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FOOD INSECURITY
AND DISEASE
Prevalence, Policy, and Politics
FOOD INSECURITY
AND DISEASE
Prevalence, Policy, and Politics

Edited by
Areej Hassan, MD, MPH
Apple Academic Press Inc. Apple Academic Press Inc.
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Library and Archives Canada Cataloguing in Publication

Food insecurity and disease : prevalence, policy, and politics / edited by Areej Hassan, MD, MPH.
Includes bibliographical references and index.
Issued in print and electronic formats.
ISBN 978-1-77188-491-4 (hardcover).--ISBN 978-1-315-36576-3
1. Food security. 2. Food security--Health aspects.
3. Public health. 4. Nutrition. 5. Food supply. I. Hassan, Areej, editor
HD9000.5.F648 2017 338.1’9 C2016-907673-3 C2016-907674-1

CIP data on file with US Library of C

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About the Editor

Areej Hassan, MD, MPH

Areej Hassan, MD, MPH, is an attending in the Division of Adolescent/
Young Adult Medicine at Boston Children’s Hospital and Assistant Professor
of Pediatrics at Harvard Medical School. She completed her residency training
in Pediatrics at Brown University before her fellowship at BCH. In addition to
primary care, Dr. Hassan focuses her clinical interests on reproductive endocri-
nology and global health. She also maintains an active role in medical educa-
tion and has particular interest in building and developing innovative teaching
tools through open educational resources. She currently teaches, consults, and
is involved in pediatric and adolescent curricula development at multiple sites
abroad in Central America and Southeast Asia.
Contents

List of Contributors........................................................................................................................ix
Acknowledgments and How to Cite.........................................................................................xiii
Introduction.................................................................................................................................... xv

Part I: Defining Food Security and Insecurity............................................. 1

1. Definitions of Food Security............................................................................ 3
United States Department of Agriculture

Part II: Food Insecurity and Mental Health................................................. 9

2. Food Insecurity in Adults with Mood Disorders: Prevalence
Estimates and Associations with Nutritional and Psychological Health...... 11
Karen M. Davidson and Bonnie J. Kaplan

3. Household Food Insecurity and Mental Distress Among Pregnant

Women in Southwestern Ethiopia: A Cross Sectional Study Design............ 27
Mulusew G. Jebena, Mohammed Taha, Motohiro Nakajima, Andrine Lemieux,
Fikre Lemessa, Richard Hoffman, Markos Tesfaye, Tefera Belachew,
Netsanet Workineh, Esayas Kebede, Teklu Gemechu, Yinebeb Tariku,
Hailemariam Segni, Patrick Kolsteren, and Mustafa al’Absi

Part III: Food Insecurity and HIV............................................................. 45

4. Is Food Insecurity Associated with HIV Risk? Cross-Sectional
Evidence from Sexually Active Women in Brazil........................................... 47
Alexander C. Tsai, Kristin J. Hung, and Sheri D. Weiser

5. Food Insecurity Is a Barrier to Prevention of Mother-to-Child HIV

Transmission Services in Zimbabwe: A Cross-Sectional Study.................... 69
Sandra I. McCoy, Raluca Buzdugan, Angela Mushavi, Agnes Mahomva,
Frances M. Cowan, and Nancy S. Padian

6. A Pre-Post Pilot Study of Peer Nutritional Counseling and

Food Insecurity and Nutritional Outcomes among Antiretroviral
Therapy Patients in Honduras........................................................................ 89
Kathryn P. Derose, Melissa Felician, Bing Han, Kartika Palar, Blanca Ramírez,
Hugo Farías, and Homero Martínez
viii Contents

7. Relationship between Food Insecurity and Mortality among

HIV-Positive Injection Drug Users Receiving Antiretroviral
Therapy in British Columbia, Canada.......................................................... 105
Aranka Anema, Keith Chan, Yalin Chen, Sheri Weiser, Julio S. G. Montaner,
and Robert S. Hogg

8. Shamba Maisha: Pilot Agricultural Intervention for Food Security

and HIV Health Outcomes in Kenya: Design, Methods, Baseline
Results and Process Evaluation of a Cluster-Randomized
Controlled Trial............................................................................................ 125
Craig R. Cohen, Rachel L. Steinfeld, Elly Weke, Elizabeth A. Bukusi,
Abigail M. Hatcher, Stephen Shiboski, Richard Rheingans, Kate M. Scow,
Lisa M. Butler, Phelgona Otieno, Shari L. Dworkin, and Sheri D. Weiser

