The Ukraine–Russia War Is Deepening Food Insecurity, Unhealthy Dietary Patterns and the Lack of Dietary Diversity in Lebanon: Prevalence, Correlates and Findings from a National Cross-Sectional Study

Background: Due to Russia and Ukraine’s key roles in supplying cereals and oilseeds, the Russia–Ukraine war intensifies the current food availability and price challenges in Lebanon, which is a major wheat importer. Given these constraints, we conducted this study to assess the prevalence and correlates of food insecurity, low dietary diversity (DD), unhealthy dietary patterns, and the shifts in households’ food-related habits in response to the Russia–Ukraine war among a representative sample of Lebanese household’s members aged 18 years and above (N = 914). Methods: Data were collected between June and July 2022 using self-administered questionnaires; Results: Findings showed that nearly half of the households consume an undiversified diet (46%), and 55.3% ate fewer than two meals per day. The prevalence of food insecurity among Lebanese households was 74%, with one in every four households being severely food insecure. In addition, the majority of households’ members went out shopping and purchased food less than the pre-war period (68.7% and 70.3%, respectively). Furthermore, almost 68.3% of households’ members highlighted price increases for cereal products, which were the least available and most stocked items. Findings obtained through binary logistic regression also showed that food insecurity was two times higher among households with low monthly income, 35% higher among females, and three times higher among married participants; Conclusions: The impact of the Russia–Ukraine conflict on food security in Lebanon requires a systems-thinking approach as well as international effort to understand the challenges and find solutions to minimize the war’s negative effects.


Introduction
Russia and Ukraine are two of the world's major suppliers of agricultural commodities [1]. Prior to the Russia-Ukraine war, these two countries provided 30% of the world's wheat and one-fifth of maize exports [1]. They also provide the vast majority of global

Study Design and Sampling
The current investigation was a national cross-sectional study conducted between June and July 2022. Study participants were sampled using the probability cluster sampling technique. Subsequently, the clusters from where participants had been recruited are the eight Lebanese governorates (Mount Lebanon, Beirut, South Lebanon, North Lebanon, Akkar, Beqaa, Baalbeck-Hermel, and Nabatieh). The heads of households were recruited from each district using a probability proportional to size sampling technique. A single population formula (n = [p (1 − p)] × [(Z ∝/2 ) 2 /(e) 2 ]) was used to determine the sample size, where n denotes the sample size, Z_(∝/2) is the reliability coefficient of standard error at a 5% level of significance = 1.96, p represents the probability of adults (18-64 years) who were unable to practice preventive measures of the diseases (50%), and e refers to the level of standard error tolerated (5%) as stated by Hosmer and Lemeshow [10]. Based on this formula, it was determined that the minimum acceptable sample size of 450 respondents is sufficient to ensure appropriate power for statistical analyses. Subsequently, considering a non-response rate of around 10%, we reached a total of 914 Lebanese household's members who were invited to participate in the study by filling out an online form of a self-administered questionnaire, which was distributed through social media platforms (WhatsApp, Facebook, and Instagram). Thus, we reached a representative sample of 914 Lebanese household members for their data to be included in the analysis. The sample representativeness was enhanced by a weighting the governorate and gender variables. All household's members voluntarily participated in the study. The online questionnaire was available in Arabic, the native language used in Lebanon. Only one household's member from each Lebanese household aged 18 to 64 years old was considered eligible to participate in the study. On the other hand, non-Lebanese, members from the same household, and those who were not among the required age were excluded. The recruitment process is illustrated in Figure 1. analysis purposes. The fourth section was added to evaluate the current dietary diversity (DD) of Lebanese households by calculating the Food Consumption Score (FSC). FCS was calculated using the frequency of consumption of different food groups by a household during the seven days preceding the survey. The calculation formula of the FCS is as follows: (starches × 2) + (pulses × 3) + vegetables + fruit + (meat × 4) + (dairy products × 4) + (fats × 0.5) + (sugar × 0.5) [17]. Households were then classified as having a high DD (FCS ≥ 42) or a low DD (FCS < 42) [17]. This questionnaire is available upon request.

