Climate change is projected to increase the burden of food insecurity (FI) globally, particularly among populations that depend on subsistence agriculture. The impacts of climate change will have disproportionate effects on populations with higher existing vulnerability. Indigenous people consistently experience higher levels of FI than their non-Indigenous counterparts and are more likely to be dependent upon land-based resources. The present study aimed to understand the sensitivity of the food system of an Indigenous African population, the Batwa of Kanungu District, Uganda, to seasonal variation.

A concurrent, mixed methods (quantitative and qualitative) design was used. Six cross-sectional retrospective surveys, conducted between January 2013 and April 2014, provided quantitative data to examine the seasonal variation of self-reported household FI. This was complemented by qualitative data from focus group discussions and semi-structured interviews collected between June and August 2014.

Ten rural Indigenous communities in Kanungu District, Uganda.

FI data were collected from 130 Indigenous Batwa Pygmy households. Qualitative methods involved Batwa community members, local key informants, health workers and governmental representatives.

The dry season was associated with increased FI among the Batwa in the quantitative surveys and in the qualitative interviews. During the dry season, the majority of Batwa households reported greater difficulty in acquiring sufficient quantities and quality of food. However, the qualitative data indicated that the effect of seasonal variation on FI was modified by employment, wealth and community location.

These findings highlight the role social factors play in mediating seasonal impacts on FI and support calls to treat climate associations with health outcomes as non-stationary and mediated by social sensitivity.

To compare the breast-milk iodine concentrations (BMIC) of lactating women before and after the mandatory iodine fortification of bread in Australia in 2009.

Cross-sectional study. Breast milk samples were collected from two cohorts of women in South Australia within 7 d of delivery to determine BMIC. The percentage of samples with iodine concentration below 100 µg/l, a level considered adequate for breast-fed infants, was calculated. Sociodemographic information and intake of dietary supplements were obtained from all women.

The breast milk samples were collected between 2006 and 2007 in the pre-fortification cohort and between 2012 and 2013 in the post-fortification cohort.

The median (interquartile range) BMIC was higher in the post-fortification samples compared with samples collected in the pre-fortification period (187 (130–276) v. 103 (73–156) µg/l; P<0·05). Overall, the percentage of women with BMIC <100 µg/l was lower in the post-fortification cohort than in the pre-fortification cohort (13 v. 49 %; P<0·01). The percentage of women with BMIC <100 µg/l in the post-fortification cohort was lower among women who took iodine supplements in pregnancy (12 v. 29 %; P<0·01).

Mandatory iodine fortification of bread has resulted in an increase in the iodine content of breast milk in Australian women. However, iodine supplementation may still be required in some women post-iodine fortification to reach the level of BMIC that is considered adequate to meet the iodine requirement of full-term infants.

To develop a technology-based method for evaluating the nutritional quality of chain-restaurant menus to increase the efficiency and lower the cost of large-scale data analysis of food items.

Using a Modified Nutrient Profiling Index (MNPI), we assessed chain-restaurant items from the MenuStat database with a process involving three steps: (i) testing ‘extreme’ scores; (ii) crowdsourcing to analyse fruit, nut and vegetable (FNV) amounts; and (iii) analysis of the ambiguous items by a registered dietitian.

In applying the approach to assess 22 422 foods, only 3566 could not be scored automatically based on MenuStat data and required further evaluation to determine healthiness. Items for which there was low agreement between trusted crowd workers, or where the FNV amount was estimated to be >40 %, were sent to a registered dietitian. Crowdsourcing was able to evaluate 3199, leaving only 367 to be reviewed by the registered dietitian. Overall, 7 % of items were categorized as healthy. The healthiest category was soups (26 % healthy), while desserts were the least healthy (2 % healthy).

An algorithm incorporating crowdsourcing and a dietitian can quickly and efficiently analyse restaurant menus, allowing public health researchers to analyse the healthiness of menu items.