Part IV: Food Security and Obesity and Diabetes................................... 159

9. Challenges of Diabetes Self-Management in Adults Affected by
Food Insecurity in a Large Urban Centre of Ontario, Canada.................... 161
Justine Chan, Margaret DeMelo, Jacqui Gingras, and Enza Gucciardi

10. Children’s Very Low Food Security is Associated with Increased

Dietary Intakes in Energy, Fat, and Added Sugar among
Mexican-Origin Children (6-11 Y) in Texas Border Colonias..................... 179
Joseph R. Sharkey, Courtney Nalty, Cassandra M. Johnson, and Wesley R. Dean

11. Obesity Prevention and National Food Security: A Food

Systems Approach........................................................................................ 199
Lila Finney Rutten, Amy Lazarus Yaroch, Heather Patrick, and Mary Story

Part V: Policy, Power, and Politics........................................................... 219

12. Food Sovereignty: Power, Gender, and the Right to Food.......................... 221
Rajeev C. Patel

13. Big Food, Food Systems, and Global Health............................................... 231

David Stuckler and Marion Nestle

Keywords.............................................................................................................. 241
Author Notes........................................................................................................ 243
Index..................................................................................................................... 251
List of Contributors

Mustafa al’Absi
Duluth Medical Research Institute, Department of Bio behavioral Health and Population Sciences, University
of Minnesota Medical School
Aranka Anema
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia,
Canada, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British
Columbia, Canada

Tefera Belachew
Population and Family Health, Jimma University

Elizabeth A. Bukusi
Centre for Microbiology Research, Kenya Medical Research Institute

Lisa M. Butler
Boston Children’s Hospital and Harvard Medical School

Raluca Buzdugan
University of California

Justine Chan
Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3

Keith Chan
Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia,
Canada
Yalin Chen
Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia,
Canada

Craig R. Cohen
Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco;
Center of Expertise in Women’s Health & Empowerment, University of California Global Health Institute

Frances M. Cowan
Centre for Sexual Health and HIV Research; University College London

Karen M. Davison
Department of Community Health Sciences, University of Calgary
Department of Biology, Health Science Program, Kwantlen Polytechnic University

Wesley R. Dean
Program for Research in Nutrition and Health Disparities, School of Rural Public Health, Texas A&M Health
Science Center, MS 1266

Margaret DeMelo
University Health Network, 399 Bathurst Street, Toronto, ON, Canada M5T 2S
x List of Contributors

Kathryn P. Derose
Health Program, RAND Corporation

Shari L. Dworkin
Departments of Social and Behavioral Sciences, University of California San Francisco; Center of Expertise in
Women’s Health & Empowerment, University of California Global Health Institute

Hugo Farías
Regional Office for Latin America and the Caribbean, United Nations World Food Program

Melissa Felician
Pardee RAND Graduate School

Teklu Gemechu
Department of Psychology, Jimma University

Jacqui Gingras
Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3

Enza Gucciardi
Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3

Bing Han
Health Program, RAND Corporation

Abigail M. Hatcher
Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco; Wits
Reproductive Health and HIV Institute, University of the Witwatersrand
Richard Hoffman
Duluth Medical Research Institute, Department of Bio behavioral Health and Population Sciences, University
of Minnesota Medical School

Robert S. Hogg
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia,
Canada, Faculty of Health Sciences, University of British Columbia, Burnaby, British Columbia, Canada
Kristin J. Hung
Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts,
United States of America

Mulusew G. Jebena
Population and Family Health, Jimma University; Department of Food Safety and Food Quality, Ghent
University, CoupureLinks

Cassandra M. Johnson
UNC Center for Health Promotion and Disease Prevention and Department of Nutrition, UNC Gillings
School of Global Public Health

Bonnie J. Kaplan
Department of Community Health Sciences, University of Calgary
Department of Pediatrics, University of Calgary
The Alberta Children’s Hospital Research Institute

Esayas Kebede
Department of Internal Medicine, Jimma University
List of Contributors xi

Patrick Kolsteren
Department of Food Safety and Food Quality, Ghent University, CoupureLinks

