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BACKGROUND: Historically, the voluntary addition of micronutrients to foods in the United States has been regarded as an important means to lessen problems of nutrient inadequacy. With expanding voluntary food fortification and widespread supplement use, it is important to understand how voluntary food fortification has an impact on the likelihood of excessive usual intakes. Our objective was to investigate whether individuals in the United States with greater frequency of exposure to micronutrients from voluntarily fortified foods (vFF) are more likely to have usual intakes approaching or exceeding the respective tolerable upper intake levels (UL). SUBJECTS/METHODS: The National Cancer Institute method was applied to data from the 2007-2008 National Health and Nutrition Examination Survey (NHANES) to estimate the joint distribution of usual intake from both vFF and non-vFF sources for 12 nutrients and determine the probability of consuming these nutrients from vFF on a given day. For each nutrient, we estimated the distribution of usual intake from all food sources by quintile of probability of consuming vFF and compared the distributions with ULs. RESULTS: An increased probability of consuming zinc, retinol, folic acid, selenium and copper from vFF was associated with a greater risk of intakes above the UL among children. Among adults, increased probability of consuming calcium and iron from vFF was associated with a greater risk of intakes above the UL among some age/sex groups. CONCLUSION: The high nutrient exposures associated with vFF consumption in some population subgroups suggest a need for more careful weighing of the risks and benefits of uncontrolled food fortification. European Journal of Clinical Nutrition (2013) 67, 592-597; doi: 10.1038/ejcn.2013.51; published online 6 March 2013 Keywords: voluntary food fortification; NHANES; tolerable upper intake level, INTRODUCTION In the United States, fortification of any non-standardized food with a vitamin or mineral is permitted at the discretion of the manufacturer. (1) Voluntary nutrient additions are guided by [...]

Objectives: A number of studies have pointed to the pressure that housing costs can exert on the resources available for food. The objectives of the present study were to characterise the relationship between the proportion of income absorbed by housing and the adequacy of household food expenditures across the Canadian population and within income quintiles; and to elucidate the impact of receipt of a housing subsidy on adequacy of food expenditures among low-income tenant households.Design: The 2001 Survey of Household Spending, conducted by Statistics Canada, was a national cross-sectional survey that collected detailed information on expenditures on goods and services. The adequacy of food spending was assessed in relation to the cost of a basic nutritious diet.Setting: Canada.Subjects: The person with primary responsibility for financial maintenance from 15 535 households from all provinces and territories.Results: As the proportion of income allocated to housing increased, food spending adequacy declined significantly among households in the three lowest income quintiles. After accounting for household income and composition, receipt of a housing subsidy was associated with an improvement in adequacy of food spending among low-income tenant households, but still mean food spending fell below the cost of a basic nutritious diet even among subsidised households.Conclusions: This study indicates that housing costs compromise the food access of some low-income households and speaks to the need to re-examine policies related to housing affordability and income adequacy. [ABSTRACT FROM AUTHOR]

Objective: To determine the extent to which identified nutrient inadequacies in the dietary intakes of a sample of food-insecure women could be ameliorated by increasing their access to the 'healthy' foods they typically eat.Design: Merged datasets of 226 food-insecure women who provided at least three 24-hour dietary intake recalls over the course of a month. Dietary modelling, with energy adjustment for severe food insecurity, explored the effect of adding a serving of the woman's own, and the group's typically chosen, nutrient-rich foods on the estimated prevalence of nutrient inadequacy.Setting and Subjects: One study included participants residing in 22 diverse community clusters from the Atlantic Provinces of Canada, and the second study included food bank attendees in Toronto, Ontario, Canada. Of the 226 participants, 78% lived alone with their children.Results: While nutritional vulnerability remained after modelling, adding a single serving of either typically chosen 'healthy' foods from women's own diets or healthy food choices normative to the population reduced the prevalence of inadequacy by at least half for most nutrients. Correction for energy deficits resulting from severe food insecurity contributed a mean additional 20% improvement in nutrient intakes.Conclusions: Food-insecure women would sustain substantive nutritional gains if they had greater access to their personal healthy food preferences and if the dietary compromises associated with severe food insecurity were abated. Increased resources to access such choices should be a priority. [ABSTRACT FROM AUTHOR]

Objectives: To examine the associations of adiposity, dietary restraint and other personal characteristics with energy reporting quality.Design/subjects: Secondary analysis of 230 women and 158 men from the 1997/98 Ontario Food Survey.Methods: Energy reporting quality was estimated by ratios of energy intake (EI) to both basal metabolic rate (BMR) and total energy expenditure (TEE). Multivariate regression analyses were conducted to examine energy reporting quality between two dietary recalls and in relation to body mass index (BMI) with adjustment for potential confounders. Energy reporting quality was explored across categories of age, BMI, income, education, dieting status and food insecurity through analysis of variance (ANOVA).Results: From the ANOVA, energy reporting quality was associated with BMI group, age category and weight loss for men and women, as well as with education among women (P 0.05). EI:BMR and EI:TEE on the first and second 24-hour recalls were positively related (P < 0.0001 for men and women). A higher proportion of variance in energy reporting quality was explained for women than for men (R2 = 0.19 and 0.14, respectively).Conclusions: Studies of diet and adiposity are probably hindered to some extent by BMI-related variation in energy reporting quality. Methods to address this issue are urgently needed if population surveys will continue to serve as the primary source of dietary intake data. [ABSTRACT FROM AUTHOR]

Objectives: To compare food expenditure patterns between low-income households and higher- income households in the Canadian population, and to examine the relationship between food expenditure patterns and the presence or absence of housing payments among low-income households.Design: Secondary data analysis of the 1996 Family Food Expenditure Survey conducted by Statistics Canada.Setting: Sociodemographic data and 1-week food expenditure data for 9793 households were analysed.Subjects: Data were collected from a nationally representative sample drawn through stratified multistage sampling. Low-income households were identified using Statistics Canada's Low Income Measures.Results: Total food expenditures, expenditures at stores and expenditures in restaurants were lower among low-income households compared with other households. Despite allocating a slightly greater proportion of their food dollars to milk products, low-income households purchased significantly fewer servings of these foods. They also purchased fewer servings of fruits and vegetables than did higher-income households. The effect of low income on milk product purchases persisted when the sample was stratified by education and expenditure patterns were examined in relation to income within strata. Among low-income households, the purchase of milk products and meat and alternatives was significantly lower for households that had to pay rents or mortgages than for those without housing payments.Conclusions: Our findings indicate that, among Canadian households, access to milk products and fruits and vegetables may be constrained in the context of low incomes. This study highlights the need for greater attention to the affordability of nutritious foods for low-income groups. [ABSTRACT FROM AUTHOR]