Controversy exists surrounding the health effects of added sugar (AS) and sugar-sweetened beverage (SSB) intakes, primarily due to a reliance on self-reported dietary intake. The purpose of the current investigation was to determine if a 6-month intervention targeting reduced SSB intake would impact δ13C AS intake biomarker values.

A randomized controlled intervention trial. At baseline and at 6 months, participants underwent assessments of anthropometrics and dietary intake. Fasting fingerstick blood samples were obtained and analysed for δ13C value using natural abundance stable isotope MS. Statistical analysis included descriptive statistics, correlational analyses and multilevel mixed-effects linear regression analysis using an intention-to-treat approach.

Rural Southwest Virginia, USA.

Adults aged ≥18 years who consumed ≥200 kcal SSB/d (≥837 kJ/d) were randomly assigned to either the intervention (n 155) or a matched-contact group (n 146). Participants (mean age 42·1 (sd 13·4) years) were primarily female and overweight (21·5 %) or obese (57·0 %).

A significant group by time difference in δ13C value was detected (P<0·001), with mean (sd) δ13C value decreasing in the intervention group (pre: −18·92 (0·65) ‰, post: −18·97 (0·65) ‰) and no change in the comparison group (pre: −18·94 (0·72) ‰, post: −18·92 (0·73) ‰). Significant group differences in weight and BMI change were also detected. Changes in biomarker δ13C values were consistent with changes in self-reported AS and SSB intakes.

The δ13C sugar intake biomarker assessed using fingerstick blood samples shows promise as an objective indicator of AS and SSB intakes which could be feasibly included in community-based research trials.

CVD is a leading cause of mortality and morbidity, and nutrition is an important lifestyle factor. The aim of the present systematic review was to synthesise the literature relating to knowledge translation (KT) of dietary evidence for the prevention and treatment of CVD into practice in populations with or at high risk of CVD.

A systematic search of six electronic databases (CINAHL, Cochrane, EMBASE, MEDLINE, PsycINFO and Scopus) was performed. Studies were included if a nutrition or dietary KT was demonstrated to occur with a relevant separate measureable outcome. Quality was assessed using a tool adapted from two quality checklists.

Population with or at high risk of CVD or clinicians likely to treat this population.

A total of 4420 titles and abstracts were screened for inclusion, with 354 full texts retrieved to assess inclusion. Forty-three articles were included in the review, relating to thirty-five separate studies. No studies specifically stated their aim to be KT. Thirty-one studies were in patient or high-risk populations and four targeted health professionals. Few studies stated a theory on which the intervention was based (n 10) and provision of instruction was the most common behaviour change strategy used (n 26).

KT in nutrition and dietary studies has been inferred, not stated, with few details provided regarding how dietary knowledge is translated to the end user. This presents challenges for implementation by clinicians and policy and decision makers. Consequently a need exists to improve the quality of publications in this area.

Many jurisdictions in the USA and globally are considering raising the prices of sugar-sweetened beverages (SSB) through taxes as a strategy to reduce their consumption. The objective of the present study was to identify whether the rationale provided for an SSB price increase affects young adults’ behavioural intentions and attitudes towards SSB.

Participants were randomly assigned to receive one of eight SSB price increase rationales. Intentions to purchase SSB and attitudes about the product and policy were measured.

A forty-six-item cross-sectional Internet survey.

Undergraduate students (n 494) at a large US Midwestern university.

Rationale type was significantly associated with differences in participants’ purchasing intentions for the full sample (F7,485=2·53, P=0·014). Presenting the rationale for an SSB price increase as a user fee, an effort to reduce obesity, a strategy to offset health-care costs or to protect children led to lower SSB purchasing intentions compared with a message with no rationale. Rationale type was also significantly associated with differences in perceptions of soda companies (F7,485=2·10, P=0·043); among low consumers of SSB, messages describing the price increase as a user fee or tax led to more negative perceptions of soda companies.

The rationale attached to an SSB price increase could influence consumers. However, these message effects may depend on individuals’ level of SSB consumption.