Ethical Considerations
The study was approved by the Ethical Committee at Al-Zahraa University Medical Center (#15/2022), and it follows the criteria approved by the Declaration of Helsinki. All participants provided written informed consent before taking part in the study. The participation was voluntary and exposed participants to no possible risks. On average, it takes the respondent 7-10 min to complete the survey.

Statistical Analysis
Data were analyzed using Statistical Package of Social Science Software (SPSS), version 25.0. A descriptive analysis was conducted, where continuous variables were reported as mean (SD) and categorical variables were reported as frequencies (N) and

Study Instrument
A pre-tested, self-administered questionnaire encompassing 4 main sections and composed of different types of questions (single and multiple-choice options) was used to meet study aims. The demographic and socio-economic characteristics of the recruited households were captured in the first section. It included age, gender, governorate, marital status, education level, work discipline, history of chronic diseases, monthly income (the respondent was asked to rate his/her income compared to other Lebanese households), average monthly expenditure for food at home, and household composition. Body weight and height were self-reported by households' members in order to allow the calculation of body mass index (BMI) [11]. In addition, the total number of persons and rooms per household were obtained to calculate the crowding index. The latter was calculated as the total number of household members (excluding infants) divided by the total number of rooms in a household (excluding kitchens and bathrooms) [12]. Households were then classified as having one person per room (no crowding), 1.5 persons per room (crowding), and more than 1.5 persons per room (over-crowding) [13]. This index was used as a proxy measure of household socio-economic status in the present study and provided a reliable result among the Lebanese population [12,14]. The second part consisted of 10 questions concerning the impact of the Russia-Ukraine War on food-related habits, including food purchasing behaviors, food consumption habits, and food storage. These questions were derived from a previously published paper by other authors [15] and by our research group describing the same study variables before the Russia-Ukraine war. It asked about the changes in dietary patterns and in the consumption data by households during the current war period in comparison to the preceding one. In the third section (10 questions), the Arab Family Food Security Scale (AFFS) was used to assess food insecurity among households in a snapshot way [16]. Using AFFS, the food security status of the Lebanese households was grouped into 3 categories (food secure, moderately food insecure, and severely food insecure). However, "moderately food insecure" and "severely food insecure" were combined under one "food insecure" category, for statistical analysis purposes. The fourth section was added to evaluate the current dietary diversity (DD) of Lebanese households by calculating the Food Consumption Score (FSC). FCS was calculated using the frequency of consumption of different food groups by a household during the seven days preceding the survey. The calculation formula of the FCS is as follows: (starches × 2) + (pulses × 3) + vegetables + fruit + (meat × 4) + (dairy products × 4) + (fats × 0.5) + (sugar × 0.5) [17]. Households were then classified as having a high DD (FCS ≥ 42) or a low DD (FCS < 42) [17]. This questionnaire is available upon request.

Ethical Considerations
The study was approved by the Ethical Committee at Al-Zahraa University Medical Center (#15/2022), and it follows the criteria approved by the Declaration of Helsinki. All participants provided written informed consent before taking part in the study. The participation was voluntary and exposed participants to no possible risks. On average, it takes the respondent 7-10 min to complete the survey.

Statistical Analysis
Data were analyzed using Statistical Package of Social Science Software (SPSS), version 25.0 (IBM, Chicago, IL, USA). A descriptive analysis was conducted, where continuous variables were reported as mean (SD) and categorical variables were reported as frequencies (N) and percentages (%). The chi-squared test was used to determine the association between categorical variables. Additionally, significant predictors of household food insecurity were determined using binary logistic regression analysis. The binary logistic regression model shows the variability of the dependent variable, which is the household food insecurity in response to the introduced independent variables. Initially, 14 variables were introduced to the model. A confidence interval of 95% was applied, and the level of significance was predetermined at 5% (p < 0.05 was considered to be significant).