This study investigated food intake patterns and contextual factors related to household food insecurity with hunger among a sample of 153 women in families seeking charitable food assistance in Toronto. Women in households characterized by food insecurity with severe or moderate hunger over the past 30 d (as assessed by the Food Security Module) reported lower intakes of vegetables and fruit, and meat and alternatives than those in households with no hunger evident. Women were more likely to report household food insecurity with hunger over the past 12 mo and 30 d if they also reported longstanding health problems or activity limitations, or if they were socially isolated. The circumstances that women identified as precipitating acute food shortages in their households included chronically inadequate incomes; the need to meet additional, unusual expenditures; and the need to pay for other services or accumulated debts. Women who reported delaying payments of bills, giving up services, selling or pawning possessions, or sending children elsewhere for a meal when threatened with acute food shortages were more likely to report household food insecurity with hunger. These findings suggest that expenditures on other goods and services were sometimes foregone to free up money for food, but the reverse was also true. Household food insecurity appears inextricably linked to financial insecurity. [ABSTRACT FROM AUTHOR]

A study of food insecurity and nutritional adequacy was conducted with a sample of 153 women in families receiving emergency food assistance in Toronto, Canada. Contemporaneous data on dietary intake and household food security over the past 30 d were available for 145 of the women. Analyses of these data revealed that women who reported hunger in their households during the past 30 d also reported systematically lower intakes of energy and a number of nutrients. The effect of household-level hunger on intake persisted even when other economic, socio-cultural, and behavioral influences on reported dietary intake were considered. Estimated prevalences of inadequacy in excess of 15% were noted for Vitamin A, folate, iron, and magnesium in this sample, suggesting that the low levels of intake associated with severe household food insecurity are in a range that could put women at risk of nutrient deficiencies. [ABSTRACT FROM AUTHOR]

Abstract Title An exploration of socioeconomic variation in lifestyle factors and adiposity in the Ontario Food Survey through structural equation models. Background Socioeconomic indicators have been inversely associated with overweight and obesity, with stronger associations observed among women. The objective of the present secondary analysis was to examine the relationships among socioeconomic measures and adiposity for men and women participating in the Ontario Food Survey (OFS), and to explore lifestyle factors as potential mediators of these associations. Methods The cross-sectional 1997/98 OFS collected anthropometric measurements, a food frequency questionnaire, data on socio-demographics (age, sex, income, and education) and physical activity from 620 women and 467 men, ages 18 to 75. Based on the 2003 Health Canada guidelines, waist circumference and BMI values were used to derive least risk, increased risk, and high risk adiposity groups. Structural equation modeling was conducted to examine increased risk and high risk adiposity in relation to education and income, with leisure time physical activity, fruit and vegetable intake, and smoking status included as potential mediators of these associations. Results The probability of high risk adiposity was directly associated with education (β-0.19, p < 0.05) and income (β-0.22, p < 0.05) for women, but not for men. Fruit and vegetable intake was a marginally significant mediator of the relationship between education and high risk adiposity for women. Increased risk adiposity was not associated with income or education for men or women. Conclusion The socioeconomic context of adiposity continues to differ greatly between men and women. For women only in the OFS, fruit and vegetable intake contributed to the inverse association between education and high risk adiposity; however, additional explanatory factors are yet to be determined.

In both Canada and the United States, nutrition labeling is now mandatory for most packaged foods. The labeling is intended to help consumers select foods that can contribute to a healthful diet, but current label values are based on outdated notions of nutrient requirements. The Committee on Use of Dietary Reference Intakes in Nutrition Labeling has recommended that the reference values used for nutrition labeling be based on a population-weighted Estimated Average Requirement (EAR) for any nutrient for which requirements have been estimated. This value approximates the median of the distribution of nutrient requirements for individuals who are members of the target population for food labels. It provides the most scientifically valid, single point of comparison for an appraisal of the probable contribution of a specific food to the overall nutrient needs of individuals in the target population. In contrast, a reference value based on a population coverage approach would understate the nutrient contribution of the food item relative to the requirements of the vast majority of individuals in the target population and thus offer misinformation rather than positive guidance to the consumer. Copyright © 2006 American Society for Nutrition [ABSTRACT FROM AUTHOR]

Background: Household food insecurity (HFI) has been associated with suboptimal breastfeeding practices. Postpartum factors reported by caregivers include stressful life circumstances and maternal diet quality concerns. It is unknown whether prenatal breast milk feeding intentions, a well-established predictor of breastfeeding outcomes, differ by HFI status. We explored associations between HFI and prenatal intentions to feed any and only breast milk in the first 6 months postpartum, and achievement of these intentions., Methods: We utilized data from self-identified biological mothers with children 6-12 months of age who responded to a retrospective, cross-sectional online infant feeding survey conducted in Nova Scotia, Canada. HFI (yes/no) was assessed using the Household Food Security Survey Module. Prenatal intentions to feed any and only breast milk were assessed based on responses to five options for infant milk feeding plans. Achievement of intentions was assessed by breast milk and formula feeding practices in the first 6 months. Multivariable logistic regressions were conducted, adjusting for maternal socio-demographics., Results: Among 459 respondents, 28% reported HFI; 88% intended to feed any breast milk and 77% intended to feed only breast milk, with no difference by HFI status. Of those intending to feed any breast milk, 99% succeeded, precluding further analysis. Among mothers who intended to provide only breast milk, only 51% achieved their intention, with lower odds among those with HFI (aOR 0.54, 95% CI 0.29-0.98)., Conclusion: HFI was not associated with intentions for feeding breast milk in the first 6 months postpartum, but mothers with HFI were less likely to achieve their intention to provide only breast milk. Further research is needed to understand the underlying reasons for this and to guide intervention designs to address HFI and help mothers reach their breastfeeding goals., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Francis, Mildon, Tarasuk and Frank.)

Objective: The objective of this systematic review is to synthesise the evidence on public policy interventions and their ability to reduce household food insecurity (HFI) in Canada., Design: Four databases were searched up to October 2023. Only studies that reported on public policy interventions that might reduce HFI were included, regardless of whether that was the primary purpose of the study. Title and abstract screening, full-text screening, data extraction, risk of bias and certainty of the evidence assessments were conducted by two reviewers., Results: Seventeen relevant studies covering three intervention categories were included: income supplementation, housing assistance programmes and food retailer subsidies. Income supplementation had a positive effect on reducing HFI with a moderate to high level of certainty. Housing assistance programmes and food retailer studies may have little to no effect on HFI; however, there is low certainty in the evidence that could change as evidence emerges., Conclusion: The evidence suggests that income supplementation likely reduces HFI for low-income Canadians. Many questions remain in terms of how to optimise this intervention and additional high-quality studies are still needed.