To characterise participants who dropped out of the Food4Me Proof-of-Principle study.

The Food4Me study was an Internet-based, 6-month, four-arm, randomised controlled trial. The control group received generalised dietary and lifestyle recommendations, whereas participants randomised to three different levels of personalised nutrition (PN) received advice based on dietary, phenotypic and/or genotypic data, respectively (with either more or less frequent feedback).

Seven recruitment sites: UK, Ireland, The Netherlands, Germany, Spain, Poland and Greece.

Adults aged 18–79 years (n 1607).

A total of 337 (21 %) participants dropped out during the intervention. At baseline, dropouts had higher BMI (0·5 kg/m2; P<0·001). Attrition did not differ significantly between individuals receiving generalised dietary guidelines (Control) and those randomised to PN. Participants were more likely to drop out (OR; 95 % CI) if they received more frequent feedback (1·81; 1·36, 2·41; P<0·001), were female (1·38; 1·06, 1·78; P=0·015), less than 45 years old (2·57; 1·95, 3·39; P<0·001) and obese (2·25; 1·47, 3·43; P<0·001). Attrition was more likely in participants who reported an interest in losing weight (1·53; 1·19, 1·97; P<0·001) or skipping meals (1·75; 1·16, 2·65; P=0·008), and less likely if participants claimed to eat healthily frequently (0·62; 0·45, 0·86; P=0·003).

Attrition did not differ between participants receiving generalised or PN advice but more frequent feedback was related to attrition for those randomised to PN interventions. Better strategies are required to minimise dropouts among younger and obese individuals participating in PN interventions and more frequent feedback may be an unnecessary burden.

There have been few studies investigating the association between food security and breast-feeding duration and none have been conducted among Canadian Inuit, a population disproportionately burdened with food insecurity. We evaluated the association between household food security and breast-feeding duration in Canadian Inuit children.

Data were obtained from the Nunavut Inuit Child Health Survey, a population-based cross-sectional survey.

The Canadian Territory of Nunavut in 2007 and 2008.

Caregivers of Inuit children aged 3–5 years. Participating children were randomly sampled from community medical centre lists.

Out of 215 children, 147 lived in food-insecure households (68·4 %). Using restricted mean survival time models, we estimated that children in food-secure households were breast-fed for 16·8 (95 % CI 12·5, 21·2) months and children in food-insecure households were breast-fed for 21·4 (95 % CI 17·9, 24·8) months. In models adjusting for social class, traditional knowledge and child health, household food security was not associated with breast-feeding duration (hazard ratio=0·82, 95 % CI 0·58, 1·14).

Our research does not support the hypothesis that children living in food-insecure households were breast-fed for a longer duration than children living in food-secure households. However, we found that more than 50 % of mothers in food-insecure households continued breast-feeding well beyond 1 year. Many mothers in food-secure households also continued to breast-feed beyond 1 year. Given the high prevalence of food insecurity in Inuit communities, we need to ensure infants and their caregivers are being adequately nourished to support growth and breast-feeding, respectively.

To investigate changes in dietary diversity and dietary composition among adolescents in four developing countries.

We analysed dietary diversity and consumption of seven food groups and foods with added sugars as reported by adolescents from two cohorts growing up 8 years apart, when they were aged about 12 years.

Ethiopia, India (Andhra Pradesh), Peru and Vietnam in 2006 and 2013.

Adolescents (n 3659) from the older cohort (OC) born in 1995/96 and adolescents (n 7422) from the younger cohort (YC) born in 2001/02 (N 11 081).

