We aimed to evaluate the DHA and arachidonic acid (AA) levels in human breast milk worldwide by country, region and socio-economic status.

Descriptive review conducted on English publications reporting breast-milk DHA and AA levels.

We systematically searched and identified eligible literature in PubMed from January 1980 to July 2015. Data on breast-milk DHA and AA levels from women who had given birth to term infants were included.

Seventy-eight studies from forty-one countries were included with 4163 breast-milk samples of 3746 individuals.

Worldwide mean levels of DHA and AA in breast milk were 0·37 (sd 0·11) % and 0·55 (sd 0·14) % of total fatty acids, respectively. The breast-milk DHA levels from women with accessibility to marine foods were significantly higher than those from women without accessibility (0·35 (sd 0·20) % v. 0·25 (sd 0·14) %, P<0·05). Data from the Asian region showed the highest DHA concentration but much lower AA concentration in breast milk compared with all other regions, independent of accessibility to marine foods. Comparison was made among Canada, Poland and Japan – three typical countries (each with sample size of more than 100 women) from different regions but all with high income and similar accessibility to fish/marine foods.

The current review provides an update on worldwide variation in breast-milk DHA and AA levels and underlines the need for future population- or region-specific investigations.

The relationship between caesarean sections (C-sections) and infant feeding varies between different samples and indicators of feeding. The current study aimed to determine the relationship between C-sections and five indicators of infant milk feeding (breast-feeding within 1 h after delivery, at the time of the survey (current) and ever; milk-based prelacteal feeds; and current non-breast milk use) over time in a country with a rapidly rising C-section rate.

Secondary data analysis on cross-sectional data from Demographic and Health Surveys from six different time points between 1986 and 2013.

Dominican Republic.

Infants under 6 months of age.

Over 90 % of infants were ever breast-fed in each survey sample. However, non-breast milk use has expanded over time with a concomitant drop in predominant breast-feeding. C-section prevalence has increased over time reaching 63 % of sampled infants in the most recent survey. C-sections remained significantly related to three infant feeding practices – the child not put to the breast within 1 h after delivery, milk-based prelacteal feeds and current non-breast milk use – in multivariate models that included sociodemographic control variables. However, current non-breast milk use was no longer related to C-sections when milk-based prelacteal feeds were factored into the model.

Reducing or avoiding milk-based prelacteal feeds, particularly among those having C-sections, may improve subsequent breast-feeding patterns. Simultaneously, efforts are needed to understand and help reduce the exceptionally high C-section rate in the Dominican Republic.

The persistence of undernutrition, along with overweight and obesity, constitute the double burden of malnutrition. The present study aimed to: (i) describe the prevalence and trends of concurrent stunting and overweight in Indonesian children; (ii) identify potentially associated risk factors; and (iii) determine whether stunted children are at greater risk of overweight compared with those of healthy height.

A secondary data analysis of children aged 2·0–4·9 years in four cross-sectional studies of the Indonesian Family Life Survey. Children’s height and BMI Z-scores were calculated based on the WHO Child Growth Standards (2006). We defined ‘concurrent stunting and overweight’ as height-for-age Z-score <−2 and BMI Z-score >+1. Multivariate generalised linear latent and mixed models were used to determine associated risk factors.

Thirteen out of twenty-seven provinces in Indonesia.

Children (n 4101) from four waves of the Indonesian Family Life Survey (1993–2007).

There were inconsistent trends in the prevalence of concurrent stunting and overweight from waves 1 to 4. Children were more likely to be stunted and overweight when they were in the youngest age group (2·0–2·9 years), were weaned after the age of 6 months, had short-statured mothers or lived in rural areas. Stunted children were significantly more likely to be overweight than healthy-height children (OR>1) but did not differ significantly different across each wave (OR=1·34–2·01).

Concurrent stunting and overweight occurs in Indonesian children aged 2·0–4·9 years. Current policies and programmes need to be tailored for the management of this phenomenon.

Nutritional status during childhood plays an important role in the human life cycle. The present study examined the prevalence trends in different grades of nutritional status (thinness, normal weight, overweight and obesity) among children and adolescents in Shandong, China.

Data for the study were obtained from six cross-sectional surveys of schoolchildren carried out in 1985, 1995, 2000, 2005, 2010 and 2014. Height and weight of all children were measured; BMI was calculated from their height and weight. International BMI cut-offs were used to define thinness, overweight and obesity.

