the COVID-19 impact on economic situation in Lebanon, the households were asked to assess their economic situation during the pandemic compared to the phase before and whether their ability to execute their work has been threaten as a consequence of containment measures. Around 38.3% of Lebanese respondents reported being poor since the outbreak of COVID-19 ( Table 2). The percentage of respondents from both genders who reported being below the poverty line tripled from 4.6% before the pandemic to 13.5% since the outbreak (Table 2). More than 60% of respondents from both genders were afraid of poverty and according to the InCharge Financial Distress/Financial Well-Being Scale, used to assess the feelings of overpressure in respondents during the last 4 weeks, all respondents from all governorates were feeling overpressure concerning their financial situation (Table 2).  When asked about taking debt or being helped financially in the past 24 months to cover basic needs, about 54.1% of Lebanese households reported incurring debts ( Table 2). The highest percentage of debts was observed in Beqaa and Akkar (p < 0.001) (Appendix B). Debt was incurred to cover the cost of food (37.9%), rent payments (18.3%), education expenses (8.3%), health expenses (8.1%) and for investment (8.2%) ( Table 2). As for assistances, the highest number of assistances were reported to Beqaa households (41%) and the lowest to Akkar households (6.6%) where the majority were receiving food vouchers (14.7%) (Appendix B).

1.
Food groups consumption score It was observed that almost all respondents eat main food groups in a frequency of fewer than 3 days per week (Table 3). Men were consuming fewer white tubers (i.e., potatoes, onions and carrots) (p = 0.014), less vegetables (p = 0.045), less fruit (p = 0.006), less dairy products (p = 0.002), more fats and oils (p = 0.004), more sweets (p = 0.002) and more spices and condiments (p < 0.001) compared to women (Table 3). Both genders were eating cereals, meats, eggs, pulses, nuts and fish similarly (p > 0.05). Most households in all governorates except in Nabatieh and South Lebanon consumed non-diversified food groups (Appendix C). According to this assessment, 53% of the Lebanese household had a poor FCS. On the other hand, 29% had an acceptable FCS (Table 4). Among those who had poor FCS, the highest percentage was in the age range between 20 and 54 years (p < 0.001) (Data not shown). Beqaa has the largest proportion of households with a poor FCS, with 83% of households calculated to have a poor FCS, followed by Akkar which sees 73% of its inhabitants with a poor FCS (Table 4). On the other hand, Nabatieh has the highest proportion of households with an acceptable FCS (more than 40%) ( Table 4). In further analyses that were not reported in this assessment, the households with poor FCS were relying mainly on cereals and vegetables. Fruit, pulses, meat, and dairy products were less consumed due to the price inflations discussed previously in this paper. On the other hand, households with acceptable FCS consumed fewer amounts of vegetable, higher amounts of fruit, pulses, meat, dairy products, sugar and fat and oils compared to those who have low FCS (Data not shown).

2.
Coping strategies Coping Strategy index and livelihood coping strategies in last 30 days The survey found that 82.1% of households had a low reliance on livelihood coping strategies in the last 30 days. However, 11.8% of the population have a medium reliance on coping strategies and 6.1% only rely heavily on coping strategies (Table 5). At governmental level, South Lebanon, Mount Lebanon and Akkar had the biggest proportion of households that rely heavily on coping mechanisms (Appendix D).  One in two Lebanese households resorted to severe crisis or emergency livelihood coping strategies including spent savings (27.7%), selling household (38.1%) and practices assets (24.1%). It was observed that women were coping with lack of food by asking charities to provide assistances compared to men (p = 0.012) who borrowed money, sold productive assets, took high risk labor or any type of labors to meet basic food needs (Table 5).
Food-based coping strategies in the previous 7 days In the last 7 days, 23.5% of households, reported eating cheaper food in more than 4 days per week (Table 5). Moreover, 17.3% of households borrowed foods or received assistances, and more than 25% ate less meals and less portions and sizes in the last week of response. In addition, more than 30% of the respondents reported eating less to spare food for their children (Table 5). This latter was remarked mainly in women (35.9%) compared to men (27.7%) (p = 0.05). Baalbek-El Hermel had the biggest percentage of people relying on coping strategies in frequency of 4 days and more per week (Appendix D).
Food-based coping strategies in the previous 30 days Nearly 9 in every 16 households were eating less than 2 meals per day while more than 70% of them considered this pattern as "usual pattern" (Table 5). Furthermore, apparent large percentages (70%) of the respondents from all governorates reported skipping their meals to spare food in the 30 last days. Moreover, 13.7% were worried about not having enough to eat, 5.4% were unable to eat healthy food and 7% ate few kinds of foods. Furthermore, 5% ate less, spend their days not eating the whole day and staying hungry ( Figure 2).