Controlling for other factors, dietary diversity increased in Peru (OC=4·89, YC=5·34, P<0·001) and Ethiopia (OC=3·52, YC=3·94, P=0·001). Dietary diversity was stable in India (OC=4·28, YC=4·29, P=0·982) and Vietnam (OC=4·71, YC=4·73, P=0·814); however, changes in dietary composition were observed. YC adolescents were more likely to consume eggs (India: +32 %, P=0·038; Vietnam: +50 %, P<0·001) and milk and dairy (India: +12 %, P=0·029; Vietnam: +46 %, P<0·001). Other notable shifts included meat consumption in Peru (+72 %, P<0·001) and consumption of fruit and vegetables in Ethiopia (+36 %, P<0·001). Compared with OC, the prevalence of added sugar consumption was greater among the YC in Ethiopia (+35 %, P=0·001) and Vietnam (+44 % P<0·001). Between 2006 and 2013, disparities in dietary diversity associated with household wealth and place of residence declined, although this varied by country. No marked gender disparities in dietary diversity were evident.

We found significant changes over time in dietary diversity among adolescents in four countries consistent with the hypothesis of the nutrition transition.

To test the association between coffee consumption and risk of all-cause, CVD and cancer death in a European cohort.

Prospective cohort study. Cox proportional hazards models with adjustment for potential confounders to estimate multivariable hazard ratios (HR) and 95 % CI were used.

Czech Republic, Russia and Poland.

A total of 28561 individuals followed for 6·1 years.

A total of 2121 deaths (43·1 % CVD and 35·7 % cancer mortality) occurred during the follow-up. Consumption of 3–4 cups coffee/d was associated with lower mortality risk in men (HR=0·83; 95 % CI 0·71, 0·99) and women (HR=0·63; 95 % CI 0·47, 0·84), while further intake showed non-significant reduced risk estimates (HR=0·71; 95 % CI 0·49, 1·04 and HR=0·51; 95 % CI 0·24, 1·10 in men and women, respectively). Decreased risk of CVD mortality was also found in men (HR=0·71; 95 % CI 0·54, 0·93) for consumption of 3–4 cups coffee/d. Stratified analysis revealed that consumption of a similar amount of coffee was associated with decreased risk of all-cause (HR=0·61; 95 % CI 0·43, 0·87) and cancer mortality (HR=0·59; 95 % CI 0·35, 0·99) in non-smoking women and decreased risk of all-cause mortality for >4 cups coffee/d in men with no/moderate alcohol intake.

Coffee consumption was associated with decreased risk of mortality. The protective effect was even stronger when stratification by smoking status and alcohol intake was performed.

Poor diet quality contributes to morbidity, including poor brain health outcomes such as cognitive decline and dementia. African Americans and individuals living in poverty may be at greater risk for cognitive decrements from poor diet quality.

Cross-sectional.

Baltimore, MD, USA.

Participants were 2090 African Americans and Whites (57 % female, mean age=47·9 years) who completed two 24 h dietary recalls. We examined cognitive performance and potential interactions of diet quality with race and poverty status using baseline data from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Healthy Eating Index-2010 (HEI-2010) scores were calculated and interpreted using federal guidelines. A neurocognitive test battery was administered to evaluate cognitive function over several domains.

Linear regression analyses showed that lower HEI-2010 scores were associated with poorer verbal learning and memory (P<0·05) after adjustment for covariates. Diet quality within the sample was poor. Significant interactions of HEI-2010 and poverty status (all P<0·05) indicated that higher diet quality was associated with higher performance on tests of attention and cognitive flexibility, visuospatial ability and perceptual speed among those below the poverty line. No significant race interactions emerged. Higher diet quality was associated with better performance on two measures of verbal learning and memory, irrespective of race and poverty status.

Findings suggest that diet quality and cognitive function are likely related at the population level. Future research is needed to determine whether the association is clinically significant.

The study aimed to investigate, for the first time, the association between diet quality (food variety and dietary diversity), intakes of anti-inflammatory nutrients and food groups, and subclinical inflammation as assessed by categories of high-sensitivity C-reactive protein (hs-CRP).

Cross-sectional study.

Resource-poor, rural children in the Eastern Cape, South Africa.