Background: Food insecurity is a serious public health problem and is linked to the mental health of children and adolescents; however, its relationship with mental health service use is unknown. We sought to estimate the association between household food insecurity and contact with health services for mental or substance use disorders among children and adolescents in Ontario, Canada., Methods: We used health administrative data, linked to 5 waves of the Canadian Community Health Survey, to identify children and adolescents (aged 1-17 yr) who had a household response to the Household Food Security Survey Module. We identified contacts with outpatient and acute care services for mental or substance use disorders in the year before survey completion using administrative data. We estimated prevalence ratios for the association between household food insecurity and use of mental health services, adjusting for several confounding factors., Results: The sample included 32 321 children and adolescents, of whom 5216 (16.1%) were living in food-insecure households. Of the total sample, 9.0% had an outpatient contact and 0.6% had an acute care contact for a mental or substance use disorder. Children and adolescents in food-insecure households had a 55% higher prevalence of outpatient contacts (95% confidence interval [CI] 41%-70%), and a 74% higher prevalence of acute care contacts (95% CI 24%-145%) for a mental or substance use disorder, although contacts for substance use disorders were uncommon., Interpretation: Children and adolescents living in a food-insecure household have greater use of health services for mental or substance use disorders than those living in households without food insecurity. Focused efforts to support food-insecure families could improve child and adolescent mental health and reduce strain on the mental health system., Competing Interests: Competing interests: Kelly Anderson reports funding from the Department of Psychiatry Seed Fund Competition, the Petro Canada Young Innovator Award and the Canadian Institutes of Health Research. Kristin Clemens reports honoraria from the CPD Network and the Canadian Medical and Surgical Knowledge Translation Research Group. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Objective: To assess the prevalence, severity and socio-demographic predictors of household food insecurity among vulnerable women accessing the Canada Prenatal Nutrition Program (CPNP) and to examine associations between household food insecurity and breastfeeding practices to 6 months., Design: Cohort investigation pooling data from two studies which administered the 18-item Household Food Security Survey Module at 6 months postpartum and collected prospective infant feeding data at 2 weeks and 2, 4 and 6 months. Household food insecurity was classified as none, marginal, moderate or severe. Logistic regression analyses were performed to assess predictors of household food insecurity and associations between household food security (any and severity) and continued and exclusive breastfeeding., Setting: Three Toronto sites of the CPNP, a federal initiative targeting socially and/or economically vulnerable women., Participants: 316 birth mothers registered prenatally in the CPNP from 2017 to 2020., Results: Household food insecurity at 6 months postpartum was highly prevalent (44 %), including 11 % in the severe category. Risk of household food insecurity varied by CPNP site ( P < 0·001) and was higher among multiparous participants (OR 2·08; 95 % CI 1·28, 3·39). There was no association between the prevalence or severity of food insecurity and continued or exclusive breastfeeding to 6 months postpartum in the adjusted analyses., Conclusions: Household food insecurity affected nearly half of this cohort of women accessing the CPNP. Further research is needed on household food insecurity across the national CPNP and other similar programmes, with consideration of the implications for programme design, service delivery and policy responses.

Objectives: Household food insecurity is almost four times more prevalent among adolescents than among older adults in Canada, and it adversely affects their health. Our objective was to describe the sociodemographic and geographic patterning of household food insecurity among adolescents., Methods: Our analytic sample comprised all 12-17-year-old respondents to the 2017-2018 Canadian Community Health Survey with complete data on household food insecurity (n = 8416). We used bivariate and multivariable logistic regression models to identify respondent- and household-level sociodemographic characteristics associated with household food insecurity., Results: The prevalence of household food insecurity among adolescents was 20.7%. The adjusted odds of food insecurity were significantly elevated among adolescents who identified as Black or Indigenous (aOR 1.80), those living with a single parent (aOR 1.60), those living with a greater number of children ≤ 5 years (aOR 1.45) or 12-17 years (aOR 1.25), those in rented accommodation (aOR 1.98), those in households with only secondary school education (aOR 1.38), and those in households reliant on social assistance (aOR 2.03). Higher before-tax income was protective (aOR 0.99). In comparison with Ontario, the adjusted odds of food insecurity among adolescents were higher in Nunavut (aOR 6.77), Northwest Territories (aOR 2.11), and Alberta (aOR 1.48), and lower in Manitoba (aOR 0.66)., Conclusion: The markedly higher odds of exposure to household food insecurity among adolescents who are Black or Indigenous and those living in households characterized by markers of social and economic disadvantage highlight the need for more effective policy interventions to protect vulnerable families from this hardship., (© 2023. The Author(s).)

Background: The results of several recent campus-based studies indicate that over half of post-secondary students in Canada are food insecure, but the vulnerability of this group has not been considered in research on predictors of food insecurity in the Canadian population. Our objectives were to (1) compare the prevalence of food insecurity among post-secondary students and non-students of similar age; (2) examine the relationship between student status and food insecurity among young adults while accounting for sociodemographic characteristics; and (3) identify the sociodemographic characteristics associated with food insecurity among post-secondary students., Methods: Using data from the 2018 Canadian Income Survey, we identified 11,679 young adults aged 19-30 and classified them into full-time postsecondary students, part-time post-secondary students, and non-students. Food insecurity over the past 12 months was assessed with the 10-item Adult Scale from the Household Food Security Survey Module. Multivariable logistic regression analyses were used to estimate the odds of food insecurity by student status while accounting for sociodemographic characteristics, and to identify sociodemographic characteristics predictive of food insecurity among post-secondary students., Results: The prevalence of food insecurity was 15.0% among full-time postsecondary students, 16.2% among part-time students, and 19.2% among non-students. After adjusting for sociodemographic factors, full-time postsecondary students had 39% lower odds of being food insecure as compared to non-students (aOR 0.61, 95% CI 0.50-0.76). Among postsecondary students, those with children (aOR 1.93, 95%CI 1.10-3.40), those living in rented accommodation (aOR 1.60, 95%CI 1.08-2.37), and those in families reliant on social assistance (aOR 4.32, 95%CI 1.60-11.69) had higher adjusted odds of food insecurity, but having at least a Bachelor's degree appeared protective (aOR: 0.63, 95% CI 0.41-0.95). Every $5000 increase in adjusted after-tax family income was also associated with lower adjusted odds of food insecurity (aOR 0.88, 95%CI 0.84-0.92) among post-secondary students., Conclusions: In this large, population-representative sample, we found that young adults who did not attend post-secondary school were more vulnerable to food insecurity, particularly severe food insecurity, than full-time post-secondary students in Canada. Our results highlight the need for research to identify effective policy interventions to reduce food insecurity among young, working-age adults in general., (© 2023. The Author(s).)

Introduction: Household food insecurity (HFI) is a persistent public health issue in Canada that may have disproportionately affected certain subgroups of the population during the COVID-19 pandemic. The purpose of this systematic review is to report on the prevalence of HFI in the Canadian general population and in subpopulations after the declaration of the COVID-19 pandemic in March 2020., Methods: Sixteen databases were searched from 1 March 2020 to 5 May 2021. Abstract and full-text screening was conducted by one reviewer and the inclusions verified by a second reviewer. Only studies that reported on the prevalence of HFI in Canadian households were included. Data extraction, risk of bias and certainty of the evidence assessments were conducted by two reviewers., Results: Of 8986 studies identified in the search, four studies, three of which collected data in April and May 2020, were included. The evidence concerning the prevalence of HFI during the COVID-19 pandemic is very uncertain. The prevalence of HFI (marginal to severe) ranged from 14% to 17% in the general population. Working-age populations aged 18 to 44 years had higher HFI (range: 18%-23%) than adults aged 60+ years (5%-11%). Some of the highest HFI prevalence was observed among households with children (range: 19%-22%), those who had lost their jobs or stopped working due to COVID-19 (24%-39%) and those with job insecurity (26%)., Conclusion: The evidence suggests that the COVID-19 pandemic may have slightly increased total household food insecurity in Canada during the COVID-19 pandemic, especially in populations that were already vulnerable to HFI. There is a need to continue to monitor HFI in Canada., Competing Interests: The authors have no conflicts of interest.