Demographic and Socio-Economic Characteristics of the Sampled Households
A total number of 1004 participants were screened to be included in the study. The nonresponse rate was 10%. A final sample of 914 participants belonging to Lebanese households was recruited. Females represented 53.4% of the study population, while 46.6% were males. The average mean age of the overall sample population was 32.0 (SD = 12.0), males (mean = 34.0; SD = 13.0), and females (mean = 31.0; SD = 11.0). Around 60.3% of participants were aged more than 24 years old. In total, 34.3% of males were between 18-24 years old, while 44.4% of females were in this age group, p = 0.002. Nearly half of participants (48.9%) had normal body weight, 30.9% were overweight, 16.6% were obese, and 3.6% were underweight. However, the proportion of male participants with normal BMI (41%) was significantly lower than the proportion of females with acceptable body weight (55.8%). Moreover, the proportion of males with overweight (38.2%), and obesity (19.4%) was higher than females (24.6% and 14.1%, respectively), p < 0.001. Furthermore, 13.6% of the households were residing in Mount Lebanon, 13.1% in Beirut, 12.6% in North Lebanon, and 11.4% in South Lebanon. Moreover, 13% and 11.8% lived in the Bekaa and Baalbeck-Hermel, respectively. In addition, more than half of participants (51.2%) were single, 45% were married, while only 1.8%% were divorced. However, the proportion of single females (55.2%) was significantly higher than that of males (46.6%), p = 0.002. Regarding their educational level, the majority (74.4%, n = 680) of study participants had university education level, whereas only 1% reported that they are illiterate. Concerning the working status, the majority of respondents (40.4%) reported that they work, 28.4% were students, while 26.1% were not working. The proportion of unemployed females (29.6%) was significantly higher than that of males (22.1%), p < 0.001. As for chronic diseases, 32.1% of the study population reported that they had a history of chronic diseases. However, an equal proportion of males and females reported having chronic diseases, p = 0.071. Among the 294 sample participants who had chronic diseases, 33% had depression, followed by hypertension (25%, n =74) and diabetes (21.42%, n = 63). Other diseases were also reported, including asthma (19.38%, n = 57), cardiovascular diseases (17%, n = 50), osteoporosis (11.9%, n = 35), liver diseases (6.46%, n = 19), renal diseases (4.76%, n = 14), and anemia (2.72%, n = 8). Moreover, diabetes was the most reported disease by males; however, depression was mostly reported by females, p < 0.001 (Data not shown). Concerning the monthly income, 41.8% of households were earning more than 1.5 million LBP and 17.5% were earning less than 1.5 million LBP. Furthermore, the current household income was less than 300 USD for 19.8%, and more than 300 USD for 14%. However, lower monthly income (<1.5 million LBP) was reported more by females (20.4%), as compared to males (14.2%), p = 0.002. However, around 41.8% of the households reported that they spent more than 3 million LBP as an average monthly expenditure for food at home. In terms of the household characteristics of the study sample, most of the households were composed of multiple adults (45.6%), 33.9% were composed of multiple adults with at least one child, while 10.4% and 10.1% were composed of one adult with at least one child and one adult, respectively. Furthermore, nearly half of the participants (56.5%) reported that they do not have children, 32.7% have less than three children, and only 10.8% reported that they have more than three children. In addition, 49.6 % had a crowding index of ≤1 person/room (no crowding), whereas 28.4% of respondents had an over-crowding index (>1.5 persons/room). Moreover, nearly half of the household heads of the participants were aged more than 50 years old (52.7%), 38.2% were between 35-50 years old, and only 9% were less than 35 years old. Additionally, 33.4% of household heads were studying or had studied at university, while only 6.5% were illiterate. To investigate the impact of the Russia-Ukraine war on the economic situation in Lebanon, households were asked about the impact of this war on their monthly income, where 34% admitted that their income had declined after the Russia-Ukraine war. Moreover, nearly half the households reported that their monthly income is estimated to be less than most other Lebanese households (48%). These findings are presented in Table 1. Bold means significant at p-value < 0.05.