A sample size formula determined a representative sample of 235. Five schools were purposively selected and cluster sampling used to select 240 participants. Measurements included 24 h recall and dietary diversity questionnaires, anthropometric and biochemical measurements.

The sample consisted of 50·4 % (n 118) girls and 49·6 % (n 116) boys. No obesity was found, but overweight was prevalent in 4·2 % of the children. The hs-CRP concentration (median (25th, 75th percentile)) of the low, medium and high risk inflammatory categories was 0·6 (0·4, 0·7), 1·6 (1·2, 2·2) and 4·2 (3·4, 6·4) mg/l, respectively. Body composition parameters did not differ between hs-CRP groups. Most of the anti-inflammatory nutrient intakes (dietary Fe, Zn, Mg, vitamin C, folate, linolenic acid, linoleic acid, MUFA and PUFA) differed significantly between the hs-CRP groups, with intakes increasing from low to high hs-CRP groups, with similar results for linolenic acid (P=0·022) intake. No significant relationships between hs-CRP and any of the food groups could be established, but significant relationships were established between hs-CRP levels and the high density of living arrangements and unhygienic ablution facilities.

Although no link could be established between overnutrition and hs-CRP levels, an association was found between hs-CRP and dietary quality, as well as socio-economic status.

To determine if 7 d physical activity (PA) predicts energy intake over the same days and if PA on a given day predicts energy intake on the same day, the next day or subsequent days.

A 7 d prospective investigation. PA was measured using accelerometers worn for seven consecutive days. During the same week, total energy intake (including alcohol) was assessed using weighed food records.

Twenty cities in the USA.

Three hundred middle-aged women.

After controlling for the covariates, energy intake was 36 (se 8) kJ higher for each additional 100000 activity counts (F=19·0, P<0·0001), based on the entire week of monitoring. Women with Low PA (n 75) had a mean energy intake of 8364 (sd 1235) kJ/d (1998 (sd 295) kcal/d), those with Moderate PA (n 150) consumed 8523 (sd 1264) kJ/d (2036 (sd 302) kcal/d) and those with High PA (n 75) consumed 9079 (sd 1473) kJ/d (2169 (sd 352) kcal/d; F=6·4, P=0·0019), a 5023 kJ/d (1200 kcal/d) difference between the High and Low PA groups. PA on a given day was predictive of energy consumption on the same day on four of the seven monitored days, and was predictive of energy intake the next day, with five of six associations significant. PA was not consistently predictive of energy intake on days beyond the next day.

Over 7 d, PA and energy consumption tend to be positively related. Considered day to day, increased PA is weakly associated with increased energy intake the following day and, to a lesser extent, the same day. Therefore, managing weight by increasing PA may not result in the energy deficit expected.

To investigate the association of seasonality with dietary diversity, household food security and nutritional status of pregnant women in a rural district of northern Bangladesh.

A cross-sectional study was conducted from February 2013 to February 2015. Data were collected on demographics, household food security (using the Household Food Insecurity Access Scale), dietary diversity (using the women’s dietary diversity questionnaire) and mid-upper arm circumference. Descriptive statistics were used to explore demographics, dietary diversity, household food security and nutritional status, and inferential statistics were applied to explore the role of seasonality on diversity, household food security and nutritional status.

Twelve villages of Pirganj sub-district, Rangpur District, northern Bangladesh.

Pregnant women (n 288).

Seasonality was found to be associated with dietary diversity (P=0·026) and household food security (P=0·039). Dietary diversity was significantly lower in summer (P=0·029) and spring (P=0·038). Food security deteriorated significantly in spring (P=0·006) and late autumn (P=0·009).

Seasons play a role in women’s household food security status and dietary diversity, with food security deteriorating during the lean seasons and dietary diversity deteriorating during the second ‘lesser’ lean season and the season immediately after. Interventions that aim to improve the diet of pregnant women from low-income, subsistence-farming communities need to recognise the role of seasonality on diet and food security and to incorporate initiatives to prevent seasonal declines.