3.
Sources of drinking water and planting crops A majority (40%) of households were drinking water from market stores and no one reported drinking water from municipal connection. Half the women were buying water from market stores compared to 31% men (p < 0.001) (Data not shown). Even though most of the respondents (more than 60%), were interested in planting crops, and 62% of them requested training in agricultural production, only 23% of respondents were planting crops except for Nabatieh and Baalbek-El Hermel (p < 0.001) (Data not shown). Almost all 75% of the crops were consumed by the household itself and 25% were bought to increase monthly income or freely given for community support (Data not shown).

4.
Physical access to food: Markets, shopping behaviors, and food stocks Market accessibility is an important indicator to physical access of food. To evaluate the access to markets, this assessment asked Lebanese households about the markets accessed to purchase food, transportation tool they use to travel there, and the duration to reach these markets. Nearly 68% of households all over Lebanon access local shops to purchase food and only 17.1% access open air markets. A total of 85% of the respondents need around 30 min to access food markets and around half the respondents use cars to reach markets. Only 28.5% walk on feet. People who plant crops were asked about the place of selling their products; the majority 38.2% sell their crops at the marketplaces and around 12% sell at farms and agriculture cooperatives (Data not shown).

Correlates of Household Food Insecurity
The binary logistic regression model shows the relationship between several independent variables and the dependent variables FCS and CSI. Initially, 10 variables were introduced to the model for both FCS and CSI. Subjects were then grouped into 3 categories (poor, borderline, and high) based on their calculated FCS and CSI as follows: fewer than 28, between 28-42, more than 42 for FCS, and fewer than 18.6, between 18.6-37.5 and more than 37.5 for CSI, respectively. Other subgroups were also analyzed according to the following subgroups: acceptable FCS (≥42) versus unacceptable FCS (<42) and acceptable CSI (≥37.5) versus unacceptable CSI (<37.5).

1.
Food consumption score According to Table 6, many factors were affecting the FCS of the Lebanese households of which: age, place of living, number of children, incurring debts, planting crops, the time needed to access the market, education, and monthly income. As per the binary logistic analyses, it was shown that older participants heading the household have lower FCS compared to youngers. Those between 35 to 54 years showed 96% less FCS compared to participants between 14  ). In addition, those with more than 3 children had 4 times higher FCS compared to the households with fewer than 3 children (OR = 4.2, 95% CI [2.5, 6.6]). Moreover, it was shown that households who incurred debts in the previous 24 months, spent their money on buying food and had 2.7-fold higher FCS compared to those who did not incurred debts (OR = 2.72, 95% CI [1.93, 3.82]). Respondents who lived far from market and spend more than 1 h to reach it had 91% lower FCS compared to those who lived nearby (OR = 0.09, 95% [0.01, 0.58]). In addition, people who had an income of less than 3 million Lebanese pounds (equivalent to USD 234) and more than 3 million Lebanese pounds had a lower FCS ranging between 87% and 52% lower than those who had an income of more than USD 2000, respectively.

Coping strategy index
The investigation, through binary logistic regression, of the correlates affecting CSI in the survey's respondents showed rare significance of almost all the factors studied in relation to CSI except for the factors "number of family members" "debts incurrence" and "receiving assistances". Households in which family members incurred debts and assistances were coping more than 10-fold higher than those who did not (OR = 14.212, 95CI [1.85, 109.10]) and (OR 12.1, 95% CI [1.20, 122.4]), respectively. In addition, households with more than 3 children were coping 20 times more compared to those with fewer than 3 children (OR = 20.7, 95% CI [1.73, 248.1]).