Household Food Security Scale
Using the scale Arab Family Food Security Scale (AFFSS), the majority (74%) of households were food-insecure (including "moderately food insecure" and "severely food insecure") ( Figure 3a). Additionally, among those who were food-insecure, 29% of households were severely food insecure (Figure 3a). However, the highest percentage of food insecurity ("moderately food insecure" and "severely food insecure) was observed in Akkar and North Lebanon (86%) (Figure 3b). Interestingly, the highest percentage of food security was in Beirut (50%) (Figure 3b).

Household Food Security Scale
Using the scale Arab Family Food Security Scale (AFFSS), the majority (74%) of households were food-insecure (including "moderately food insecure" and "severely food insecure") ( Figure 3a). Additionally, among those who were food-insecure, 29% of households were severely food insecure (Figure 3a). However, the highest percentage of food insecurity ("moderately food insecure" and "severely food insecure) was observed in Akkar and North Lebanon (86%) (Figure 3b). Interestingly, the highest percentage of food security was in Beirut (50%) (Figure 3b).

Household Food Security Scale
Using the scale Arab Family Food Security Scale (AFFSS), the majority (74%) of households were food-insecure (including "moderately food insecure" and "severely food insecure") ( Figure 3a). Additionally, among those who were food-insecure, 29% of households were severely food insecure (Figure 3a). However, the highest percentage of food insecurity ("moderately food insecure" and "severely food insecure) was observed in Akkar and North Lebanon (86%) (Figure 3b). Interestingly, the highest percentage of food security was in Beirut (50%) (Figure 3b).

Changes in Food Shopping Behaviors during the Outbreak of Russia-Ukraine War
Regarding shopping behaviors, in comparison with the pre-war period, 68.7% of the household's members stated making fewer grocery-shopping trips than usual after the outbreak of the Russia-Ukraine war, 30.1% reported going shopping as usual, while only 1.3% stated that they go shopping more than usual. The percentage of females who reported going shopping less than usual was significantly higher than that of males (73.1% and 63.6%, respectively), p = 0.009. Additionally, the majority of household's members (70.3%) specified that they buy less food than usual on each shopping trip. Moreover, a higher significant proportion of females (74.6%) mentioned buying food less than usual, as compared to males (65.3%), after the outbreak of the Russia-Ukraine war, p = 0.026. Furthermore, almost 70.3% of the households reported that their food wastage decreased after the Russia-Ukraine war. Moreover, 35.6% of the households reported having stocked up food during the war (Table 3). The findings also indicated that the most stocked items during the Russia-Ukraine war were cereal products (55% of the households), oils (22.1%), sugars (16.4%), and legumes (14.6%). Additionally, the results revealed that some food items were less available after the outbreak of the Russia-Ukraine war compared to the pre-war period, including cereals products (55.3% of the households), oils (35.1%), and sugars (19.9%). However, the majority of households (68.3%) highlighted price increase for cereals products. Other items were also highlighted for their price increase including oils (51.7%), legumes (46.2%), roots and tubers (46.2%), milk and dairy products (35.2%), fruits and vegetables (34.8%), and canned food (33.2%) ( Table 4). As shown in Figure 4, in comparison to the pre-war period, the findings of food sourcing during the Russia-Ukraine war demonstrate significant changes in Lebanese households' behaviors related to food shopping. Specifically, 28.5% of the household's members ate out less (e.g., restaurants/cafeteria/fast-food) and 27.4% ordered less takeaway or fast-food meals with deliveries (all by including "slightly less" and "much less" answer options). In addition, the majority of household's members stated that they never order groceries or meals online (69.8% and 60.2%, respectively). On the other hand, a significant proportion of the household's members buy less food in person from large supermarkets (41.4%) or small supermarkets (44.5%) during the Russia-Ukraine war (all by including "slightly less" and "much less") ( Figure 4). As shown in Figure 4, in comparison to the pre-war period, the findings of food sourcing during the Russia-Ukraine war demonstrate significant changes in Lebanese households' behaviors related to food shopping. Specifically, 28.5% of the household's members ate out less (e.g., restaurants/cafeteria/fast-food) and 27.4% ordered less takeaway or fast-food meals with deliveries (all by including "slightly less" and "much less" answer options). In addition, the majority of household's members stated that they never order groceries or meals online (69.8% and 60.2%, respectively). On the other hand, a significant proportion of the household's members buy less food in person from large supermarkets (41.4%) or small supermarkets (44.5%) during the Russia-Ukraine war (all by including "slightly less" and "much less") ( Figure 4).

