Mali is one of the poorest countries in Africa, with 72 % of its population surviving on less than $US 1·00 per day. Health and demographic indicators are bleak. With few exceptions, studies related to the health of women in Mali have largely been under-represented. In addition, in recent years a new type of malnutrition stemming from weight gain and obesity has been observed throughout Africa. The present study aimed to (i) describe geographic and health variations of women of reproductive age, (ii) describe geographic variations of household salt iodine levels and (iii) investigate potential factors associated with women's anthropometric status and use of adequately iodized salt among households in Mali.

Demographic and Health Survey data, multistage-stratified cluster sampling methodology.

Rural and urban areas of Mali.

Non-pregnant women (n 6015) between the ages of 19 and 44 years.

Nineteen per cent of the women were overweight or obese while 11 % were underweight. Seventy-eight per cent of the households utilized adequately iodized salt. Underweight women were more prevalent in southern Mali, while obesity was more frequent in the north-east and within the major urban areas. Households located within the southern parts of Mali were more likely to utilize adequately iodized salt. Education, age, modern contraceptive use, breast-feeding status at time of the survey and household wealth index were significantly associated with the women's BMI or households’ use of adequately iodized salt.

The combined use of statistical and geographic system analysis contributes to improve targeting of interventions among vulnerable populations.

To compare micronutrient intakes and status in Central and Eastern Europe (CEE) with those in other European countries and with reference values.

Review of the micronutrient intake/status data from open access and grey literature sources from CEE.

Micronutrients studied were folate, iodine, Fe, vitamin B12 and Zn (for intake and status) and Ca, Cu, Se, vitamin C and vitamin D (for intake). Intake data were based on validated dietary assessment methods; mean intakes were compared with average nutrient requirements set by the Nordic countries or the US Institute of Medicine. Nutritional status was assessed using the status biomarkers and cut-off levels recommended primarily by the WHO.

For all population groups in CEE, the mean intake and mean/median status levels were compared between countries and regions: CEE, Scandinavia, Western Europe and Mediterranean.

Mean micronutrient intakes of adults in the CEE region were in the same range as those from other European regions, with exception of Ca (lower in CEE). CEE children and adolescents had poorer iodine status, and intakes of Ca, folate and vitamin D were below the reference values.

CEE countries are lacking comparable studies on micronutrient intake/status across all age ranges, especially in children. Available evidence showed no differences in micronutrient intake/status in CEE populations in comparison with other European regions, except for Ca intake in adults and iodine and Fe status in children. The identified knowledge gaps urge further research on micronutrient intake/status of CEE populations to make a basis for evidence-based nutrition policy.

To compare BMI with abdominal skinfold thickness (ASF), waist circumference and waist-to-height ratio in the prediction of insulin resistance (IR) in prepubertal Colombian children.

We calculated age- and sex-specific Z-scores for BMI, ASF, waist circumference, waist-to-height ratio and three other skinfold-thickness sites. Logistic regression with stepwise selection (P = 0·80 for entry and P = 0·05 for retention) was performed to identify predictors of IR and extreme IR, which were determined by age- and sex-specific Z-scores to identify the ≥ 90th and ≥ 95th percentile of homeostasis model assessment (HOMAIR), respectively. We used receiver operating characteristic curves to compare the area under the curve between models.

Bucaramanga, Colombia.

Children (n 1261) aged 6–10 years in Tanner stage 1 from a population-based study.

A total of 127 children (seventy girls and fifty-seven boys) were classified with IR, including sixty-three children (thirty-three girls and thirty boys) classified with extreme IR. Only ASF and BMI Z-scores were retained as predictors of IR by stepwise selection. Adding ASF Z-score to BMI Z-score improved the area under the curve from 0·794 (95 % CI 0·752, 0·837) to 0·811 (95 % CI 0·770, 0·851; P for contrast = 0·01). In predicting extreme IR, the addition of ASF Z-score to BMI Z-score improved the area under the curve from 0·837 (95 % CI 0·790, 0·884) to 0·864 (95 % CI 0·823, 0·905; P for contrast = 0·01).

ASF Z-score predicted IR independent of BMI Z-score in our population of prepubertal children. ASF and BMI Z-scores together improved IR risk stratification compared with BMI Z-score alone, opening new perspectives in the prediction of cardiometabolic risk in prepubertal children.

To inform public health approaches for chronic disease prevention, the present study identified sociodemographic, anthropometric and behavioural correlates of work, transport and leisure physical inactivity and sitting time among adults in Oman.