Objectives: The prevalence of household food insecurity in Newfoundland and Labrador (NL) fell sharply between 2007 and 2011, but it appears to have risen since then. Our objective was to compare the prevalence of food insecurity between 2011-2012 and 2017-2018 in relation to population socio-demographic characteristics., Methods: Our analytic sample comprised all NL households in the Canadian Community Health Survey (CCHS) cycles 2011-2012 and 2017-2018, n = 6800. We stratified the prevalence of household food insecurity for each cycle by socio-demographic characteristics and applied multivariable logistic regression models to determine food insecurity odds in 2017-2018 compared with 2011-2012 after controlling for socio-demographic covariates. Interactions of covariates with survey cycle were tested and models stratified when warranted., Results: The prevalence of food insecurity rose from 12.0% (95% CI 10.5, 13.6) in 2011-2012 to 14.7% (95% CI 13.1, 16.6) in 2017-2018. After adjusting for household socio-demographic variables, the odds of food insecurity was 1.49 (95% CI 1.27, 1.75) in 2017-2018. The prevalence of food insecurity had increased significantly among unattached individuals, renters, households with low educational attainment, and households with income above the Low Income Measure, with concomitant increases in the contribution of these groups to the total provincial prevalence of food insecurity in 2017-2018 compared with that in 2011-2012., Conclusion: The odds of food insecurity among NL households increased significantly from 2011-2012 to 2017-2018. Given the serious negative health implications of household food insecurity, the province should draw on the lessons from its earlier success in food insecurity reduction to reverse the current trend., (© 2021. The Author(s) under exclusive license to The Canadian Public Health Association.)

Background: Food insecurity, inadequate access to food due to financial constraints, is a major public health issue in the United States and Canada, where the same 18-item questionnaire is used to monitor food insecurity. Researchers often assume that findings on food insecurity from the 2 countries are comparable with each other, but there are between-country differences in how food insecurity status is determined., Objectives: We aimed to compare the distribution of household food insecurity in the Canadian population applying the US and Canadian classification schemes. We also examined the extent to which associations between food insecurity and adults' health differ under the 2 schemes., Methods: We used the population-representative Canadian Community Health Survey 2005-2017 linked to administrative health records. Food insecurity was measured by the Household Food Security Survey Module. Adults 18 y and older with valid food insecurity status were included from all jurisdictions except Quebec (n = 403,200). We cross-tabulated food insecurity status classified by the US and Canadian schemes. We also fitted logistic regressions on self-reported and objective health measures adjusting for confounders., Results: Applying the Canadian classification scheme, 7.7% of households were food insecure; the number fell to 6.0% with the US scheme. Associations between food insecurity status and health measures were mostly similar across classification schemes, although the associations between food insecurity and self-reported health were slightly larger if the US scheme was applied. Marginal food security/insecurity was associated with worse health measures irrespective of the classification scheme. United States-Canada discordance in classification of marginal food security/insecurity had a limited effect on health prediction., Conclusions: United States-Canada differences in classification affected the apparent distribution of household food insecurity but not the associations between food insecurity and measures of adult health. Marginal food security/insecurity should be set apart from the food-secure group for trend monitoring and health research., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Objective: To examine the relationship between the dietary quality of Canadian children and adults and household food insecurity status., Design: Dietary intake was assessed with one 24-h recall. Households were classified as food secure or marginally, moderately or severely food insecure based on their responses to the Household Food Security Survey Module. We applied multivariable analyses of variance to determine whether % energy from ultra-processed foods, fruit and vegetable intake, Healthy Eating Index (HEI) scores, macronutrient composition and micronutrient intakes per 1000 kcal differed by food insecurity status after accounting for income, education and region. Analyses were run separately for children 1-8 years and 9-18 years and men and women 19-64 years of age., Setting: Ten provinces in Canada., Participants: Respondents to the 2015 Canadian Community Health Survey-Nutrition, aged 1-64 years, with complete food insecurity data and non-zero energy intakes, N 15 909., Results: Among adults and children, % energy from ultra-processed foods was strongly related to severity of food insecurity, but no significant trend was observed for fruit and vegetable intake or HEI score. Carbohydrate, total sugar, fat and saturated fat intake/1000 kcal did not differ by food insecurity status, but there was a significant negative trend in protein/1000 kcal among older children, a positive trend in Na/1000 kcal among younger children and inverse associations between food insecurity severity and several micronutrients/1000 kcal among adults and older children., Conclusions: With more severe household food insecurity, ultra-processed food consumption was higher, and diet quality was generally lower among both adults and children.

Objective: The cost of food is a key influence on diet. The majority of diet cost studies match intake data from population-based surveys to a single source of food supply prices. Our aim was to examine the methodological significance of using food supply data to price dietary intakes., Methods: Nationally representative 24-hour dietary recall data from the 2015 Canadian Community Health Survey-Nutrition (CCHS-N) was matched to the 2015 Canadian Consumer Price Index (CPI) food price list. Proportions and means of reported intakes covered by the 2015 CPI price list were used to compare reported intakes of food groups and food components of interest and concern overall, and by quartile of CPI coverage., Setting: Canada., Participants: 20,487 Canadians ages one and older., Results: The CPI covered on average 76.3% of total dietary intake (g) without water. Staple food groups that were more commonly consumed had better CPI price coverage than those less commonly consumed. Yet some food groups (vegetables, additions, sweets) that were also commonly consumed by Canadians were not well covered by price data. Individuals in the poorest CPI coverage quartile reported consuming significantly greater fibre (g), gram weight (g), dietary fibre (g), and energy (kcal) as compared to those with the best coverage., Conclusions: Differential CPI price coverage exists among food components and commonly consumed food groups; additionally dietary intake differs significantly in the population by CPI coverage. Methodological refinements are needed to better account for error when using prices from food supply data to estimate diet costs.

Background: As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals' pain-driven emergency department visits., Methods: We designed a cross-sectional study linking the Canadian Community Health Survey 2005-2017 to the National Ambulatory Care Reporting System 2003-2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chest-throat pain, abdomen-pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non-pain-driven emergency department visits in the models., Results: The sample contained 212 300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [CI] 1.20-1.68), 1.64 (95% CI 1.37-1.96) and 1.99 (95% CI 1.61-2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents. Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits., Interpretation: Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization., Competing Interests: Competing interests: None declared., (© 2022 CMA Impact Inc. or its licensors.)