Fikre Lemessa
Department of Horticulture and Plant Sciences, Jimma University

Andrine Lemieux
Duluth Medical Research Institute, Department of Bio behavioral Health and Population Sciences, University
of Minnesota Medical School
Agnes Mahomva
Elizabeth Glaser Pediatric AIDS Foundation

Homero Martínez
Health Program, RAND Corporation; Hospital Infantil de México Federico Gómez

Sandra I. McCoy
University of California

Julio S. G. Montaner
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia,
Canada, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British
Columbia, Canada
Angela Mushavi
Ministry of Health and Child Welfare

Motohiro Nakajima
Duluth Medical Research Institute, Department of Bio behavioral Health and Population Sciences, University
of Minnesota Medical School

Courtney Nalty
Program for Research in Nutrition and Health Disparities, School of Rural Public Health, Texas A&M Health
Science Center, MS 1266

Marion Nestle
Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York, United
States of America, Department of Nutritional Sciences, Cornell University, Ithaca, New York, United States
of America
Phelgona Otieno
Centre for Clinical Research, Kenya Medical Research Institute

Nancy S. Padian
University of California

Kartika Palar
Division of HIV, ID and Global Medicine, Department of Medicine, University of California San Francisco

Rajeev C. Patel
School of Development Studies, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa

Heather Patrick
Health Behaviors Research Branch, National Cancer Institute, 6130 Executive Boulevard, MSC 7335,
Bethesda, MD 20892, USA

Blanca Ramírez
Honduran Country Office, United Nations World Food Program
xii List of Contributors

Richard Rheingans
Department of Environmental and Global Health, University of Florida

Lila Finney Rutten

Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905, USA; Division of Epidemiology and Community Health, School of Public Health,
University of Minnesota, 1300 S 2nd Street, Suite 300, Minneapolis, MN 55454, USA
Kate M. Scow
Department of Soil Science and Soil Microbial Biology, University of California Davis

Hailemariam Segni
Department of Obstetrics and Gynecology, Jimma University

Joseph R. Sharkey
Program for Research in Nutrition and Health Disparities, School of Rural Public Health, Texas A&M Health
Science Center, MS 1266

Stephen Shiboski
Departments of Epidemiology and Biostatistics, University of California San Francisco

Rachel L. Steinfeld
Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco

Mary Story
Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905, USA

David Stuckler
Department of Sociology, University of Cambridge, Cambridge, United Kingdom, Department of Public
Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
Mohammed Taha
Department of Epidemiology, Jimma University

Yinebeb Tariku
Department of Chemistry, Jimma University

Markos Tesfaye
Department of Psychiatry, Jimma University

Alexander C. Tsai
Robert Wood Johnson Health and Society Scholars Program, Harvard University, Cambridge, Massachusetts,
United States of America, Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts,
United States of America
Sheri D. Weiser
Division of HIV/AIDS, San Francisco General Hospital, University of California San Francisco, San
Francisco, California, United States of America; Center for AIDS Prevention Studies, University of California
San Francisco, San Francisco, California, United States of America
Elly Weke
Centre for Microbiology Research, Kenya Medical Research Institute
Netsanet Workineh
Department of Pediatrics and Child Health, Jimma University
Amy Lazarus Yaroch
Gretchen Swanson Center for Nutrition, 505 Durham Research Plaza, Omaha, NE 68105, USA
Acknowledgments and How to Cite

The editor and publisher thank each of the authors who contributed to this
book. Many of the chapters in this book were previously published elsewhere.
To cite the work contained in this book and to view the individual permissions,
please refer to the citation at the beginning of each chapter. The editor carefully
selected each chapter individually to provide a nuanced look at food insecurity
and its connection to disease.
Introduction

We know that food insecurity and disease are inextricably linked. The articles
selected for this compendium reinforce that message by specifically linking food
insecurity to various forms of chronic disease, including HIV/AIDS and obesity,
as well as mental health issues. The research in the fifth section of this book then
goes a step further by asking, “What next?” In other words, how can we shape
politics and policy to address this urgent international crisis?
The quality of the research gathered here is incredibly high. The authors
have done much to advance our understanding of this issue—and they have
provided us with a solid foundation on which to build well-informed clinical
practice, further research, and effective future policy.
—Areej Hassan, MD