Cross-sectional study using the WHO STEPwise study methodology.

Sur City, Oman.

Men and women aged 20 years and older (n 1335) in the Sur City Healthy Lifestyle Study who had complete data for demographic variables (gender, age, education, work status and marital status), BMI and behavioural risk factors – smoking and dietary habits plus physical inactivity and sitting time (the outcome variables).

The highest level of physical inactivity was in the leisure domain (55·4 %); median sitting time was about 2 h/d. Gender-stratified logistic regression models found that the statistically significant (P < 0·05) correlates of inactivity (in one or more domains) were age, work status and fruit and vegetable intake in women, and age, education, work status, marital status and BMI in men. Gender-stratified linear regression models found that the statistically significant correlates of sitting time were age, work status and BMI in women and education in men.

Findings suggest that public health interventions need to be gender responsive and focus on domain-specific physical inactivity. In the Omani context, this might include gender-segregated exercise facilities to promote leisure physical activity among women and walking-friendly environmental initiatives to promote transport physical activity among men. Further evidence on barriers to physical activity and factors that influence prolonged sitting is required to develop relevant public health interventions.

To measure total daily salt intake using 24 h urinary Na excretion within a sample of Victorian schoolchildren aged 5–13 years and to assess discretionary salt use habits of children and parents.

Cross-sectional study.

Completed within a convenience sample of independent primary schools (n 9) located in Victoria, Australia.

Two hundred and sixty children completed a 24 h urine collection over a school (34 %) or non-school day (66 %). Samples deemed incomplete (n 18), an over-collection (n 1) or that were incorrectly processed at the laboratory (n 3) were excluded.

The sample comprised 120 boys and 118 girls with a mean age of 9·8 (sd 1·7) years. The average 24 h urinary Na excretion (n 238) was 103 (sd 43) mmol/24 h (salt equivalent 6·0 (sd 2·5) g/d). Daily Na excretion did not differ by sex; boys 105 (sd 46) mmol/24 h (salt equivalent 6·1 (sd 2·7) g/d) and girls 100 (sd 41) mmol/24 h (salt equivalent 5·9 (sd 2·4) g/d; P = 0·38). Sixty-nine per cent of children (n 164) exceeded the recommended daily Upper Limit for Na. Reported discretionary salt use was common: two-thirds of parents reported adding salt during cooking and almost half of children reported adding salt at the table.

The majority of children had salt intakes exceeding the recommended daily Upper Limit. Strategies to lower salt intake in children are urgently required, and should include product reformulation of lower-sodium food products combined with interventions targeting discretionary salt use within the home.

To systematically review evidence from field interventions on the effectiveness of monetary subsidies in promoting healthier food purchases and consumption.

Keyword and reference searches were conducted in five electronic databases: Cochrane Library, EconLit, MEDLINE, PsycINFO and Web of Science. Studies were included based on the following criteria: (i) intervention: field experiments; (ii) population: adolescents 12–17 years old or adults 18 years and older; (iii) design: randomized controlled trials, cohort studies or pre–post studies; (iv) subsidy: price discounts or vouchers for healthier foods; (v) outcome: food purchases or consumption; (vi) period: 1990–2012; and (vii) language: English. Twenty-four articles on twenty distinct experiments were included with study quality assessed using predefined methodological criteria.

Interventions were conducted in seven countries: the USA (n 14), Canada (n 1), France (n 1), Germany (n 1), Netherlands (n 1), South Africa (n 1) and the UK (n 1). Subsidies applied to different types of foods such as fruits, vegetables and low-fat snacks sold in supermarkets, cafeterias, vending machines, farmers’ markets or restaurants.

Interventions enrolled various population subgroups such as school/university students, metropolitan transit workers and low-income women.

All but one study found subsidies on healthier foods to significantly increase the purchase and consumption of promoted products. Study limitations include small and convenience samples, short intervention and follow-up duration, and lack of cost-effectiveness and overall diet assessment.

Subsidizing healthier foods tends to be effective in modifying dietary behaviour. Future studies should examine its long-term effectiveness and cost-effectiveness at the population level and its impact on overall diet intake.

Pre-pregnancy obesity has been associated with adverse birth outcomes. Poor essential fatty acid (EFA) and micronutrient status during pregnancy may contribute to these associations. We assessed the associations between pre-pregnancy BMI and nutritional patterns of maternal micronutrient and EFA status during mid-pregnancy.