Introduction: The Canada Prenatal Nutrition Program (CPNP) supports community organizations to provide maternal-infant health services for socially/economically vulnerable women. As part of our research program exploring opportunities to provide postnatal breastfeeding support through the CPNP, we investigated the sociodemographic and psychosocial characteristics of clients enrolled in a Toronto CPNP site and explored associations with participation., Methods: Data were collected retrospectively from the charts of 339 women registered in one southwest Toronto CPNP site from 2013 to 2016. Multivariable regression analyses were used to assess associations between 10 maternal characteristics and three dimensions of prenatal program participation: initiation (gestational age at enrolment in weeks), intensity (number of times one-on-one supports were received) and duration (number of visits)., Results: The mean (SD) age of clients was 31 (5.7) years; 80% were born outside of Canada; 29% were single; and 65% had household incomes below the Statistics Canada family size-adjusted low-income cut-offs. Income was the only characteristic associated with all dimensions of participation. Compared to clients living above the low-income cut-off, those living below the low-income cut-off enrolled in the program 2.85 weeks earlier (95% CI: -5.55 to -0.16), had 1.29 times higher number of one-on-one supports (95% CI: 1.03 to 1.61) and had 1.29 times higher number of program visits (95% CI: 1.02 to 1.63)., Conclusion: Our findings show that this CPNP site serves vulnerable women, with few differences in participation based on maternal characteristics. This evidence can guide service provision and monitoring decisions at this program site. Further research is needed to explore new program delivery models to enhance perinatal services for vulnerable women., Competing Interests: The authors declare that they have no conflicts of interest

Objectives: To understand the differential vulnerability to household food insecurity of the Black population as compared with white counterparts in Canada., Methods: Using data for households with Black and white respondents in pooled Canadian Community Health Survey cycles from 2005 to 2014, the 18-question Household Food Security Survey Module was analyzed (N = 491,400). Bivariate and multivariate logistic and multinomial regression models were run using respondent's race, immigration status, and six well-established predictors of household food insecurity in the general population. Additional multivariable logistic regression models were run, with race interacted with each predictor individually to yield predicted probabilities., Results: The weighted prevalence of household food insecurity was 10.0% for white respondents and 28.4% for Black respondents. The odds of Black households being food-insecure as compared with white households fell from 3.56 (95% CI: 3.30-3.85) to 1.88 (95% CI: 1.70-2.08) with adjustment for household socio-demographic characteristics. In contrast with white households, there was relative homogeneity of risk of food insecurity among Black subgroups defined by immigration status, household composition, education, and province of residence. Homeownership was associated with lower probabilities of food insecurity for Black and white households, but the probability among Black owners was similar to that for white renters (14.7% vs. 14.3%). Black households had significantly higher predicted probabilities of food insecurity than their white counterparts across all main sources of household income except child benefits and social assistance., Conclusion: Being racialized as Black appears to be an overriding factor shaping vulnerability to food insecurity for the Black population in Canada. Future research and public policy on food insecurity should seriously consider the role of racism at the systemic and institutional levels., (© 2021. The Canadian Public Health Association.)

Background: Food insecurity, as an indicator of socioeconomic disadvantages and a determinant of health, may be associated with injury by increasing risk exposure and hampering risk mitigation. We examined the association between food insecurity and common causes of injury in the general population., Methods: Linking the Canadian Community Health Survey 2005-2017 to National Ambulatory Care Reporting System 2003-2017, this retrospective cohort study estimated incidence of injury-related emergency department (ED) visits by food insecurity status among 212,300 individuals 12 years and above in the Canadian provinces of Ontario and Alberta, adjusting for prior ED visits, lifestyle, and sociodemographic characteristics including income., Results: Compared to those in food-secure households, individuals from moderately and severely food-insecure households had 1.16 (95% confidence interval [CI] 1.07-1.25) and 1.35 (95% CI 1.24-1.48) times higher incidence rate of ED visits due to injury, respectively, after confounders adjustment. The association was observed across sex and age groups. Severe food insecurity was associated with intentional injuries (adjusted rate ratio [aRR] 1.81; 95% CI 1.29-2.53) including self-harm (aRR 1.87; 95% CI 1.03-3.40) and violence (aRR 1.79; 95% CI 1.19-2.67) as well as non-intentional injuries (aRR 1.34; 95% CI 1.22-1.46) including fall (aRR 1.43; 95% CI 1.24-1.65), medical complication (aRR 1.39; 95% CI 1.06-1.82), being struck by objects (aRR 1.43; 95% CI 1.07-1.91), overexertion (aRR 1.31; 95% CI 1.04-1.66), animal bite or sting (aRR 1.60; 95% CI 1.08-2.36), skin piercing (aRR 1.80; 95% CI 1.21-2.66), and poisoning (aRR 1.65; 95% CI 1.05-2.59). Moderate food insecurity was associated with more injuries from violence (aRR 1.56; 95% CI 1.09-2.21), falls (aRR 1.22; 95% CI 1.08-1.37), being struck (aRR 1.20; 95% CI 1.01-1.43), and overexertion (aRR 1.25; 95% CI 1.04-1.50). Moderate and severe food insecurity were associated with falls on stairs and being struck in non-sports settings but not with falls on same level or being struck during sports. Food insecurity was not related to transport injuries., Conclusions: Health inequity by food insecurity status extends beyond diseases into differential risk of injury, warranting policy intervention. Researchers and policymakers need to address food insecurity as a social determinant of injury to improve health equity., (© 2021. The Author(s).)