Socio-demographic Characteristics of the Study Population
A sample of 1388 respondents was reached. It includes 52.5% females, 70.5% school education, while 10.3% were illiterate. A total of 72.7% were married, and the majority (76.1%) have more than 4 family members and fewer than 3 children (74.6%) in the same household. The mean age of respondents was 41.5 years (SD = 14.2). Concerning work status, 20.1% were active workers where only 7.7% worked in the health sector, 43.7% do not work (housewives and retired), and 31.5% were licensed from work.
Almost all the respondents were current smokers and around 1.9% of alcohol drinker consume more than 1 cup per day. Among participants, 88.8% declared being severely affected, as households, by the Beirut Port Explosions on August 4, 2020 (Table 7).

Food Insecurity Experience Scale
Using the scale Arab Family Food Security Scale (AFFSS), the majority (75.4%) of households were severely food-insecure. Similarly, the majority (43%) of respondents also were shown to be severely food-insecure, using Food Insecurity Experience Scale (FIES). Using both scales AFFSS and FIES, more than 60% of people (heading households) were food-insecure, and the highest percentage of food insecurity was observed in the age category between 14 and 47 years (youth group). The survey respondents were asked about the most appropriate sentence describing the household status during the previous 6 months. A total of 31% of households were consuming what they want to consume in enough quantity. On the other hand, the same percentage of people were also consuming enough quantity of food but not as they want. Furthermore, there was a percentage of households, in a range between 3% and 9%, who did not have enough to eat. The same result was observed also when asking the head of each household men and women each alone (Appendix E). The results of the Pearson correlation analysis used to investigate the association between food insecurity and the factors studied showed that any factors influenced the food security status of these households affected by the Beirut explosions including the number of family members, the number of children in each household, education, and occupation as presented in Table 8.