Shandong Province, China.

A total of 56 045 students aged 7–18 years were included in the current analysis.

In the past 29 years, the prevalence of thinness decreased from 18·22 % and 23·45 % in 1985 to 7·18 % and 9·49 % in 2014 for boys and girls, respectively. Conversely, the prevalence of combined overweight and obesity increased from 1·79 % and 1·66 % in 1985 to 31·12 % and 20·11 % in 2014 for boys and girls, respectively.

The nutritional profile of Shandong children and adolescents had an obvious change over the past 29 years. Special attention should be paid to controlling the rapid rise of childhood overweight and obesity.

The main indicator adopted to track universal salt iodization has been the coverage of adequately iodized salt in households. Rapid test kits (RTK) have been included in household surveys to test the iodine content in salt. However, laboratory studies of their performance have concluded that RTK are reliable only to distinguish between the presence and absence of iodine in salt, but not to determine whether salt is adequately iodized. The aim of the current paper was to examine the performance of RTK under field conditions and to recommend their most appropriate use in household surveys.

Standard performance characteristics of the ability of RTK to detect the iodine content in salt at 0 mg/kg (salt with no iodine), 5 mg/kg (salt with any added iodine) and 15 mg/kg (‘adequately’ iodized salt) were calculated. Our analysis employed the agreement rate (AR) as a preferred metric of RTK performance.

Twenty-five data sets from eighteen population surveys which assessed household iodized salt by both the RTK and a quantitative method (i.e. titration or WYD Checker) were obtained from Asian (nineteen data sets), African (five) and European (one) countries.

In detecting iodine in salt at 0 mg/kg, the RTK had an AR>90 % in eight of twenty-three surveys, while eight surveys had an AR<80 %. When the RTK was used for detecting adequately iodized salt, the AR decreased significantly, with only one of fourteen surveys achieving an AR>90 %.

The RTK is not suited for assessment of adequately iodized salt coverage. Quantitative assessment, such as by titration or WYD Checker, is necessary for estimates of adequately iodized salt coverage.

To estimate factors associated with double burden of nutritional outcomes in the mother–child dyad at the household level (child stunting and/or maternal overweight).

Cross-sectional study using the Brazilian Demographic and Health Survey. Nutritional outcomes were: mother with normal weight and child with normal height; overweight mother and child with normal height; mother with normal weight and short-stature child; and overweight mother and child with short stature (double burden). The child was classified as short when height-for-age Z-score was <−2 and the mother as overweight when BMI was ≥25·00 kg/m2. Socio-economic status, environment, social vulnerability, maternal characteristics and the child’s food intake were the exposure factors. The hierarchical approach for multinomial logistic regression modelling was used to assess the associations.

National Demographic and Health Survey of Children and Women conducted in Brazil, 2006–2007.

Mother–child dyads (n 3676).

After adjustments, lower maternal educational level (OR=3·53; 95 % CI 1·33, 9·33) and inadequate household (non-masonry house; OR=2·54; 95 % CI 1·39, 4·66) were associated with the double burden of malnutrition. Mother’s short stature (OR=3·41; 95 % CI 1·76, 6·61), child’s vegetable intake on less than or equal to 4 d/week (OR=2·21; 95 % CI 1·03, 4·75) and inadequate household (non-masonry house; OR=2·29; 95 % CI 1·36, 3·87) were associated with child’s short stature. The lack of breast-feeding (OR=2·00; 95 % CI 1·07, 3·72) was associated with maternal overweight.

The present findings contribute to establishing strategies promoting health and healthy diets, by considering the growth deficit and overweight/obesity concomitantly.

The present study aimed to identify the role of mother’s education in the nutritional status of children aged 2–5 years in Serbia.

Nationally representative population-based study. Age- and gender-specific BMI percentiles of children were analysed. In accordance with the WHO growth reference, children with BMI less than the 5th percentile were considered undernourished. Logistic regression was used to calculate the association between mother’s education and other socio-economic determinants as possible confounders.

UNICEF’s fourth Multiple Indicator Cluster Survey, conducted in both Roma and non-Roma settlements in Serbia.

Children (n 2603) aged 2–5 years (mean age 3·05 years).