To investigate the extent to which individual-level as well as macro-level contextual factors influence the likelihood of underweight across adult sub-populations in India.

Population-based cross-sectional survey included in India’s National Health Family Survey conducted in 2005–06. We disaggregated into eight sub-populations.

Multistage nationally representative household survey covering 99 % of India’s population.

The survey covered 124 385 females aged 15–49 years and 74 369 males aged 15–54 years.

A social gradient in underweight exists in India. Even after allowing for wealth status, differences in the predicted probability of underweight persisted based upon rurality, age/maturity and gender. We found individual-level education lowered the likelihood of underweight for males, but no statistical association for females. Paradoxically, rural young (15–24 years) females from more educated villages had a higher likelihood of underweight relative to those in less educated villages; but for rural mature (>24 years) females the opposite was the case. Christians had a significantly lower likelihood of underweight relative to other socio-religious groups (OR=0·53–0·80). Higher state-level inequality increased the likelihood of underweight across most population groups, while neighbourhood inequality exhibited a similar relationship for the rural young population subgroups only. Individual states/neighbourhoods accounted for 5–9 % of the variation in the prediction of underweight. We found that rural young females represent a particularly highly vulnerable sub-population.

Economic growth alone is unlikely to reduce the burden of malnutrition in India; accordingly, policy makers need to address the broader social determinants that contribute to higher underweight prevalence in specific demographic subgroups.

To determine the effectiveness of a personal support lifestyle education programme (PSMetS) for reducing risk factors in individuals with metabolic syndrome (MetS).

A two-arm randomised controlled trial.

Companies in metropolitan Tokyo, Japan.

Male workers with diagnosed MetS or a high risk for MetS according to the Counselling Guidance Program, Japan (n 193).

The reduction in the number of risk factors for MetS (as defined according to the criteria published by the Japanese Ministry of Health, Labor and Welfare in April 2007 (MHLW-MetS)) in the PSMetS group was not significantly different from that in the usual care group by van Elteren’s test (baseline-adjusted P=0·075) for intention-to-treat (ITT), while it was significant (baseline-adjusted P=0·038) for per-protocol set (PPS). The proportion of MHLW-MetS was significantly different between groups by van Elteren’s test (baseline-adjusted P=0·031). Two components of MHLW-MetS showed significant reductions in the PSMetS group: waist circumference (baseline-adjusted P=0·001) and BMI (baseline-adjusted P=0·002). PPS and ITT analyses showed similar results.

For male workers with MHLW-MetS or a high risk of MHLW-MetS, PSMetS reduced the number of risk factors for MHLW-MetS.

To investigate the impact of an early intervention programme, Preparing for Life, on dietary intake between 12 and 36 months of age, and the mediating role played by diet on cognitive functioning.

A randomised controlled trial evaluation of a community-based home visiting programme. The intervention involved biweekly visits from mentors from pregnancy until age 5 years and parent training at age 2 years. Dietary intake was assessed at 12, 18, 24 and 36 months using an FFQ to calculate the proportion meeting dietary recommendations. Cognitive functioning was measured at 24 and 36 months. Treatment effects were estimated using conventional χ2 tests, permutation testing, inverse probability weighting and the stepdown procedure. Mediation analysis examined the indirect effect of the intervention on cognitive functioning via its effect on dietary intake.

Socio-economically disadvantaged communities in Dublin, Republic of Ireland.

Pregnant women (n 233) were assigned to the intervention (n 115) or control (n 118) group using an unconditional probability randomisation strategy.

Positive treatment effects were observed for meeting dietary recommendations for protein foods at 24 (OR=2·52) and 36 (OR=2·42) months, and all food groups at 24 (OR=3·92) months. There were no effects on grain, dairy, fruit and vegetable, or fatty/sugary food recommendations in most models. The conventional and more novel methods yielded similar results. Mediation analysis indicated that 13 % of the intervention’s effect on cognitive functioning was mediated by 36-month protein food consumption.