Background: Levels of child malnutrition and hunger across the world have decreased substantially over the past century, and this has had an important role in reducing mortality and improving health. However, progress has stalled. We examined whether family policies (eg, cash transfers from governments that aim to support households with children) are associated with reduced food insecurity., Methods: In this observational analysis, we used a dataset of individual-level data that captured experience-based measures of food insecurity and sociodemographic characteristics collected by the Gallup World Poll in 142 countries for 2014-17. We then combined this dataset with indicators of the type and generosity of family policies in these countries, taken from the University of California, Los Angeles' World Policy Analysis Center. We used multilevel regression models to examine the association between the presence of family policies for households with children and the probability of reporting moderate or severe food insecurity or severe food insecurity (moderate or severe food insecurity was defined as a "yes" response to at least four of eight questions on the Gallup Food Insecurity Experience Scale, and severe food insecurity was defined as a "yes" response to at least seven questions). We controlled for multiple covariates, including individual-level measures of social position and country-level measures, such as gross domestic product. We further examined whether this association varied by household income level., Findings: Using data from 503 713 households, we found that, on average, moderate or severe food insecurity is 4·09 percentage points (95% CI 3·50-4·68) higher in households with at least one child younger than 15 years than in households with no children and severe food insecurity is 2·20 percentage points (1·76-2·63) higher. However, the additional risk of food insecurity among households with children is lower in countries that provide financial support (either means-tested or universal) for families than for countries with little or no financial assistance. These policies not only reduce food insecurity on average, but they also reduce inequalities in food insecurity by benefiting the poorest households most., Interpretation: In some countries, family policies have been cut back in the past decade and such retrenchment might expose low-income households to increased risk of food insecurity. By increasing investment in family policies, progress towards Sustainable Development Goal 2, zero hunger, might be accelerated and, in turn, improve health for all., Funding: Wellcome Trust., Competing Interests: Declaration of interests We declare no competing interests. The Food Insecurity Experience Scale was collected as part of the Gallup World Poll. The FAO commissioned Gallup to include this scale on their survey and purchased a number of licenses to share with researchers. Our research team applied for access to the data and were awarded one of these licenses., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: In Canada, regulatory changes have expanded marketing opportunities for voluntarily fortified products (VFPs), with micronutrient additions permitted at levels well in excess of human requirements., Objective: To examine how the consumption of VFPs relates to usual nutrient intakes in the Canadian population., Design: The 2015 Canadian Community Health Survey comprises single 24-h dietary intake recalls on a population-representative sample of 20,487 individuals aged 1 year and older, with second recalls on a subset of 7,608. The intake data included 15 food codes denoting VFP (e.g. energy drinks, fortified beverages, cereals, and bars). We assessed VFP consumption and estimated usual intake distributions for riboflavin, niacin, zinc, and vitamins A, B6, B12, and C for VFP consumers and non-consumers 14-50 years old ( n = 8,442) using the National Cancer Institute method. We applied the 'shrink and add' method to estimate usual intakes among supplement users and assessed apparent benefits and risks by comparing usual intake distributions to EARs and ULs., Results: Only 2.4% of the population reported any consumption of VFP on the first 24-h recall. VFP consumers were overrepresented in the upper quartile of population intake distributions for niacin, riboflavin, vitamin B6, vitamin B12, and zinc. The median usual intakes of VFP consumers were 24-111% higher than the median usual intakes of non-consumers, and VFP consumers had significantly lower prevalence of inadequacy for riboflavin and vitamins A, B6, B12, and C. Irrespective of VFP consumption, usual intake distributions reached the ULs for vitamin A and zinc with the addition of supplement intakes., Discussion: Given the limited differentiation of VFP in this survey, we have likely underestimated nutrient exposure levels., Conclusions: VFP consumption was associated with elevated usual nutrient intakes, but we found limited evidence that it protected consumers from nutrient inadequacies or propelled intakes above tolerable upper levels., Competing Interests: The authors declare no potential conflicts of interests. The authors have not received any funding or benefits from industry to conduct this study., (© 2021 Tarasuk and Brassard.)

Objectives. To examine the association between wage-setting policy and food insecurity. Methods. We estimated multilevel regression models, using data from the Gallup World Poll (2014-2017) and UCLA's World Policy Analysis Center, to examine the association between wage setting policy and food insecurity across 139 countries (n = 492 078). Results. Compared with countries with little or no minimum wage, the probability of being food insecure was 0.10 lower (95% confidence interval = 0.02, 0.18) in countries with collective bargaining. However, these associations varied across employment status. More generous wage-setting policies (e.g., collective bargaining or high minimum wages) were associated with lower food insecurity among full-time workers (and, to some extent, part-time workers) but not those who were unemployed. Conclusions. In countries with generous wage-setting policies, employed adults had a lower risk of food insecurity, but the risk of food insecurity for the unemployed was unchanged. Wage-setting policies may be an important intervention for addressing risks of food insecurity among low-income workers.

Chronic pain has been on the rise in recent decades in Canada. Accordingly, the use of prescription opioids (PO) in Canada increased drastically between 2005 and 2014, only starting to decrease in 2015. Both pain and PO use have serious public health repercussions, disproporionately affecting select socially disadvantaged populations. Food insecurity is a strong risk factor for mental disorders and suicidal outcomes, yet its relationship to chronic pain and PO use is largely unknown. Using two recent cycles from the population representative Canadian Community Health Survey (CCHS), we examined the association of household food insecurity status with chronic pain and PO use among Canadians 12 years and older, adjusting for health and sociodemographic characteristics. Compared to food-secure individuals, marginally, moderately, and severely food-insecure individuals had 1.31 (95% confidence interval [CI] 1.15-1.48), 1.89 (95% CI 1.71-2.08), and 3.29 (95% CI 2.90-3.74) times higher odds of experiencing chronic pain and 1.55 (95% CI 1.30-1.85), 1.77 (95% CI 1.54-2.04), and 2.65 (95% CI 2.27-3.09) times higher odds of using PO in the past year, respectively. The graded association with food insecurity severity was also found in severe pain experience and pain-induced activity limitations among chronic pain patients and, less consistently, in intensive, excess, and alternative use of PO and its acquisition through means other than medical prescription among past-year PO users. Food insecurity was a much more powerful predictor of chronic pain and PO use than other well-established social determinants of health like income and education. Policies reducing food insecurity may lower incidence of chronic pain and help contain the opioid crisis., Competing Interests: The authors declared no competing interests., (© 2021 The Author(s).)

Background: In Canada, 91% of all mothers initiate breastfeeding, but 40-50% stop by 6 months and only 34% breastfeed exclusively for 6 months, with lower rates among socially and/or economically vulnerable women. The Canada Prenatal Nutrition Program (CPNP) aims to support breastfeeding among vulnerable women, but there is no formal framework or funding for sites to integrate proactive postnatal breastfeeding support. This research aimed to i) describe infant feeding practices among clients of one Toronto CPNP site using charitable funds to offer a lactation support program (in-home lactation consultant visits, breast pumps); ii) determine whether breastfeeding outcomes at 6 months differ based on maternal sociodemographics and food insecurity; and iii) assess utilization of the lactation support program., Methods: Infant feeding practices were collected prospectively at 2 weeks, 2, 4 and 6 months postpartum via telephone questionnaires (n = 199). Maternal sociodemographics were collected at 2 weeks and food insecurity data at 6 months postpartum. Program monitoring records were used to determine utilization of the lactation support program., Results: Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump., Conclusions: This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women. Study registered at clinicaltrials.gov as NCT03400605 .