According to the USDA, food security means access by all people at all times
to enough food for an active, healthy life. We begin our compendium with the
USDA’s definitions of food security and insecurity.
Because little is known about food insecurity in people with mental health
conditions, the authors of chapter 2 investigated relationships among food inse-
curity, nutrient intakes, and psychological functioning in adults with mood disor-
ders. Data from a study of adults randomly selected from the membership list of
the Mood Disorder Association of British Columbia (n = 97), Canada, were ana-
lyzed. Food insecurity status was based on validated screening questions asking
if in the past 12 months did the participant, due to a lack of money, worry about
or not have enough food to eat. Nutrient intakes were derived from 3-day food
records and compared to the Dietary Reference Intakes (DRIs). Psychological
functioning measures included Global Assessment of Functioning, Hamilton
Depression scale, and Young Mania Rating Scale. Using binomial tests of two
proportions, Mann–Whitney U tests, and Poisson regression authors exam-
ined: (1) food insecurity prevalence between the study respondents and a gen-
eral population sample from the British Columbia Nutrition Survey (BCNS;
n = 1,823); (2) differences in nutrient intakes based on food insecurity status;
and (3) associations of food insecurity and psychological functioning using
bivariate and Poisson regression statistics. In comparison to the general popu-
lation (BCNS), food insecurity was significantly more prevalent in the adults
xvi Introduction

with mood disorders (7.3% in BCNS vs 36.1%; p < 0.001). Respondents who
were food-insecure had lower median intakes of carbohydrates and vitamin C
(p < 0.05). In addition, a higher proportion of those reporting food insecurity
had protein, folate, and zinc intakes below the DRI benchmark of potential inad-
equacy (p < 0.05). There was significant association between food insecurity
and mania symptoms (adjusted prevalence ratio = 2.37, 95% CI 1.49–3.75,
p < 0.05). The authors found that food insecurity is associated with both nutri-
tional and psychological health in adults with mood disorders. Investigation of
interventions aimed at food security and income can help establish its role in
enhancing mental health.
There are compelling theoretical and empirical reasons that link house-
hold food insecurity to mental distress in the setting where both problems are
common. However, little is known about their association during pregnancy in
Ethiopia. A cross-sectional study is reported in chapter 3 that was conducted
to examine the association of household food insecurity with mental distress
during pregnancy. Six hundred and forty-two pregnant women were recruited
from 11 health centers and one hospital. Probability proportional to size (PPS)
and consecutive sampling techniques were employed to recruit study subjects
until the desired sample size was obtained. The Self Reporting Questionnaire
(SRQ-20) was used to measure mental distress and a 9-item Household Food
Insecurity Access Scale was used to measure food security status. Descriptive
and inferential statistics were computed accordingly. Multivariate logistic regres-
sion was used to estimate the effect of food insecurity on mental distress. Fifty-
eight of the respondents (9 %) were moderately food insecure and 144 of the
respondents (22.4 %) had mental distress. Food insecurity was also associated
with mental distress. Pregnant women living in food insecure households were
4 times more likely to have mental distress than their counterparts (COR = 3.77,
95% CI: 2.17, 6.55). After controlling for confounders, a multivariate logistic
regression model supported a link between food insecurity and mental distress
(AOR = 4.15, 95% CI: 1.67, 10.32). The study found a significant association
between food insecurity and mental distress. However, the mechanism by which
food insecurity is associated with mental distress is not clear. Further investiga-
tion is therefore needed to understand either how food insecurity during preg-
nancy leads to mental distress or weather mental distress is a contributing factor
in the development of food insecurity.
Understanding how food insecurity among women gives rise to differen-
tial patterning in HIV risks is critical for policy and programming in resource-
limited settings. This is particularly the case in Brazil, which has undergone
Introduction xvii