A cross-sectional analysis from a prospective cohort study. Women provided non-fasting blood samples at ≤20 weeks’ gestation that were assayed for red cell EFA; plasma folate, homocysteine and ascorbic acid; and serum retinol, 25-hydroxyvitamin D, α-tocopherol, soluble transferrin receptors and carotenoids. These nutritional biomarkers were employed in a factor analysis and three patterns were derived: EFA, Micronutrients and Carotenoids.

The Antidepressant Use During Pregnancy Study, Pittsburgh, PA, USA.

Pregnant women (n 129).

After adjustment for parity, race/ethnicity and age, obese pregnant women were 3·0 (95 % CI 1·1, 7·7) times more likely to be in the lowest tertile of the EFA pattern and 4·5 (95 % CI 1·7, 12·3) times more likely to be in the lowest tertile of the Carotenoid pattern compared with their lean counterparts. We found no association between pre-pregnancy obesity and the Micronutrient pattern after confounder adjustment.

Our results suggest that obese pregnant women have diminished EFA and carotenoid concentrations.

To examine students’ school food choice in relation to school food standards and entitlement to free school meals (FSM).

Cross-sectional analysis of students’ school food choices.

Two large secondary schools in Yorkshire, England.

Students (n 2660) aged 11–18 years.

Sandwiches and pizza were the most popular main food items: 40·4 % and 31·2 %, respectively, in School A; 48·3 % and 27·3 %, respectively, in School B. More nutritionally valuable ‘dishes of the day’ accounted for 8·7 % and 8·3 % of main foods for School A and School B, respectively. FSM students were more likely (P < 0·0 0 1) to choose main foods (School A: FSM 87·04 %, non-FSM 70·28 %; School B: FSM 75·43 %, non-FSM 56·13 %). Dishes of the day were chosen on a significantly greater (P < 0·0 0 1) percentage of days by FSM v. non-FSM students (School A: FSM 15·67 %, non-FSM 7·11 %; School B: FSM 19·42 %, non-FSM 5·17 %).

Despite the availability of nutritionally valuable dishes of the day, the most popular food items were sandwiches, pizza and desserts. FSM students were more likely to choose the more nutritionally valuable dish of the day. School food standards should be reassessed in light of students’ preferences.

To study the associations between intakes of iodine and water chemicals and the thyroid gland status of schoolchildren living in the coastal city of Port Sudan.

In our previous nationwide study on goitre, it was observed that the prevalence of goitre was high in Port Sudan city despite high urinary iodine excretion. A cross-sectional study including schoolchildren aged 6–12 years was designed. Measurements determined the prevalence of goitre, urinary iodine concentration and thiocyanate secretion in casual urine samples, serum levels of thyroxine, triiodothyronine, thyroid-stimulating hormone and thyroglobulin, as well as the levels of Cl–, F–, Ca2+, Mg2+ and total hardness of drinking water.

Schoolchildren (n 654) aged 6–12 years.

Port Sudan city is located at the western bank of the Red Sea. The city is surrounded by a mountainous area known as the Red Sea Hills. It is the main sea port in the Sudan, inhabited by ethnically and socio-economically heterogeneous populations.

The prevalence of goitre in Port Sudan was 34·86 % while the median urinary iodine concentration was 46·4 μg/dl. Out of thirty-one pupils from Port Sudan, twenty-four (77·42 %) were found to have urinary iodine concentration greater than 30 μg/dl and twelve (38·71 %) had different degrees of biochemical hypothyroidism. Excessive concentrations of Cl–, Ca2+, Mg2+ and water hardness (369·2, 116·48, 60·21 and 539·0 mg/l, respectively) were detected in drinking water samples collected from Port Sudan that exceeded levels permitted by the WHO.

The coastal city of Port Sudan is a goitre-endemic area. In contrast to other Sudanese cities in which endemic goitre is related to iodine deficiency, goitre in Port Sudan is associated with iodine excess. Water chemicals seemed to have no effects on thyroid status.

Dietary patterns capture the overall diet and thereby provide information on how nutrients are consumed in combinations, and have been suggested to be a better method than studying single nutrients. The present study explored the relationship between dietary patterns at baseline and incidence of obesity at 10-year follow-up in women.

A longitudinal study using baseline measurements from 1992–1996, including food intake, medication, heredity, socio-economic status, lifestyle and measured body composition, and follow-up data collected in 2002–2006 including measured body composition.