Discussion
Food insecurity can change over time for a variety of reasons. Between 1914 and 1918, as the First World War raged across Europe and beyond, a dark chapter unfolded in what was then known as Greater Syria. During this period, food shortages were so severe that civilians in the Ottoman territories saw their cost-of-living rise to unprecedented levels and at a much higher rate than civilians in for example Paris, London, and Berlin. For example, the price of wheat in Beirut, according to one account, rose from by a factor of eight from five ghurūsh per rot . l in February 1916 to forty ghurūsh in November of the same year, whereas in Paris and London prices doubled and tripled in Berlin [5].In fact, the crisis of civilian provisioning in some regions of the empire-urban Beirut and rural Mount Lebanon most notably-escalated into a fully fledged famine; a famine so cruel and relentless that it would dominate the memory of World War I as the "war of famine" for generations. Indeed, the effects of the "war of famine" were so severe that by its end in 1918, all that seemed to have been left were cities filled with starving refugees and villages emptied of their young men if not all their residents and drained of their political opposition and exhausted from hunger. This marked the beginning of a period that is now often just a footnote in the history books: the Great Famine of 1915-1918, which left an estimated 500,000 people dead. With a lack of accurate data, estimates range from 100,000 to 200,000 deaths in Mount Lebanon alone. At this time, the population of Lebanon was estimated at about 400,000, meaning that half its people died. It is perhaps imprecise to say that capitalism 'caused' the famine. The crisis happened because the interests of French industrial capital and the local bourgeoise dominated Lebanese social organization. In that regard, it was an exception in the rural Ottoman Empire. Lebanon's tragedy can only be explained regarding capitalism's proclivity for producing crises in the human relationship with the rest of the environment. In 1920, the implementation of food insecurity came hand by hand with the creation of Greater Lebanon. Thus, to ensure that Mount Lebanon would not suffer famine again, Akkar, the Beqaa Valley, and South Lebanon-all predominantly agricultural areaswere added to Mount Lebanon. Nevertheless, this addition faced political challenges. Since 1947 (Palestinian war), passing by 2003 (Iraqi war) and 2011 (Syrian war), Lebanon hosts the largest number of Syrian refugees per capita, with a government estimate of 1.5 million Syrian refugees. It also hosts an additional 18,500 refugees from Ethiopia, Iraq, Sudan, and other countries, as well as more than 200,000 Palestinian refugees under UNRWA's mandate [22]. The influx of such high numbers of displaced people has had a serios impact on the political and socio-economic situation in Lebanon, contributing to increased instability. Displaced populations were competing with Lebanese citizens for jobs, markets, public services, and infrastructure mainly for already scarce and fragile natural resources such as land, water, and forests. Increased competition between local workers and displaced populations resulted in reduced household incomes among host communities. In addition, decreases in wages and increases in expenditures are also potential threats to the food security situation of host communities. All these issues together pushed poor and very poor households of the host communities into asset depletions, poverty, and increased vulnerability to future shocks. The impact of the Palestinian and Syrian crises on Lebanon's rural economy and agriculture sector is another concern. Since the end of the civil war in 1990, the political tempo has been high; governments have come and gone and policy has been fragmented, not least with respect to food and nutrition security. Tax bases have remained low while successive governments have adapted to spending requirements through borrowing, mostly from local banks. The political turmoil has resulted in economic growth not keeping pace with rising debt which now stands as one of the highest in the world compared to the gross domestic product. Partially as a result, social safety nets remain underdeveloped, and the poverty rate has remained high. Heavily indebted, Lebanon is also import dependent on the very foods that it consumes the most, such as bread and other cereals. In addition, while it can maintain a reasonably sufficient supply of food, economic access to food and nutrition creates a raft of issues, especially during price shocks. To our knowledge, and since the ordeals of COVID-19, economic crisis, and the Beirut port explosions, the present study is the first to inspect the prevalence and correlates of food insecurity among a representative sample of Lebanese households. Findings show that food insecurity is an immediate problem for households in Beirut and in many governorates in Lebanon. Between November 2020 and March 2021, 9 in every 16 households ate less than 2 meals per day and more than 70% of them skipped their meals to spare food. These findings were higher than the results reported by the WFP report published in June 2020, prior to the Beirut explosions, in which 19% of households used to skip meals or stay hungry all days or nights. Even though half the population studied had a low FCS, 82.4% of the people were not relying on livelihood coping strategies. However, more than three out of ten of these people relied on at least three food-based coping strategies. In the present study, the number of people whose FCS was poor (53%) was found to be higher compared to those reported previously in 2015 (11.1%) [18] and higher than those reported in other middle-income countries in the MENA region, including Jordan (15%), Syrian Arab republic (9% to 22% between June and September 2020) [23] and Palestine (13%) [24]. According to our findings, at government level, Beqaa and Akkar have the largest proportion of households with a poor FCS, with 83% and 73% of households are calculated to have a poor FCS, respectively. These results came hand by hand with the data published by the world Food Program (WFP) in October 2020, in which Beqaa and Akkar presented the lowest FCS compared to other governorates [25]. In addition, as for livelihoods, our findings found that most Lebanese households reported a decline in income along with an expansion in debt incurrences in the last 24 months; the top reasons for it being the inflations in prices and the unemployment. Moreover, the main reason behind debt incurrence by households was food purchase. In addition, the high rate of unemployment has caused an inflation in salary cuts, which in return reduces the ability to afford adequate and sufficient food. This was obvious in our study, where an increase in income showed an improvement in the FCS. Households who were suffering for monetary instabilities and unemployment, were among the group of poor FCS who were facing failure to meet fundamental needs which this can lead to future physical and mental well-being issues, including malnutrition and depression.
When investigating correlates of coping strategies, our findings showed that households CSI was linked with socioeconomical characteristics including monthly income, monetary debts, and number of family members. According to many studies, similar coping strategies were previously observed among Syrian, Iraqi and Palestinian refugees in Lebanon [26][27][28], such consuming cheaper food items and borrowing money to purchase food. Such strategies among households with children can have serious impact on the overall health status of children in the short and long term, and it should warrant further attention [29].
According to the area affected by the Beirut port explosions, three out of four households were severely food-insecure as per AFFSS and one out two households were shown to be severely food-insecure, using FIES. Many factors influenced the food security status of households affected by the Beirut explosions including the number of family members, the number of children in each household, low educational attainment, and unemployment. Recent studies support our finding, including 18 countries in the Eastern Mediterranean region (including Lebanon, Palestine, Egypt, Jordan) highlight that the five common correlates of food insecurity across these countries were low levels of education, low household income and unemployment [30,31]. Between 2014 and 2018, the percentage of Lebanese household food insecurity per year ranged between 24% and 34%, respectively. However, today, according to our findings, the percentage of food-insecure households doubled, mainly in those affected by the Beirut explosions.
All the above findings indicate an alarming situation that is due to the financial and economic crisis that in turn led to a macro-financial failure that included defacement of the banking sector which led to loss of peoples' deposits. In addition, the exchange rate had collapsed resulting in a triple-digit inflation rates along with a severe contraction in the banking sector due to the impacts from the COVID-19 pandemic, including necessary lockdowns that further exacerbated the whole situation [32]. In addition, and since 2011, the overabundance from the Syrian Arab republic resulted in providing the larging refugee population per capita in the world. Moreover, the blast limited the trade of food products, destroyed the plant and animal quarantines offices in Beirut port and destroyed the equipment and laboratories that were in charge for measuring the quality of imported wheat. To add, the small-scale fishing industry was devastated due to the massive death in fishes available close to the epicenter of the blast. As known, new imports must be funded with US Dollars obtained after November 2019, and require advanced payment to foreign suppliers. The restriction on the foreign currency transactions, placed since October 2019, limited the sectors of agribusinesses and the importation of food markets, meats, fish, and chicken resulting in potential shortages in imported food products and animal feeds. All these factors together led to an increase in the cost of the food component of the SMEB that reached an aggregate expansion of 109% between September 2019 and May 2020 [32]. Additionally, a decrease by 14.4% of food imports was observed between October 2019 and March 2020 compared to October 2018 and March 2019, which caused an overpressure on the prices due to reduce in food availability [32].