Background: Household food insecurity has been associated with pregnancy complications and poorer birth outcomes in the United States and with maternal mental disorders in the United Kingdom, but there has been little investigation of the effects of food insecurity during this life stage in Canada., Objectives: Our objective was to examine the relationship between the food insecurity status of women during pregnancy and maternal and birth outcomes and health in infancy in Canada., Methods: We drew on data from 1998 women in Ontario, Canada, whose food insecurity was assessed using the Household Food Security Survey Module on the Canadian Community Health Survey, cycles 2005 to 2011-2012. These records were linked to multiple health administrative databases to identify indications of adverse health outcomes during pregnancy, at birth, and during children's first year of life. We included women who gave birth between 9 months prior and 6 months after their interview date, and for whom infant outcome data were available. Multivariable Poisson regression models were used to compare outcomes by maternal food security status, expressed as adjusted relative risks (aRR) with 95% CIs., Results: While pregnant, 5.6% of women were marginally food insecure and 10.0% were moderately or severely food insecure. Food insecurity was unrelated to pregnancy complications and adverse birth outcomes, but 26.8% of women with moderate or severe food insecurity had treatment for postpartum mental disorders in the 6-month postpartum period, compared to 13.9% of food-secure women (aRR, 1.86; 95% CI, 1.40-2.46). Children born to food-insecure mothers were at elevated risk of being treated in an emergency department in the first year of life (aRR, 1.18; 95% CI, 1.01-1.38)., Conclusions: Maternal food insecurity during pregnancy in Ontario, Canada, is associated with postpartum mental disorders and a greater likelihood of infants being treated in an emergency department., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Background: The prevalence of food insecurity among adults over 65 in Canada is less than half of that among adults approaching 65, possibly due in part to the public pension universally disbursed from the age of 65. Given research associating food insecurity with higher risk of premature mortality, our objective was to determine the likelihood that food-insecure adults with incomes below the national median would live past 65 to collect the public pension., Methods: We linked respondents of the Canadian Community Health Survey 2005-15 to the death records from the Canadian Vital Statistics Database 2005-17. We assessed household food insecurity status through a validated 18-item questionnaire for 50,780 adults aged 52-64 at interview and with household income below the national median. We traced their vital status up to the age of 65. We fitted Cox proportional hazard models to compare hazard of all-cause mortality before 65 by food insecurity status while adjusting for individual demographic attributes, baseline health, and household socioeconomic characteristics. We also stratified the sample by income and analyzed the subsamples with income above and below the Low Income Measure separately., Results: Marginal, moderate, and severe food insecurity were experienced by 4.1, 7.3, and 4.5% of the sampled adults, respectively. The crude mortality rate was 49 per 10,000 person-years for food-secure adults and 86, 98, and 150 per 10,000 person-years for their marginally, moderately, and severely food-insecure counterparts, respectively. For the full sample and low-income subsample, respectively, severe food insecurity was associated with 1.24 (95% CI: 1.06, 1.45) and 1.28 (95% CI: 1.07, 1.52) times higher hazard of dying before 65 relative to food security. No association was found between food insecurity and mortality in the higher-income subsample., Conclusions: Severely food-insecure adults approaching retirement age were more likely to die before collecting public pensions that might attenuate their food insecurity. Policymakers need to acknowledge the challenges to food security and health faced by working-age adults and provide them with adequate assistance to ensure healthy ageing into retirement.

Background: Eradicating food insecurity is necessary for achieving global health goals. Liberal trade policies might increase food supplies but how these policies influence individual-level food insecurity remains uncertain. We aimed to assess the association between liberal trade policies and food insecurity at the individual level, and whether this association varies across country-income and household-income groups., Methods: For this observational analysis, we combined individual-level data from the Food and Agricultural Organization of the UN with a country-level trade policy index from the Konjunkturforschungsstelle Swiss Economic Institute. We examined the association between a country's trade policy score and the probability of individuals reporting moderate-severe or severe food insecurity using regression models and algorithmic weighting procedures. We controlled for multiple covariates, including gross domestic product, democratisation level, and population size. Additionally, we examined heterogeneity by country and household income., Results: Our sample comprised 460 102 individuals in 132 countries for the period of 2014-17. Liberal trade policy was not significantly associated with moderate-severe or severe food insecurity after covariate adjustment. However, among households in high-income countries with incomes higher than US$25 430 per person per year (adjusted for purchasing power parity), a unit increase in the trade policy index (more liberal) corresponded to a 0·07% (95% CI -0·10 to -0·04) reduction in the predicted probability of reporting moderate-severe food insecurity. Among households in the lowest income decile (<$450 per person per year) in low-income countries, a unit increase in the trade policy index was associated with a 0·35% (0·06 to 0·60) increase in the predicted probability of reporting moderate-severe food insecurity., Interpretation: The relationship between liberal trade policy and food insecurity varied across countries and households. Liberal trade policy was predominantly associated with lower food insecurity in high-income countries but corresponded to increased food insecurity among the world's poorest households in low-income countries., Funding: Joseph Rowntree Foundation, Economic and Social Research Council., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and nutrition supports to vulnerable mothers and strongly promotes breastfeeding but does not have a formal framework for postnatal lactation support. Breastfeeding duration and exclusivity rates in Canada fall well below global recommendations, particularly among socially and economically vulnerable women. We aimed to explore CPNP participant experiences with breastfeeding and with a novel community lactation support program in Toronto, Canada that included access to certified lactation consultants and an electric breast pump, if needed. Four semistructured focus groups and 21 individual interviews (n = 46 women) were conducted between September and December 2017. Data were analysed using inductive thematic analysis. Study participants reported a strong desire to breastfeed but a lack of preparation for breastfeeding-associated challenges. Three main challenges were identified by study participants: physical (e.g., pain and low milk supply), practical (e.g., cost of breastfeeding support and maternal time pressures), and breastfeeding self-efficacy (e.g., concern about milk supply and conflicting information). Mothers reported that the free lactation support helped to address breastfeeding challenges. In their view, the key element of success with the new program was the in-home visit by the lactation consultant, who was highly skilled and provided care in a non-judgmental manner. They reported this support would have been otherwise unavailable due to cost or travel logistics. This study suggests value in exploring the addition of postnatal lactation support to the well-established national CPNP as a means to improve breastfeeding duration and exclusivity among vulnerable women., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.)

Background: Food insecurity affects 1 in 8 households in Canada, with serious health consequences. We investigated the association between household food insecurity and all-cause and cause-specific mortality., Methods: We assessed the food insecurity status of Canadian adults using the Canadian Community Health Survey 2005-2017 and identified premature deaths among the survey respondents using the Canadian Vital Statistics Database 2005-2017. Applying Cox survival analyses to the linked data sets, we compared adults' all-cause and cause-specific mortality hazard by their household food insecurity status., Results: Of the 510 010 adults sampled (3 390 500 person-years), 25 460 died prematurely by 2017. Death rates of food-secure adults and their counterparts experiencing marginal, moderate and severe food insecurity were 736, 752, 834 and 1124 per 100 000 person-years, respectively. The adjusted hazard ratios (HRs) of all-cause premature mortality for marginal, moderate and severe food insecurity were 1.10 (95% confidence interval [CI] 1.03-1.18), 1.11 (95% CI 1.05-1.18) and 1.37 (95% CI 1.27-1.47), respectively. Among adults who died prematurely, those experiencing severe food insecurity died on average 9 years earlier than their food-secure counterparts (age 59.5 v. 68.9 yr). Severe food insecurity was consistently associated with higher mortality across all causes of death except cancers; the association was particularly pronounced for infectious-parasitic diseases (adjusted HR 2.24, 95% CI 1.42-3.55), unintentional injuries (adjusted HR 2.69, 95% CI 2.04-3.56) and suicides (adjusted HR 2.21, 95% CI 1.50-3.24)., Interpretation: Canadian adults from food-insecure households were more likely to die prematurely than their food-secure counterparts. Efforts to reduce premature mortality should consider food insecurity as a relevant social determinant., Competing Interests: Competing interests: None declared., (© 2020 Joule Inc. or its licensors.)