Less than 5 % of children aged 2–5 years were undernourished. There were significantly more undernourished children among the Roma population, in the capital of Serbia and among those whose mothers were less educated. There were statistically significant differences according to mother’s education in all socio-economic characteristics (ethnicity, area, region of living and wealth index). Mother’s level of education proved to be the most important factor for child’s nutritional status; place of living (region) was also associated.

Mother’s education is the most significant predictor of children’s undernutrition. It confirms that investment in females’ education will bring benefits and progress not only for women and their children, but also for society as a whole.

To investigate the nutritional status of North African (NA) immigrant women in Italy, analysing their body size, adiposity and body image perception in comparison to Italian natives and NA residents.

The study utilized a cross-sectional design. Anthropometric traits were directly measured and a few indices were computed as proxy measures of nutritional status and adiposity. Body image perception was assessed using silhouette drawings. ANCOVA, adjusted for age, was used to compare anthropometric traits among different groups of women and the χ2 test to analyse differences in the prevalence of nutritional status.

Italy and North Africa (Tunisia, Morocco).

A sample of 433 women aged 18–60 years old: NA immigrants (n 105); Italians (n 100); Tunisians (n 104); Moroccans (n 124).

Overweight/obesity prevalence was very high in immigrants (79·8 %). Immigrants had the highest BMI value, the greatest hip circumference and mid upper-arm circumference. Their triceps skinfold thickness was significantly higher than that of Italians, but lower than that of NA residents.

NA immigrant women in Italy showed a higher incidence of overweight compared with Italians and NA residents. All groups showed a preference for a thinner body in comparison to their actual bodies and the immigrants are the most dissatisfied. Immigrants remain a high-risk group for obesity. Assessment of their body composition and health risk profile should be improved by using specific anthropometric measures that are easy to collect even in the case of large migration flows.

The present study evaluated the extent to which child-care centre menus prepared in advance correspond with food and beverage items served to children. The authors identified centre and staff characteristics that were associated with matches between menus and what was served.

Menus were collected from ninety-five centres in New York City (NYC). Direct observation of foods and beverages served to children were conducted during 524 meal and snack times at these centres between April and June 2010, as part of a larger study designed to determine compliance of child-care centres with city health department regulations for nutrition.

Child-care centres were located in low-income neighbourhoods in NYC.

Overall, 87 % of the foods and beverages listed on the menus or allowed as substitutions were served. Menu items matched with foods and beverages served for all major food groups by >60 %. Sweets and water had lower match percentages (40 and 32 %, respectively), but water was served 68 % of the time when it was not listed on the menu. The staff person making the food and purchasing decisions predicted the match between the planned or substituted items on the menus and the foods and beverages served.

In the present study, child-care centre menus included most foods and beverages served to children. Menus planned in advance have potential to be used to inform parents about which child-care centre to send their child or what foods and beverages their enrolled children will be offered throughout the day.

The aims of the present study were to assess the reliability and validity of the Food Choice Questionnaire (FCQ) and to determine the factors associated with food-choice motives in public junior-high-school students in Jakarta, Indonesia.

Cross-sectional study with self-administered questionnaires. Trained research assistants measured height and weight of the participants on the day of the data collection.

Fourteen randomly selected public junior-high schools in East Jakarta, Indonesia.

Public junior-high-school students (n 681) in grades 7 and 8, aged 13–14 years (377 girls and 304 boys).

Three food-choice motives (subscales) were obtained from factor analysis and reliability testing: (i) comfort; (ii) convenience and price; and (iii) health. The subscale with the greatest mean value was health. Family affluence was inversely associated with the convenience and price subscale (β=−0·05, P=0·01) and with the health subscale (β=−0·04; P=0·02). Females were less likely than males to consider health when choosing foods (β=−0·16; P=0·03).

While its factor structure differed from those found in previous studies of adults, the FCQ can provide reliable measures of food-choice motives among these adolescents. Students from less affluent families placed more importance on food’s convenience and price, but more affluent students did not necessarily make healthier choices. Compared with females, males were more likely to choose healthy foods. Future interventions should be tailored based on the socio-economic status of the target group.

To characterize meal patterns across ten European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study.

Cross-sectional study utilizing dietary data collected through a standardized 24 h diet recall during 1995–2000. Eleven predefined intake occasions across a 24 h period were assessed during the interview. In the present descriptive report, meal patterns were analysed in terms of daily number of intake occasions, the proportion reporting each intake occasion and the energy contributions from each intake occasion.