Changes in Food Consumption Behaviors during the Russia-Ukraine War
When asking household's members about food consumption patterns during the current situation in comparison to the preceding time, the results showed that 67.1% of Leb-

Changes in Food Consumption Behaviors during the Russia-Ukraine War
When asking household's members about food consumption patterns during the current situation in comparison to the preceding time, the results showed that 67.1% of Lebanese households consumed less meat, 61.1% consumed fewer fruits and vegetables, 53.9% fewer sweets, cookies, cakes and candies, 50.1% fewer healthy snacks, and 44.3% less healthy food compared to the period preceding the war ( Figure 5).  Table 5 shows the relationship between the food insecurity and households' characteristics. The proportion of food insecurity was significantly higher among those aged more than 24 years old than those aged 18 to 24 years old (66.1% and 33.9%, respectively), p < 0.001. However, food insecurity prevalence was significantly higher among households having household heads older than 50 years old (49.9%) compared to households with younger household heads, p = 0.005. Additionally, the prevalence of food insecurity was significantly higher among females than males (56.5% and 43.5%, respectively), p = 0.001. Although participants with normal BMI had the highest percentage of food insecurity (49.6%), the difference was not significant compared to overweight (31.0%), obese (16.1%), and underweight (3.3%) participants, p = 0.628. Furthermore, 14.5% of food-insecure households were residing in North Lebanon, followed by Mount Lebanon (14.1%), Beqaa (13.8%), and Akkar (13.5%), p < 0.001. Among food-insecure households' members, nearly half (50.9%) were married, which was significantly higher than those who were single (44.3%), p < 0.001. Similarly, respondents who reported that they studied or were studying at university had the highest proportion of food insecurity (67.3%), p < 0.001. However, household heads who had school education level were shown to have the highest proportion of food insecurity (64.7%), p < 0.001. Moreover, the proportion of food insecurity among unemployed households' members (30.3%) was significantly higher than employed household's members (38.6%), p < 0.001. However, non-medical sector workers had a significantly higher proportion of food insecurity, as opposed to medical sector workers (86.3% versus 13.7%, p < 0.001). Households with more than three children (4.9%) were shown to have a significantly lower proportion of food security compared to households with fewer children, p < 0.001. Additionally, food insecurity prevalence was the highest among households composed of multiple adults (43%), p = 0.001. Households earning the highest income (>300 USD/month) had the highest proportion of food security (38.2%), p < 0.001. Moreover, the proportion of food-insecure households who reported a decline in their monthly income (22.5%) after the Russia-Ukraine war was significantly higher than the proportion of households who reported an increase in their monthly income (0.3%), p < 0.001. Moreover, food insecurity prevalence was the highest among  Table 5 shows the relationship between the food insecurity and households' characteristics. The proportion of food insecurity was significantly higher among those aged more than 24 years old than those aged 18 to 24 years old (66.1% and 33.9%, respectively), p < 0.001. However, food insecurity prevalence was significantly higher among households having household heads older than 50 years old (49.9%) compared to households with younger household heads, p = 0.005. Additionally, the prevalence of food insecurity was significantly higher among females than males (56.5% and 43.5%, respectively), p = 0.001. Although participants with normal BMI had the highest percentage of food insecurity (49.6%), the difference was not significant compared to overweight (31.0%), obese (16.1%), and underweight (3.3%) participants, p = 0.628. Furthermore, 14.5% of food-insecure households were residing in North Lebanon, followed by Mount Lebanon (14.1%), Beqaa (13.8%), and Akkar (13.5%), p < 0.001. Among food-insecure households' members, nearly half (50.9%) were married, which was significantly higher than those who were single (44.3%), p < 0.001. Similarly, respondents who reported that they studied or were studying at university had the highest proportion of food insecurity (67.3%), p < 0.001. However, household heads who had school education level were shown to have the highest proportion of food insecurity (64.7%), p < 0.001. Moreover, the proportion of food insecurity among unemployed households' members (30.3%) was significantly higher than employed household's members (38.6%), p < 0.001. However, non-medical sector workers had a significantly higher proportion of food insecurity, as opposed to medical sector workers (86.3% versus 13.7%, p < 0.001). Households with more than three children (4.9%) were shown to have a significantly lower proportion of food security compared to households with fewer children, p < 0.001. Additionally, food insecurity prevalence was the highest among households composed of multiple adults (43%), p = 0.001. Households earning the highest income (>300 USD/month) had the highest proportion of food security (38.2%), p < 0.001. Moreover, the proportion of food-insecure households who reported a decline in their monthly income (22.5%) after the Russia-Ukraine war was significantly higher than the proportion of households who reported an increase in their monthly income (0.3%), p < 0.001. Moreover, food insecurity prevalence was the highest among households spending 1 to 3 million LBP as an average monthly expenditure for food (38.7%), p < 0.001. The percentage of food-insecure households with over-crowding (32.5%) was shown to be considerably more than food-insecure crowded households (22.5%), p < 0.001. Interestingly, among food-insecure households, the proportion of households with low DD (55.2%) was significantly higher than that for those with high DD (44.8%), p < 0.001.   Bold means significant at p-value < 0.05.