successive changes in the gender and socio-geographic composition of its com-

plex epidemic over the past three decades. The authors of chapter 4 used data
from a national survey of Brazilian women to estimate the relationship between
food insecurity and HIV risk. They used data on 12,684 sexually active women
from a national survey conducted in Brazil in 2006–2007. Self-reported out-
comes were (a) consistent condom use, defined as using a condom at each occa-
sion of sexual intercourse in the previous 12 mo; (b) recent condom use, less
stringently defined as using a condom with the most recent sexual partner; and
(c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of
a sexually transmitted infection. The primary explanatory variable of interest
was food insecurity, measured using the culturally adapted and validated Escala
Brasiliera de Segurança Alimentar. In multivariable logistic regression models,
severe food insecurity with hunger was associated with a reduced odds of con-
sistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95%
CI, 0.48–0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI,
0.57–0.98). Self-reported itchy vaginal discharge was associated with all cate-
gories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute
terms, the effect sizes were large in magnitude across all outcomes. Underweight
and/or lack of control in sexual relations did not appear to mediate the observed
associations. Severe food insecurity with hunger was associated with reduced
odds of condom use and increased odds of itchy vaginal discharge, which is
potentially indicative of sexually transmitted infection, among sexually active
women in Brazil. Interventions targeting food insecurity may have beneficial
implications for HIV prevention in resource-limited settings.
Food insecurity (FI) is the lack of physical, social, and economic access to
sufficient food for dietary needs and food preferences. The authors of chapter
5 examined the association between FI and women’s uptake of services to pre-
vent mother-to-child HIV transmission (MTCT) in Zimbabwe. They analyzed
cross-sectional data collected in 2012 from women living in five of ten prov-
inces. Eligible women were ≥16 years old, biological mothers of infants born
9–18 months before the interview, and were randomly selected using multi-stage
cluster sampling. Women and infants were tested for HIV and interviewed about
health service utilization during pregnancy, delivery, and post-partum. The
authors assessed FI in the past four weeks using a subset of questions from the
Household Food Insecurity Access Scale and classified women as living in food
secure, moderately food insecure, or severely food insecure households. The
weighted population included 8,790 women. Completion of all key steps in the
PMTCT cascade was reported by 49%, 45%, and 38% of women in food secure,
xviii Introduction

moderately food insecure, and severely food insecure households, respectively

(adjusted prevalence ratio (PRa) = 0.95, 95% confidence interval (CI): 0.90,
1.00 (moderate FI vs. food secure), PRa = 0.86, 95% CI: 0.79, 0.94 (severe FI vs.
food secure)). Food insecurity was not associated with maternal or infant receipt
of ART/ARV prophylaxis. However, in the unadjusted analysis, among HIV-
exposed infants, 13.3% of those born to women who reported severe household
food insecurity were HIV-infected compared to 8.2% of infants whose mothers
reported food secure households (PR = 1.62, 95% CI: 1.04, 2.52). After adjust-
ment for covariates, this association was attenuated (PRa = 1.42, 95% CI: 0.89,
2.26). There was no association between moderate food insecurity and MTCT
in unadjusted or adjusted analyses (PRa = 0.68, 95% CI: 0.43, 1.08). Among
women with a recent birth, food insecurity is inversely associated with service
utilization in the PMTCT cascade and severe household food insecurity may
be positively associated with MTCT. These preliminary findings support the
assessment of FI in antenatal care and integrated food and nutrition programs
for pregnant women to improve maternal and child health.
Food insecurity and poor nutrition are key barriers to anti-retroviral therapy
(ART) adherence. Culturally-appropriate and sustainable interventions that
provide nutrition counseling for people on ART and of diverse nutritional sta-
tuses are needed, particularly given rising rates of overweight and obesity among
people living with HIV (PLHIV). As part of scale-up of a nutritional counseling
intervention, the authors of chapter 6 recruited and trained 17 peer counselors
from 14 government-run HIV clinics in Honduras to deliver nutritional coun-
seling to ART patients using a highly interactive curriculum that was developed
after extensive formative research on locally available foods and dietary patterns
among PLHIV. All participants received the intervention; at baseline and 2
month follow-up, assessments included: 1) interviewer-administered, in-person
surveys to collect data on household food insecurity (15-item scale), nutritional
knowledge (13-item scale), dietary intake and diversity (number of meals and
type and number of food groups consumed in past 24 h); and 2) anthropometric
measures (body mass index or BMI, mid-upper arm and waist circumferences).
The authors used multivariable linear regression analysis to examine changes
pre-post in food insecurity and the various nutritional outcomes while control-
ling for baseline characteristics and clinic-level clustering. Of 482 participants at
baseline, the authors had complete follow-up data on 356 (74%), of which 62%
were women, median age was 39, 34% reported having paid work, 52% had com-
pleted primary school, and 34% were overweight or obese. In multivariate anal-
yses adjusting for gender, age, household size, work status, and education, the
Introduction xix