Twenty-seven centres across ten European countries.

Women (64 %) and men (36 %) aged 35–74 years (n 36 020).

Pronounced differences in meal patterns emerged both across centres within the same country and across different countries, with a trend for fewer intake occasions per day in Mediterranean countries compared with central and northern Europe. Differences were also found for daily energy intake provided by lunch, with 38–43 % for women and 41–45 % for men within Mediterranean countries compared with 16–27 % for women and 20–26 % for men in central and northern European countries. Likewise, a south–north gradient was found for daily energy intake from snacks, with 13–20 % (women) and 10–17 % (men) in Mediterranean countries compared with 24–34 % (women) and 23–35 % (men) in central/northern Europe.

We found distinct differences in meal patterns with marked diversity for intake frequency and lunch and snack consumption between Mediterranean and central/northern European countries. Monitoring of meal patterns across various cultures and populations could provide critical context to the research efforts to characterize relationships between dietary intake and health.

To examine the association of both perceived and geographic neighbourhood food access with food security status among households with children.

This was a cross-sectional study in which participants’ perceptions of neighbourhood food access were assessed by a standard survey instrument, and geographic food access was evaluated by distance to the nearest supermarket. Multinomial logistic regression models were used to examine the associations.

The Midlands Family Study included 544 households with children in eight counties in South Carolina, USA. Food security status among participants was classified into three categories: food secure (FS), food insecure (FI) and very low food security among children (VLFS-C).

Compared with FS households, VLFS-C households had lower odds of reporting easy access to adequate food shopping. VLFS-C households also had lower odds of reporting neighbourhood access to affordable fruits and vegetables compared with FS households and reported worse selection of fruits and vegetables, quality of fruits and vegetables, and selection of low-fat products. FI households had lower odds of reporting fewer opportunities to purchase fast food. None of the geographic access measures was significantly associated with food security status.

Caregivers with children who experienced hunger perceived that they had less access to healthy affordable food in their community, even though grocery stores were present. Approaches to improve perceived access to healthy affordable food should be considered as part of the overall approach to improving food security and eliminating child hunger.

Little is known about the influences of maternal and infant correlates on maternal feeding beliefs and practices in the first 2 years of life, despite its important role in early obesogenic eating behaviours and weight gain.

Cross-sectional study using demographic data of mothers and infants obtained at 26–28 weeks of gestation, and postnatally from birth to 15 months, respectively. The Infant Feeding Questionnaire was administered at 15 months postpartum. The associations between maternal and infant characteristics with seven maternal feeding beliefs and practices subscales were evaluated using multivariate linear regression analysis.

Data obtained from the Singapore GUSTO (Growing Up in Singapore Towards healthy Outcomes) mother–offspring birth cohort.

Mothers and infants (n 1237).

Among other maternal correlates such as age, education, BMI, income and milk feeding practices, ethnicity was a consistent factor associated with six subscales, including concern about infant overeating/undereating and weight status, concern and awareness about infants’ hunger and satiety cues, social interaction during feeding and feeding an infant on schedule. Similarly, among infant correlates such as gender and birth order, infant body size gain (reflected by BMI Z-score change from 0 to 15 months) was significantly associated with all subscales except feeding an infant on schedule. Overall, maternal correlates had greater influence on all subscales compared with infant correlates except for the maternal concern about infant undereating or becoming underweight subscale.

The present study highlights that maternal feeding beliefs and practices can be influenced by both maternal correlates and infant correlates at 15 months of age.

To describe adolescents’ eating patterns of traditional, global/non-local and mixed foods, and the factors that may influence food consumption, access and preferences, in a globalizing city.

A representative sample of school-going adolescents completed a cross-sectional survey including an FFQ designed to identify traditional and global foods. Student’s t test and ordinal logistic regression were used to examine weekly food intake, including differences between boys and girls and between adolescents attending private and public schools.

Vijayapura city, Karnataka State, India.

Adolescents (n 399) aged 13–16 years.

Compared with dietary guidelines, adolescents consumed fruit, green leafy vegetables, non-green leafy vegetables and dairy less frequently than recommended and consumed energy-dense foods more frequently than recommended. Traditional but expensive foods (fruits, dairy, homemade sweets and added fat) were more frequently consumed by private-school students, generally from wealthier, more connected families, than by public-school students; the latter more frequently consumed both traditional (tea, coffee, eggs) and mixed foods (snack and street foods; P≤0·05). Girls reported more frequent consumption of global/non-local packaged and ready-to-eat foods, non-green leafy vegetables and added fat than boys (P≤0·05). Boys reported more frequent consumption of eggs and street foods than girls (P≤0·05).