Determinants of the Household Food Insecurity: Binary Logistic Regression Analysis
According to Table 6, many study variables were affecting food security of the Lebanese households. including the following: gender, marital status, residence, weight status, job nature, education level of the household head, and monthly income. The backward stepwise analysis shows that females compared to males had 35% higher probability to be food insecure (OR = 0.656; 95% CI (0.450-0.958), p = 0.029). Moreover, married respondents were 2.9 times more likely to be food insecure compared to single respondents (OR = 2.989; 95% CI (1.944-4.597), p < 0.001). The residency was shown to be an additional determinant; the highest estimated probability of food insecurity was among households residing in Mount Lebanon (OR = 3.393, 95% CI (1.768-6.510), p = <0.001) compared to those residing in Beirut. Furthermore, underweight household members had an 18% higher probability of being food insecure than normal-weight participants (OR = 0.821, 95% CI (0.322-2.098), p = 0.681). Additionally, the likelihood of food insecurity is significantly higher among those who worked in the non-medical sector (OR = 1.598, 95% CI (1.032-2.473), p = 0.036) compared to those who worked in the medical sector. Moreover, households with illiterate household heads were predicted to be food insecure by 52% compared to household heads with a university education level (OR = 0.481; 95% CI (0.179-1.294), p = 0.147). The backward analysis also shows that households having no monthly income were 90% more likely to be food insecure in contrast to those having an income of more than 300 USD (OR = 0.096, 95% CI (0.032-0.284), p < 0.001).