The study demonstrates some potential to alter early childhood dietary patterns through community-based intervention programmes.

To measure compliance with the International Code of Marketing of Breast-milk Substitutes (‘the Code’) in Indonesia.

The study was a cross-sectional survey using the Interagency Group on Breastfeeding Monitoring protocol.

Public and private health facilities in six provinces on Java island in Indonesia.

A total of 874 women (382 pregnant women and 492 breast-feeding mothers of infants below 6 months) and seventy-seven health workers were recruited from eighteen participating health facilities. The study also analysed a total of forty-four labels of breast-milk substitute products, twenty-seven television commercials for growing-up milk (for children >12 months) of nine brands and thirty-four print advertisements of fourteen brands.

The study found that 20 % of the women had received advice and information on the use of breast-milk substitutes and 72 % had seen promotional materials for breast-milk substitutes. About 15 % reported receiving free samples and 16 % received gifts. Nearly a quarter of the health workers confirmed receiving visits from representatives of breast-milk substitute companies. Two health workers reported having received gifts from the companies. The most common labelling violations found were statements or visuals that discouraged breast-feeding and the absence of mention about the consideration of local climate in the expiration date.

Violations of the Code by health workers, breast-milk substitute companies and their representatives were found in all provinces studied. A regular monitoring system should be in place to ensure improved compliance with and enforcement of the Code.

Applying an ecological approach to childhood obesity prevention requires a new way of thinking and working for many community-based practitioners who are used to focusing on individual behaviour change. The present study investigated individual and organizational characteristics associated with the application of an ecological approach by practitioners 6 months post-training.

Individual and organizational characteristics and outcomes of a 6-week online training course were assessed at pre-course, post-course and 6-month follow-up. The application of an ecological approach was measured by three outcomes (application of course content, implementation of an action plan and trying a different approach) and analysed using a generalized estimating equation model with a binomial distribution and logit link and linear mixed models.

An online course for participants in the USA and abroad.

Public health nutrition and youth development educators and their community partners, and other community practitioners, who completed the course and all three surveys (n 240).

One individual characteristic (networking utility) and three organizational characteristics (ecological approach within job scope, funding, course content applied to work) were positively and significantly associated with the application of an ecological approach (P<0·05). Individual characteristics that were negatively and significantly associated with the application of an ecological approach were being a registered dietitian and having ≥16 years of work experience (P<0·05).

Training of community practitioners and the scope and funding of their positions should explicitly emphasize the usefulness or utility of networking and the use of an ecological approach for preventing childhood obesity.

To examine the association between level of food security and diabetes self-management among food pantry clients, which is largely not possible using clinic-based sampling methods.

Cross-sectional descriptive study.

Community-based food pantries in California, Ohio and Texas, USA, from March 2012 through March 2014.

Convenience sample of adults with diabetes queuing at pantries (n 1237; 83 % response). Sampled adults were stratified as food secure, low food secure or very low food secure. We used point-of-care glycated Hb (HbA1c) testing to determine glycaemic control and captured diabetes self-management using validated survey items.

The sample was 70 % female, 55 % Latino/Hispanic, 25 % white and 10 % black/African American, with a mean age of 56 years. Eighty-four per cent were food insecure, one-half of whom had very low food security. Mean HbA1c was 8·1 % and did not vary significantly by food security status. In adjusted models, very-low-food-secure participants, compared with both low-food-secure and food-secure participants, had poorer diabetes self-efficacy, greater diabetes distress, greater medication non-adherence, higher prevalence of severe hypoglycaemic episodes, higher prevalence of depressive symptoms, more medication affordability challenges, and more food and medicine or health supply trade-offs.

Few studies of the health impact of food security have been able to examine very low food security. In a food pantry sample with high rates of food insecurity, we found that diabetes self-management becomes increasingly difficult as food security worsens. The efficacy of interventions to improve diabetes self-management may increase if food security is simultaneously addressed.