Adolescents’ eating patterns in a globalizing city reflect a combination of global/non-local and traditional foods, access and preferences. As global foods continue to appear in low- and middle-income countries, understanding dietary patterns and preferences can inform efforts to promote diversity and healthfulness of foods.

Over 300 million people rely on desalinated seawater and the numbers are growing. Desalination removes iodine from water and could increase the risk of iodine-deficiency disorders (IDD). The present study assessed the relationship between iodine intake and thyroid function in an area reliant on desalination.

A case–control study was performed between March 2012 and March 2014. Thyroid function was rigorously assessed by clinical examination, ultrasound and blood tests, including serum thyroglobulin (Tg) and autoimmune antibodies. Iodine intake and the contribution made by unfiltered tap water were estimated by FFQ. The contribution of drinking-water to iodine intake was modelled using three iodine concentrations: likely, worst-case and best-case scenario.

The setting for the study was a hospital located on the southern Israeli Mediterranean coast.

Adult volunteers (n 102), 21–80 years old, prospectively recruited.

After screening, seventy-four participants met the inclusion criteria. Thirty-seven were euthyroid controls. Among those with thyroid dysfunction, twenty-nine were classified with non-autoimmune thyroid disease (NATD) after excluding eight cases with autoimmunity. Seventy per cent of all participants had iodine intake below the Estimated Average Requirement (EAR) of 95 µg/d. Participants with NATD were significantly more likely to have probable IDD with intake below the EAR (OR=5·2; 95 % CI 1·8, 15·2) and abnormal serum Tg>40 ng/ml (OR=5·8; 95 % CI 1·6, 20·8).

Evidence of prevalent probable IDD in a population reliant on desalinated seawater supports the urgent need to probe the impact of desalinated water on thyroid health in Israel and elsewhere.

To examine whether women’s knowledge of pregnancy-related risks and family support received during pregnancy are associated with adherence to maternal iron–folic acid (IFA) supplementation.

Secondary data analysis of the 2002–03, 2007 and 2012 Indonesia Demographic and Health Survey. Analysis of the association between factors associated with adherence (consuming ≥90 IFA tablets), including the women’s knowledge and family support, was performed using multivariate logistic regression.

National household survey.

Women (n 19 133) who had given birth within 2 years prior to the interview date.

Knowledge of pregnancy-related risks was associated with increased adherence to IFA supplementation (adjusted OR=1·8; 95 % CI 1·6, 2·0), as was full family (particularly husband’s) support (adjusted OR=1·9; 95 % CI 1·6, 2·3). Adequate antenatal care (ANC) visits (i.e. four or more) was associated with increased adherence (adjusted OR=2·2; 95 % CI 2·0, 2·4). However, ANC providers missed opportunities to distribute tablets and information, as among women with adequate ANC visits, 15 % reported never having received/bought any IFA tablets and 30 % had no knowledge of pregnancy-related risks. A significant interaction was observed between family support and the women’s educational level in predicting adherence. Family support significantly increased the adherence among women with <9 years of education.

Improving women’s knowledge of pregnancy-related risks and involving family members, particularly the husband and importantly for less-educated women, improved adherence to IFA supplementation. ANC visit opportunities must be optimized to provide women with sufficient numbers of IFA tablets along with health information (especially on pregnancy-related risks) and partner support counselling.

Limited acceptance of government food assistance programmes such as the US Department of Agriculture’s (USDA) Supplemental Nutrition Assistance Program (SNAP) is a barrier that produces unequal access to market products for SNAP beneficiaries. There is a dearth of published evidence to explain the limited SNAP acceptance at farmers’ markets. The current project aimed to fill this gap; to identify and describe the barriers to markets’ acceptance of SNAP.

Cross-sectional, semi-structured interviews were conducted.

All interviews were conducted via telephone.

Twelve East Tennessee area market managers, vendors and other key stakeholders.

Multiple barriers exist for SNAP implementation at markets including administrative and time limitations, prejudice from market vendors against SNAP beneficiaries, and resistance to invasive and burdensome requirements of the USDA SNAP application required for farmers’ markets.