Discussion
This study explored the impact of the Russia-Ukraine war on food security among Lebanese households. It also examined the changes in food-related habits in Lebanese households. Overall, amid the Russia-Ukraine war, the majority of households' members went out shopping and purchased food less than usual (68.7% and 70.3%, respectively). In addition, almost 68.3% of households highlighted price increases for cereal products, which were the least available and most stocked items. The overall prevalence of food insecurity among Lebanese households was 74%, with one in every four households being severely food insecure. Moreover, nearly half of the households were consuming undiversified diets (46%) and 55.3% ate fewer than two meals per day.
In the current study, 68.7% of households reported making fewer shopping trips than usual since the outbreak of the Russia-Ukraine war. Furthermore, the majority of households stated that they purchase less food than usual. This could be related to the economic instability in Lebanon, which derives from many factors, including the Russia-Ukraine war, financial crisis, the Beirut Port Explosions on 4 August, and the COVID-19 pandemic. To facilitate, consumer purchasing behavior is believed to be the total of decision-making processes influenced by both internal and external factors [10]. Economic insecurity is the most critical external influence. Economic crises have a negative effect on both planned and unplanned purchasing behaviors of all consumers [18]. According to Ahorsu et al., 2020, when consumers feel insecure and anxious, their willingness to consume decreases [19]. Moreover, if consumer confidence declines as a result of economic uncertainty, expenditure budgets are considerably lower. Thus, consumers limit their future consumption by shopping and purchasing less frequently [20]. Consequently, the absence of panic-buying resulted in decreased food waste. Study findings showed that the majority of households (70.3%) reported that their food wastage decreased during the outbreak of the Russia-Ukraine war. Hopefully, this shows a potential path toward a more sustainable behavior in food consumption. Similarly, the COVID-19 pandemic has resulted in less food waste in Lebanon [21], as well as in other countries, including Qatar [15], Tunisia [22], Morocco [23], and the US [24]. However, only 35.6% of households stated that they stock up food, and this can be due to food-price inflation. In Lebanon, the cost of the basic food basket increased by 1,140 percent by January 2022 compared to October 2019, affecting household finances for basic requirements and preventing people from being able to store food [25]. This also explains our findings, in which households reported lower consumption for nearly all food groups. However, the least consumed food items were meat (67.1%) and fruits and vegetables (61.1%), indicating that households limit their purchases of food types they cannot afford, such as meat and fish, and begin consuming larger quantities of cheaper food types. Interestingly, findings also showed that the majority of households (68.3%) highlighted price increase for cereals products. Moreover, results indicate an increase in the purchase as well as the storage of non-perishable food items including cereal products, oils, and sugar. Consequently, the availability of these items was affected, where nearly half of households (55.3%) in our study stated that cereals products and oils were the most unavailable item. These findings are unsurprising, given that the Russia-Ukraine conflict exposed global markets to increased risks of shortages and international price inflations [1]. Russia and Ukraine are two of the world's major agricultural commodity producers [1]. Prior to the crisis, the two countries supplied 30% of the world's wheat and one-fifth of maize exports [1]. They also accounted for the majority of the global sunflower seed product exports (80%) [1]. Lebanon, like other nations in the Middle East and North Africa, relies largely on wheat imports from Russia and Ukraine [26]. However, the Russia-Ukraine war limited wheat access for most wheat importers [9]. Since wheat is a vital staple food throughout the Middle East and North Africa, disruptions in the wheat supply chain generated critical food security challenges in the region [26]. Consequently, the food Consumer Price Index (CPI) has increased significantly in most countries in the region in June 2022, including Lebanon (216%), Syria (71%), Egypt (24.2%), Morocco (9.5%), Iraq (7.6%), and Yemen (43%), compared to the same period last year [26]. Moreover, local cereal production in Lebanon accounts for less than 20% of total consumption [4,7]. To illustrate, during the past two years, the economic crisis has hindered the agricultural capacity of Lebanese farmers [7]. Many farmers prefer to take farming as a secondary activity, especially in places with greater economic opportunities [7]. In addition, following the explosion of Beirut's port in 2020 and the partial loss of the city's port's silos, seed storage became extremely difficult [9]. Thus, the Russia-Ukraine war limited access to wheat for import-dependent Lebanon, which was already in the grip of one of the world's worst economic crises since the mid-nineteenth century, and, in addition to wheat, other consumer products from Ukraine and Russia, such as cooking oil and milk powder, were missing from supermarket shelves [9].
Our findings also show that nearly half of the households were consuming undiversified diets (46%), and 55.3% ate fewer than two meals per day. These findings complement a recent study that aimed to assess the impact of crises on food security in Lebanon, where it showed also that 53% of households had poor DD and 55.8% ate fewer than two meals per day [6]. However, our findings were higher than those reported in previous studies among other countries in the MENA region with middle-income, such as Jordan (23.8%) and Palestine (14%) [27,28]. Additionally, Akkar is found to have the largest proportion of households with a low DD (79.1%). This result came hand-in-hand with previous reports, where Akkar presented the poorest DD compared to other governorates [29]. Furthermore, the latter results were corroborated by another study in Lebanon that showed that Beqaa and Akkar had the highest proportions of households with low DD (83% and 73%, respectively) [6].
Using the Arab Family Food Security Scale (AFFSS), three out of four households were food insecure. Similarly, a recent study done in 2021 showed that almost 75.4% of Lebanese households were food insecure [6]. In a country which is heavily dependent on food imports like Lebanon, and which is already suffering from major economic crisis, the Russia-Ukraine war will intensify the current food availability and price challenges. Reduction of crop supply resulting from the military conflict in Ukraine have lowered the available crops for food consumption. According to the Food and Agriculture Organization of the United Nations (FAO), the pillars of food security include availability, access, utilization, and stability [30]. However, the "availability" pillar of food security is affected by the shortage of food and crops supply, leading also to food insecurity [31]. At the governmental level, the highest percentage of food insecurity was among Akkar and North Lebanon (86%). According to recent reports, Akkar also recorded the highest proportion of food shortages (71%) followed by North Lebanon (63%) [32]. The fact that a high proportion of the Lebanese population are food insecure is important by itself, but the potential negative short-term and long-term health effects of food insecurity are potentially more concerning. Some of the studies have shown that food insecurity is associated with decreased nutrient intakes [33,34], increased rates of mental health problems and depression [35,36], diabetes [37,38], cardiovascular diseases [39], hyperlipidemia [38], and poor sleep outcomes [40]. In our study, the adjusted binary logistic regression analysis showed that households with low monthly income (less than 1.5 million LBP) and illiterate household heads had higher probability of food insecurity. These findings are rational, as the indicators of low socio-economic status such as lower education, low income, fewer asserts, and unemployment have been frequently associated with food insecurity [6,41,42].