Data from the Västerbotten Intervention Programme (VIP) in Sweden.

A total of 6545 initially non-obese women aged 30–50 years.

Among women reporting plausible energy intakes, the ‘Fruit and vegetables cluster’ predicted the highest incidence of obesity (OR = 1·76, 95 % CI 1·11, 2·76; P = 0·015) compared with women in the other food pattern groups combined. When adjusting for metabolic factors and BMI at baseline, the risk for obesity in the ‘Fruit and vegetables cluster’ was attenuated to non-significance. In contrast, high intake of fruit per se was associated with a decreased risk of developing obesity (OR = 0·69, 95 % CI 0·51, 0·91; P = 0·010).

Dietary pattern groups identified by cluster analysis are likely to reflect characteristics in addition to diet, including lifestyle, previous and current health status and risk factors for future disease, whereas intake of fruit per se was a stable indicator and less affected by baseline characteristics. These results underscore the need for complementary methods in understanding diet–disease relationships.

To estimate the costs per relevant unit (pupils and meals) associated with improvements to school food and the potential economic and health gains that may result.

Calculation of costs per relevant unit (pupils and meals) based on (i) Department for Education expenditure to support improvements in school food, 2005–2011 and (ii) measures of the changes in the number of pupils taking school lunch and the number of meals served over the same time period; plus examples of the use of linked data to predict longer-term economic and health outcomes of healthier eating at school.

England.

Local authorities, government departments and non-departmental public bodies.

Analysis of investment over a 6-year period indicates that costs of setting up and maintaining a change organization such as the School Food Trust were low in relation to short-term benefits in nutrition and behaviour. Models that predict long-terms gains to the exchequer and to quality-adjusted life years need further elaboration.

Modest levels of government investment in the delivery and promotion of healthier school food is likely to yield both short-term and long-term benefits in relation to nutrition, learning, economics and health.

To determine the optimal cut-offs of BMI for Malaysian adults.

Population-based, cross-sectional study. Receiver operating characteristic curves were used to determine the cut-off values of BMI with optimum sensitivity and specificity for the detection of three cardiovascular risk factors: diabetes mellitus, hypertension and hypercholesterolaemia. Gender-specific logistic regression analyses were used to examine the association between BMI and these cardiovascular risk factors.

All fourteen states in Malaysia.

Malaysian adults aged ≥18 years (n 32 703) who participated in the Third National Health and Morbidity Survey in 2006.

The optimal BMI cut-off value for predicting the presence of diabetes mellitus, hypertension, hypercholesterolaemia or at least one of these cardiovascular risk factors varied from 23·3 to 24·1 kg/m2 for men and from 24·0 to 25·4 kg/m2 for women. In men and women, the odds ratio for having diabetes mellitus, hypertension, hypercholesterolaemia or at least one cardiovascular risk factor increased significantly as BMI cut-off point increased.

Our findings indicate that BMI cut-offs of 23·0 kg/m2 in men and 24·0 kg/m2 in women are appropriate for classification of overweight. We suggest that these cut-offs can be used by health professionals to identify individuals for cardiovascular risk screening and weight management programmes.

Despite the benefits of fruit and vegetable intake, many young Americans do not consume them at adequate levels. The present study sought to determine the beliefs that children have about asking their parents to have fruits and vegetables available at home in order to better understand the role children may play in influencing their own fruit and vegetable consumption.

An instrument utilizing the Reasoned Action Approach, with closed-ended questions on demographic and behavioural variables and open-ended questions eliciting the belief structure underlying asking parents to make fruits and vegetables available, was distributed. Thematic and frequency analyses were performed for open-ended questions. Statistical analyses were conducted to assess differences between children who had v. had not asked for fruits and vegetables.

Three middle schools in rural Indiana, USA.

A sub-sample of sixty students aged 12–15 years from a larger study of 344 students.

Qualitative analysis identified benefits (i.e. make me healthier; make parents happy), disadvantages (i.e. will upset my parents) and strategies (i.e. asking when you are at the store) that could be used to improve fruit and vegetable intake. Findings also revealed that students who asked their parents for fruits and vegetables were significantly more likely to perform several healthy eating and physical activity behaviours.

Data suggest that young people's view of parental reactions is critical. While additional research is necessary, the findings support a role for children in shaping their own environment and suggest multilevel interventions that simultaneously address parents and children.

To report trends in underweight, overweight and obesity in 12–15-year-old adolescents and examine changes in dieting behaviour, which have been less well documented.

