Quantitative dataCurrent weights and patterns of weight loss

All but eight participants (98.39%) had lost weight between September 2023 and the current weight measurement in April 2024. All the participants under 18 had lost weight. The lowest current weight measured was 28 kg, and the highest was 142 kg. The mean weight had dropped to 66.22 kg ± 14.34, representing a decline in the mean by 18.72 kg. Table 2 demonstrates the respective current mean weights and SD for each subgroup, the mean weight loss, and its percentage compared to the baseline. The weight loss for the total cohort was statistically significant at (p = .000), and the value of Cohen’s D = 1, denoting a large effect. Figure 1 is a box plot representation of the cohort’s previous and current weight measurements (kg).

Table 2 Current weights, weight range, and mean weight loss for the cohort and each demographic groupFig. 1

legend: Box plot representation of baseline and current weights (kg)

Correlates of weight loss

Using Spearman correlation to test the impact of sex, current place of residence, and age on weight loss revealed significant but negligible or weak correlations. As Table 3 demonstrates, sex had a negligible impact on weight loss (Spearman correlation coefficient r=-.159, p = .000). Place of residence also was not significantly correlated with weight loss (r=-.073, p = .000). On the other hand, age was associated with a weak positive correlation with weight loss (r = .204, p = .000).

Table 3 Impact of sex, current place of residence, and age on weight lossAlternative foods and their perceived impact on health

Regarding bread, the main staple food in the Gaza Strip, the vast majority (96%) were deprived of white flour and had to seek unconventional and often unhealthy alternatives such as grinding bird feed or animal feed (Table 4).

Table 4 Flour types consumed in the three months prior to interviewsTable 5 Health complaints during the previous month attributed to the diet

As for health complications that participants linked to the dietary change, both diarrhea and constipation were reported, with frequencies of 42% and 84%, respectively. Table 5 summarizes these health complications reported by the interviewees.

Qualitative data: alternative foods and their impacts on health

Ninety-five interviews were performed and analyzed. Breadwinners and homemakers conveyed a host of limitations and challenges related to sourcing and preparing food for their families. In total, two themes and five subthemes were derived from the semi-structured interviews.

Constant feelings of hunger due to the severe food shortages

The majority of interviewees described “indescribable hunger” and “unprecedented hunger” that they had never experienced before. Also, most reported that their eating habits had changed and consisted of two daily meals instead of three, while a significant number reported having, on several occasions, eaten one meal per day for weeks on end. Many had spent at least 24 h without any food.

Limitations of food quantity

Food was scarce and difficult to obtain, and extended families had to share limited quantities. As such, older family members often volunteered their shares to children.

If I don’t keep some food for dinner, the children will cry all night. I can tolerate hunger, but the children cannot. A female participant, 40.

Also, due to severe limitations, food had to be obtained on a daily basis as the limited quantities available in the markets and the high prices meant that most people were unable to store more than a couple of days’ needs. This was further compounded by being at constant risk of moving due to the ground invasion, which meant that people worried about purchasing food that they might have to leave behind at a moment’s notice.

Limited food quality and variety

Food quality and variety were also significantly impaired. For instance, nearly all interviewees reported consuming wild edible plants (e.g., Khobiza “Malva spp.” and Hamases “Rumex spp.”) and using canned tomato sauce for cooking. On the other hand, less than ten of the 95 interviewees consumed rice or lentils. Only two had vegetables available, which were mainly homegrown onions and lemons, while none of the interviewees reported eating meat.

Due to limited food variety, available foods were consumed repeatedly for days or weeks on end.

I have cooked Khobiza daily for weeks in a row, said a female participant, 48.

Food does not taste as it used to. Some meals lack more than half of their ingredients, described another female participant, 41.

Two women described cooking couscous only with bulgur and tomato sauce. Normally, the traditional dish is cooked with a stew that is rich with at least five different types of vegetables.

Many perceived the consumption of animal and bird feed as, humiliating and undignifying, which reflects a psychological toll in addition to the physical impacts mentioned in Table 5. Regarding the health impacts of alternative foods, most participants attributed diarrhea to the consumption of wild edible plants. In contrast, constipation was attributed to unhealthy flour consumed, such as ground animal/bird feed.

Some also complained about the availability of clean water.

A female, 36, said: I have to wash greens with grossly unclean water; it is not surprising that our children get sick this often.

Daily life hurdles: obtaining and preparing foodDifficulties in obtaining food

Participants complained about having to dedicate a lot of time, effort, and financial resources to secure and prepare food for their families.

Most had to walk long distances daily searching for food in different neighborhoods and markets.

There is no fuel for cars, and transportation is very difficult and expensive, so I walk, explained a male participant who is 39 years old, adding that I leave the house early in the morning with an empty stomach.

Participants described having to use hard rocks to grind grains, which requires time and effort.

A female, 51, stated, It takes me four hours to prepare just one kilogram of flour.

Others described walking to the outskirts of the urban area to collect wild plants.

It is dangerous, but I did not feel that I had a choice. A male, 30, reflected.

Additionally, food prices skyrocketed, severely restricting the participants’ ability to purchase sufficient quantities of food when it is available.

A can of fava beans cost 25 Shekels [6.9 US Dollars], said a male, 52. One kilo of fresh meat costs 100 US Dollars, he added.

Difficulties in cooking food

Furthermore, due to the restrictions on the entry of cooking gas, participants used clay ovens or innovative mortar stoves to cook their food. These were fueled by wood scavenged from destroyed homes or broken trees.

I send the children in the early morning to obtain wood to make the fire, said a female participant, 42.

Many participants burned plastic or other materials as even wood was in scarce supply. They expressed worries about the health impacts of the fire and smoke on their and their families’ health.

My throat burns at the end of the day after so many hours by the fire and smoke, said a male, 28.