Background: Household food insecurity is a potent marker of material deprivation with adverse health consequences. Studies have repeatedly found a strong, independent relationship between owning a home and lower vulnerability to food insecurity in Canada and elsewhere, but the reasons for this relationship are poorly understood. We aimed to examine the influence of housing asset, housing debt and housing expenditure on the relationship between homeownership status and food insecurity in Canada., Methods: Cross-sectional data on food insecurity, housing tenure and expenditures, home value, income and sociodemographic characteristics were derived from the 2010 Survey of Household Spending, a population-based survey. Multivariable logistic regression models were conducted to estimate odds ratios of food insecurity among households of all incomes (n = 10,815) and those with lower incomes (n = 5547)., Results: Food insecurity prevalence was highest among market renters (28.5%), followed by homeowners with a mortgage (11.6%) and mortgage-free homeowners (4.3%). Homeowners with a mortgage (OR: 0.51, 95% CI: 0.39-0.68) and those without a mortgage (OR: 0.23, 95% CI: 0.16-0.35) had substantially lower adjusted odds of food insecurity than market renters, and accounting for the burden of housing cost had minimal impact on the association. Mortgage-free homeowners had lower adjusted odds ratios of food insecurity compared to homeowners with a mortgage, but differences in the burden of housing cost fully accounted for the association. When stratifying homeowners based on presence of mortgage and housing asset level, the adjusted odds ratios of food insecurity for market renters were not significant when compared to mortgage holders with low housing asset. Mortgage-free owners with higher housing asset were least vulnerable to food insecurity (adjusted OR: 0.18, 95% CI: 0.11-0.27)., Conclusions: Substantial disparities in food insecurity exist between households with different homeownership status and housing asset level. Housing policies that support homeownership while ensuring affordable mortgages may be important to mitigate food insecurity, but policy actions are required to address renters' high vulnerability to food insecurity.

Background: Food insecurity, defined as inadequate access to food owing to financial constraints, has been associated with poor disease management. Because cost-related nonadherence to prescription drugs is a possible explanation for such association, we examined the link between food insecurity and cost-related medication nonadherence in Canada., Methods: Drawing on data for adult respondents (age ≥ 18 yr) who participated in the Canadian Community Health Survey 2016 Rapid Response module on prescription medication use, we assessed the association between household food insecurity and cost-related nonadherence to prescription drugs in the previous 12 months. We further examined the self-perceived health consequences of cost-related nonadherence among nonadherents. We applied Poisson models with bootstrap weights adjusting for sociodemographic characteristics., Results: Of the 11 172 respondents in our sample, 930 (8.3%) reported cost-related nonadherence. Food insecurity affected 10.5% (95% confidence interval [CI] 9.1% to 11.8%) of adherents and 47.9% (95% CI 38.1% to 57.7%) of nonadherents. After adjustment for confounders, moderate and severe food insecurity were associated with 3.83 (95% CI 2.44 to 6.03) and 5.05 (95% CI 3.27 to 7.81) times higher prevalence of cost-related nonadherence, respectively, relative to food security. Despite being associated with lower probability of cost-related nonadherence, having drug insurance did not change the relation between food insecurity and cost-related nonadherence ( p > 0.1 for all interactions). Severe food insecurity was correlated with higher prevalence of health deterioration and greater use of health care services as perceived consequences of cost-related nonadherence ( p < 0.01 for both)., Interpretation: Food-insecure adults in Canada have a higher likelihood of cost-related nonadherence to prescription medications than their food-secure counterparts, which may constitute a burden on their health and lead to greater use of health care services., Competing Interests: Competing interests: None declared., (Copyright 2019, Joule Inc. or its licensors.)

Background: Household food insecurity, a measure of income-related problems of food access, is a pressing public health problem in Canada's North, especially in Nunavut. We aimed to assess the impact of Nutrition North Canada, a food retail subsidy intended to improve food access and affordability in isolated communities, on household food insecurity in Nunavut., Methods: Using data from 3250 Nunavut households sampled in the annual components of the Canadian Community Health Survey (2007 to 2016), we conducted interrupted time series regression analyses to determine whether the introduction of Nutrition North Canada was associated with changes in the rates of self-reported food insecurity, according to a validated instrument. We used propensity score weighting to control for several sociodemographic characteristics associated with food insecurity., Results: Food insecurity affected 33.1% of households in 2010 (the year before the launch of Nutrition North Canada), 39.4% of households in 2011 (the year of the launch) and 46.6% of households in 2014 (the year after full implementation). After controlling for several covariates, we found the rate of food insecurity increased by 13.2 percentage points (95% confidence interval [CI] 1.7 to 24.7) after the full implementation of the subsidy program, and the increase in food insecurity first occurred in 2011 (9.6 percentage points, 95% CI 2.7 to 16.4), the year Nutrition North Canada was launched., Interpretation: Food insecurity was a pervasive problem in Nunavut before Nutrition North Canada, but it has become even more prevalent since the program was implemented. Given the important health consequences of food insecurity, more effective initiatives to address food insecurity in Canada's North are urgently needed., Competing Interests: Competing interests: Andrée-Anne Fafard St-Germain and Valerie Tarasuk report grants from the Canadian Institutes of Health Research (CIHR) during the conduct of the study. No other competing interests were declared., (© 2019 Joule Inc. or its licensors.)

Background: Household food insecurity is a potent social determinant of health and health care costs in Canada, but understanding of the social and economic conditions that underlie households' vulnerability to food insecurity is limited., Methods: Data from the 2011-12 Canadian Community Health Survey were used to determine predictors of household food insecurity among a nationally-representative sample of 120,909 households. Household food insecurity over the past 12 months was assessed using the 18-item Household Food Security Survey Module. Households were classified as food secure or marginally, moderately, or severely food insecure based on the number of affirmative responses. Multivariable binary and multinomial logistic regression analyses were used to determine geographic and socio-demographic predictors of presence and severity of household food insecurity., Results: The prevalence of household food insecurity ranged from 11.8% in Ontario to 41.0% in Nunavut. After adjusting for socio-demographic factors, households' odds of food insecurity were lower in Quebec and higher in the Maritimes, territories, and Alberta, compared to Ontario. The adjusted odds of food insecurity were also higher among households reliant on social assistance, Employment Insurance or workers' compensation, those without a university degree, those with children under 18, unattached individuals, renters, and those with an Aboriginal respondent. Higher income, immigration, and reliance on seniors' income sources were protective against food insecurity. Living in Nunavut and relying on social assistance were the strongest predictors of severe food insecurity, but severity was also associated with income, education, household composition, Aboriginal status, immigration status, and place of residence. The relation between income and food insecurity status was graded, with every $1000 increase in income associated with 2% lower odds of marginal food insecurity, 4% lower odds of moderate food insecurity, and 5% lower odds of severe food insecurity., Conclusions: The probability of household food insecurity in Canada and the severity of the experience depends on a household's province or territory of residence, income, main source of income, housing tenure, education, Aboriginal status, and household structure. Our findings highlight the intersection of household food insecurity with public policy decisions in Canada and the disproportionate burden of food insecurity among Indigenous peoples.