Comparison of two independent representative cross-sectional surveys.

Northern Ireland.

Weight and height were objectively measured in 1324 boys and 1160 girls in 1996 and 1274 boys and 1374 girls in 2007. Participants reported whether they were following any particular diet including a self-proposed or prescribed weight-reduction diet.

Overweight and obesity increased in girls from 15 % to 23 % and 2 % to 6 %, respectively. Increases were more modest in boys with overweight increasing from 13 % to 18 % and obesity from 3 % to 6 %. The proportion of underweight adolescents decreased from 9 % to 6 % in girls and 8 % to 5 % in boys. Evidence of social disparity was observed in girls from a manual socio-economic background, with overweight/obesity prevalence rates increasing from 21 % to 36 % compared with 15 % to 26 % in girls from a non-manual background. Despite these trends fewer adolescents, in particular girls, reported following weight-reduction diets (14 % of overweight/obese girls in 2007 v. 21 % in 1996; 8 % of boys in 2007 v. 13 % in 1996). Of these girls, the proportion from a manual background following weight-reduction diets decreased from 25 % to 11 %.

Overweight and obesity are continuing to increase in adolescents despite government and media awareness strategies. There also appears to be reduced dieting behaviour, despite increasing body weight, particularly in girls from manual socio-economic backgrounds.

To propose and apply an instrument to assess the breakfast quality of children and adolescents in the Mediterranean area.

Randomized, cross-sectional survey of breakfast consumption using a validated semi-quantitative FFQ administered at school by trained dietitians between Tuesday and Friday. A Breakfast Quality Index (BQI) score was developed, assigning a positive value to the consumption of cereals, fruit, vegetables, dairy products, MUFA, Ca and compliance with energy recommendations, and to the absence of SFA and trans-rich fats. Data were analysed by Student's t test and ANOVA.

Schools in Granada and Balearic Islands (Spain).

All schoolchildren (n 4332) aged 8–17 years at randomly selected and representative schools between 2006 and 2008, stratified by age and sex.

Breakfast was not consumed by 6·5 % of participants. BQI score was highest for children aged 7–9 years and decreased with age (P = 0·001). Females scored higher in all age groups. The lowest score was in males aged 14–17 years and the highest in females aged 7–9 years (P = 0·006).

The proposed BQI appears useful to estimate the breakfast quality of schoolchildren and to form a basis for nutrition education.

Measurement errors in dietary data lead to attenuated estimates of associations between dietary exposures and health outcomes. The present study aimed to compare and evaluate different approaches of handling implausible reports by exemplary analysis of the association between dietary intakes (total energy, soft drinks, fruits/vegetables) and overweight/obesity in children.

Cross-sectional multicentre study.

Kindergartens/schools from eight European countries participating in the IDEFICS Study.

Children (n 5357) aged 2–9 years who provided one 24 h dietary recall and complete covariate information.

The 24 h recalls were classified into three reporting groups according to adapted Goldberg cut-offs: under-report, plausible report or over-report. In the basic logistic multilevel model (adjusted for age and sex, including study centre as random effect), the dietary exposures showed no significant association with overweight/obesity (energy intake: OR=0·996 (95 % CI 0·983, 1·010); soft drinks: OR = 0·999 (95 % CI 0·986, 1·013)) and revealed even a positive association for fruits/vegetables (OR = 1·009 (95 % CI 1·001, 1·018)). When adding the reporting group (dummy variables) and a propensity score for misreporting as adjustment terms, associations became significant for energy intake as well as soft drinks (energy: OR = 1·074 (95 % CI 1·053, 1·096); soft drinks: OR = 1·015 (95 % CI 1·000, 1·031)) and the association between fruits/vegetables and overweight/obesity pointed to the reverse direction compared with the basic model (OR = 0·993 (95 % CI 0·984, 1·002)).

Associations between dietary exposures and health outcomes are strongly affected or even masked by measurement errors. In the present analysis consideration of the reporting group and inclusion of a propensity score for misreporting turned out to be useful tools to counteract attenuation of effect estimates.

We examined whether drinking water per se is associated with drinking less of other beverages and whether changes in BMI are associated with the intake of water and other beverages.

Secondary analysis of a randomized trial of fourth graders followed over 1 year.

Public schools in the metropolitan area of Rio de Janeiro, Brazil.

Participants were 1134 students aged 10–11 years.