SNAP acceptance at farmers’ markets is a complex issue, especially for small, rural markets. If farmers’ markets are to serve as sustainable resources to increase food access, these issues must be addressed so that SNAP can be accepted. Successful implementation of SNAP at rural markets requires increased administrative support and vendor education about SNAP and its beneficiaries. A revised USDA SNAP application process for farmers’ markets should also be considered.

Improving diet quality is a key factor for promoting population health. Social norms can support or undermine these efforts. The present study aimed to investigate the relationship between seasonal variation in food purchases and BMI.

The study population comprises members of a South African health promotion programme. Data come from scanner data of food purchases by 400 000 enrolled households at supermarkets and repeated individual surveys (about 500 000 participants) between 2009 and 2013.

Members in the health promotion programme spent 16·7 % of total food expenditure on nutritionally undesirable foods (sugar-sweetened beverages, candy, ice cream, etc.) and 24·7 % on healthy foods (fruit/vegetables, whole grains, non-fat dairy, etc.). Fruits and vegetables accounted for 13·5 % of purchases (half of all healthy food spending). Yet there were pronounced seasonal variations, with December being the peak month for unhealthy food purchases, which were 40 % higher than in January. This holiday peak was associated with short-term weight gain, but average body mass did not revert to pre-holiday levels. From 2009 to 2013, respondents gained about 0·13 BMI units per year (0·43 kg for men, 0·30 for women). From November to January alone, the increase was 0·1 BMI units for men (0·35 kg) and 0·8 BMI units for women (0·20 kg).

Purchases of nutritionally undesirable foods peak in December and are accompanied by weight gain from November to January. Despite weight loss after January, the November to January weight gain accounts for 60–70 % of the annual gain.

The objective of the current work was to determine the association between food insecurity and frailty in older adults, within the context of a country with accelerated ageing and nutritional problems.

Cross-sectional analysis of a representative nationwide survey on health and nutrition.

Mexican nationwide survey.

A sample of 7108 adults aged 60 years or older living in communities, representative of Mexican older adults.

Multivariate regression and descriptive analyses of food insecurity and frailty were performed. From a total of 7108 adults aged 60 years or older, with a mean age of 70·7 years, most (54·7 %) were women. Food security categories were: 26·3 % had food security, 40·3 % had mild food insecurity, 20·5 % had moderate food insecurity and 12·9 % had severe food insecurity. Food insecurity categories were associated with frailty, with the severe category having the highest odds ratio of 2·41 (95 % CI 2·03, 2·86; P<0·001) after adjustment for confounding factors.

According to our results, food insecurity is associated to frailty, which in turn is a condition that renders the older adult at a higher risk of developing adverse outcomes. Targeted food programmes for older adults with a high risk of having food insecurity or of being frail may improve health in this population group.

American Indian children of pre-school age have disproportionally high obesity rates and consequent risk for related diseases. Healthy Children, Strong Families was a family-based randomized trial assessing the efficacy of an obesity prevention toolkit delivered by a mentor v. mailed delivery that was designed and administered using community-based participatory research approaches.

During Year 1, twelve healthy behaviour toolkit lessons were delivered by either a community-based home mentor or monthly mailings. Primary outcomes were child BMI percentile, child BMI Z-score and adult BMI. Secondary outcomes included fruit/vegetable consumption, sugar consumption, television watching, physical activity, adult health-related self-efficacy and perceived health status. During a maintenance year, home-mentored families had access to monthly support groups and all families received monthly newsletters.

Family homes in four tribal communities, Wisconsin, USA.

Adult and child (2–5-year-olds) dyads (n 150).

No significant effect of the mentored v. mailed intervention delivery was found; however, significant improvements were noted in both groups exposed to the toolkit. Obese child participants showed a reduction in BMI percentile at Year 1 that continued through Year 2 (P<0·05); no change in adult BMI was observed. Child fruit/vegetable consumption increased (P=0·006) and mean television watching decreased for children (P=0·05) and adults (P=0·002). Reported adult self-efficacy for health-related behaviour changes (P=0·006) and quality of life increased (P=0·02).

Although no effect of delivery method was demonstrated, toolkit exposure positively affected adult and child health. The intervention was well received by community partners; a more comprehensive intervention is currently underway based on these findings.