Limitations
The current study has several strengths. It is the first to explore the prevalence and correlates of household food insecurity among Lebanese households since the ordeals of COVID-19, economic crisis, and the Beirut port explosions. The demographic and socioeconomic characteristics of the study sample were found to be comparable to national figures most recently available in Lebanon [25,33]. Other strengths of the study include the use of a culturally sensitive questionnaire and a locally validated household food security access scale. Innovatively and unlike any other information gathering exercise ever conducted before in Lebanon, this assessment fully uses a mobile phone application called NAS which means that no paper forms are used, anyone with a smart-phone can participate, and results are automatically analyzed. For no charge, users had a chance to answer many multiple-choice and open questions regarding their food security status. However, results from the present study need to be interpreted in the light of several limitations. The NAS mobile technology considers people who are literate Internet users, with connectivity to the Internet, hence, the sample was not necessarily representative of all populations but provided trends to help decision-making at administrative level for the Lebanese. Another limitation is the inability to collect data face to face but through technology-based mobile application where there was a gap in collecting anthropometric data. The cross-sectional design of the study allowed us only to examine associations rather than explore potential causal pathways between food insecurity and many other factors. Food insecurity was also measured at the household level, and it may not reflect the severity of food insecurity that is witnessed specifically at the individual level.

Conclusions
In conclusion, food insecurity is a food system disruptor with serious repercussions for the health and future sustainability of Lebanese households. Three potential areas of consequences of food insecurity at the household level were apparent in these current surveys, namely physical, psychological, and socio-familial. This national assessment of food security in Lebanon was conducted to provide humanitarian and development actors, the government of Lebanon and other non-governmental partners with baseline information to facilitate the development of a comprehensive evidence-based strategy for food security interventions targeting Lebanese communities. Given the multiple dimensions of food security, it is time to track all food security indicators including food availability, access, consumption, and use, and promote sustainable food systems. Key issues include how the intervention in the field of food security can help work towards more resilient households, communities, and food systems, how they can contribute to stability, sustainability, bridging humanitarian and development programming in protracted crisis areas. Achieving food security for all and realizing the right to food is the key aspect of any further assessment and/or intervention. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: This study did not report any data yet.

Acknowledgments:
The authors would like to acknowledge all the students from the Faculty of Public Health and The Faculty of Pharmacy who contributed to data collection. Moreover, the authors are grateful to the non-governmental organizations "We Do Association" for their assistance in data collection as well.

Conflicts of Interest:
The authors declare no conflict of interest.
Disclaimer: The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the World Health Organization or the other institutions with which the authors are affiliated. Table A1. Socio-demographic and socio-economic characteristics of the survey respondents by their place of living.