At baseline, a higher frequency of water consumption was associated with a greater daily intake of fruit juice (P = 0·02) and a higher daily frequency of milk (P = 0·005). In the intervention group, the baseline frequency of water consumption was negatively associated with weight change over 1 year but without statistical significance (coefficient = −0·08 kg/m2; 95 % CI −0·37, 0·24 kg/m2), whereas fruit juice intake frequency was positively associated with weight change: each increase in fruit juice intake of 1 glass/d was associated with a BMI increase of 0·16 (95 % CI 0·02, 0·30) kg/m2.

Our findings do not support a protective effect of water consumption on BMI, but confirm consumption of juice drinks as a risk factor for BMI gain. Students who reported high water consumption also reported high intake of other beverages; therefore, the promotion of water consumption per se would not prevent excessive weight gain.

During the early years, parents have a major influence on children's diets and developing food choices. We investigated parenting styles as predictors of 2–5-year-old children's diets and whether general nutrition knowledge (GNK) mediated these influences.

Cross-sectional research. Questionnaires measured demographic and lifestyle variables, family environment, parenting styles and feeding practices, child diet and GNK. Regression models tested GNK as a mediator of relationships between parenting variables and child diet (fruit/vegetable and non-core food consumption), controlling for confounders and family environment.

Questionnaires were completed by main caregivers at home.

Parents of children aged 2–5 years (n 269).

Higher child fruit/vegetable consumption was associated with lower over-reactive parenting and restriction, higher authoritative parenting and dining together as a family; with lax parenting approaching statistical significance (P = 0·083) and 19 % of variance explained by the model. GNK was not a significant predictor. Conversely, non-core food consumption was associated with higher over-reactive and lax parenting as well as child age, increased takeaway food consumption and higher television viewing; GNK had a small effect (P = 0·043) and 28 % of variance was explained by the model. GNK was a significant mediator only for authoritative parenting on non-core food (effect = −0·005).

These findings highlight that young children's diets may be improved by interventions targeting a range of positive and supportive parenting practices in conjunction with nutrition knowledge education for parents of young children. Further insights will come from closer attention to the nature and role of restrictive feeding practices v. laxness and longitudinal research.

An analysis undertaken jointly in 2009 by the UN World Food Programme, The Partnership for Child Development and the World Bank was published as Rethinking School Feeding to provide guidance on how to develop and implement effective school feeding programmes as a productive safety net and as part of the efforts to achieve Education for All. The present paper reflects on how understanding of school feeding has changed since that analysis.

Data on school feeding programme outcomes were collected through a literature review. Regression models were used to analyse relationships between school feeding costs (from data that were collected), the per capita costs of primary education and Gross Domestic Product per capita. Data on the transition to national ownership, supply chains and country examples were collected through country case studies.

School feeding programmes increase school attendance, cognition and educational achievement, as well as provide a transfer of resources to households with possible benefits to local agricultural production and local market development. Low-income countries exhibit large variations in school feeding costs, with concomitant opportunities for cost containment. Countries are increasingly looking to transition from externally supported projects to national programmes.

School feeding is now clearly evident as a major social programme in most countries with a global turnover in excess of $US 100 billion. This argues for a continuing focus on the evidence base with a view to helping countries ensure that their programmes are as cost-effective as possible. Clear policy advice has never been more important.

Health-care access is associated with improved control of multiple chronic diseases, but the association between health-care access and weight change is unclear. The present study aims to test the association between health-care access and weight change.

The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a multicentre population-based prospective study. Weight change was calculated at 3 and 13 years after CARDIA year 7 (1992–1993). Health-care access was defined as no barriers or one or more barriers to access (health insurance gap, no usual source of care, not seeking care due to expense). Intermediary variables evaluated included history of dieting and use of diet pills, meal replacements or weight-control programmes.

Four cities in the USA.

Participants were aged 18–30 years at baseline (1985–1986). Analyses include 3922 black and white men and women with relevant data from CARDIA years 7, 10 and 20 (1992–1993, 1995–1996 and 2005–2006, respectively).

Mean weight change was +2·22 kg (+4·9 lb) by 3 years and +8·48 kg (+18·7 lb) by 13 years, with no differences by health-care access. Being on a weight-reducing diet was not consistently associated with health-care access across examinations. Use of diet pills, meal replacements or organized weight-control programmes was low, and did not vary by health-care access.

Weight gain was high irrespective of health-care access. Public health and clinical approaches are needed to address weight gain.