Strengths and Limitations
The current study has several strengths. It is the first study in Lebanon to investigate the prevalence and correlates of household food insecurity in the context of the Russia-Ukraine conflict. Another strength is the use of a regionally validated household food security access scale. On the other hand, this study has several limitations that should be considered in order to improve the applicability of our findings. The survey's crosssectional design limits the ability to draw causal conclusions. Furthermore, the online survey excluded a particularly vulnerable population that is difficult to track down through social media platforms, leading to a possible selection bias. Another limitation is that food insecurity was measured at the household level, and it may not assess food security status at the individual level. In addition, it is important to mention that Lebanon was already affected by severe economic crisis before the outbreak of the Russia-Ukraine war, which might bias some of our findings.

Conclusions
In conclusion, the current study's findings revealed that the prevalence of food insecurity was remarkably high among Lebanese households. However, these findings should dispel any lingering concerns that Lebanon's government and non-governmental organizations are reverting their efforts to reduce hunger and food insecurity. As a result, in the absence of a major multifaced transformation, Lebanon's complex crisis is expected to persist in 2023, raising concerns about food insecurity consequences across multiple demographic groups. However, the additional impact of the Russia-Ukraine war on food security in Lebanon highlights the importance of a systems-thinking approach and international action to better understand the challenges and develop strategies to reduce the war's terrible effects. Hopefully, this study would offer baseline data to all relevant organizations, contributing to the development of an evidence-based approach for food security interventions among the Lebanese community. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.