authors found that between baseline and follow-up, household food insecurity
decreased significantly among all participants (β = −0.47, p < .05) and among
those with children under 18 (β = −1.16, p < .01), while nutritional knowledge
and dietary intake and diversity also significantly improved, (β = 0.88, p < .001;
β = 0.30, p < .001; and β = 0.15, p < .001, respectively). Nutritional status (BMI,
mid-arm and waist circumferences) showed no significant changes, but the
brief follow-up period may not have been sufficient to detect changes. A peer-
delivered nutritional counseling intervention for PLHIV was associated with
improvements in dietary quality and reduced food insecurity among a popula-
tion of diverse nutritional statuses. Future research should examine if such an
intervention can improve adherence among people on ART.
Little is known about the potential impact of food insecurity on mortality
among people living with HIV/AIDS. The authors of chapter 7 examined the
potential relationship between food insecurity and all-cause mortality among
HIV-positive injection drug users (IDU) initiating antiretroviral therapy (ART)
across British Columbia (BC). Cross-sectional measurement of food security
status was taken at participant ART initiation. Participants were prospectively
followed from June 1998 to September 2011 within the fully subsidized ART
program. Cox proportional hazard models were used to ascertain the associa-
tion between food insecurity and mortality, controlling for potential confound-
ers. Among 254 IDU, 181 (71.3%) were food insecure and 108 (42.5%) were
hungry. After 13.3 years of median follow-up, 105 (41.3%) participants died.
In multivariate analyses, food insecurity remained significantly associated with
mortality (adjusted hazard ratio [AHR] = 1.95, 95% CI: 1.07–3.53), after adjust-
ing for potential confounders. HIV-positive IDU reporting food insecurity were
almost twice as likely to die, compared to food secure IDU. Further research is
required to understand how and why food insecurity is associated with excess
mortality in this population. Public health organizations should evaluate the
possible role of food supplementation and socio-structural supports for IDU
within harm reduction and HIV treatment programs.
Despite advances in treatment of people living with HIV, morbidity and
mortality remains unacceptably high in sub-Saharan Africa, largely due to paral-
lel epidemics of poverty and food insecurity. The authors of chapter 8 conducted
a pilot cluster randomized controlled trial (RCT) of a multisectoral agricultural
and microfinance intervention (entitled Shamba Maisha) designed to improve
food security, household wealth, HIV clinical outcomes and women’s empow-
erment. The intervention was carried out at two HIV clinics in Kenya, one
randomized to the intervention arm and one to the control arm. HIV-infected
xx Introduction

patients >18 years, on antiretroviral therapy, with moderate/severe food inse-

curity and/or body mass index (BMI) <18.5, and access to land and surface
water were eligible for enrollment. The intervention included: 1) a microfi-
nance loan (~$150) to purchase the farming commodities, 2) a micro-irrigation
pump, seeds, and fertilizer, and 3) trainings in sustainable agricultural practices
and financial literacy. Enrollment of 140 participants took four months, and the
screening-to-enrollment ratio was similar between arms. The authors followed
participants for 12 months and conducted structured questionnaires. They also
conducted a process evaluation with participants and stakeholders 3–5 months
after study start and at study end. Baseline results revealed that participants at
the two sites were similar in age, gender and marital status. A greater proportion
of participants at the intervention site had a low BMI in comparison to partici-
pants at the control site (18% vs. 7%, p = 0.054). While median CD4 count was
similar between arms, a greater proportion of participants enrolled at the inter-
vention arm had a detectable HIV viral load compared with control participants
(49% vs. 28%, respectively, p < 0.010). Process evaluation findings suggested
that Shamba Maisha had high acceptability in recruitment, delivered strong agri-
cultural and financial training, and led to labor saving due to use of the water
pump. Implementation challenges included participant concerns about repay-
ing loans, agricultural challenges due to weather patterns, and a challenging part-
nership with the microfinance institution. The authors expect the results from
this pilot study to provide useful data on the impacts of livelihood interventions
and will help in the design of a definitive cluster RCT.
The authors of chapter 9 aim to explore how food insecurity affects individu-
als’ ability to manage their diabetes, as narrated by participants living in a large,
culturally diverse urban centre. To this end, the authors underwent a qualitative
study comprising of in-depth interviews, using a semistructured interview guide.
Participants were recruited from the local community, three community health
centres, and a community-based diabetes education centre servicing a low-
income population in Toronto, Ontario, Canada. Twenty-one English-speaking
adults with a diagnosis of diabetes and having experienced food insecurity in the
past year (based on three screening questions) participated in the study. Using
six phases of analysis, the authors used qualitative, deductive thematic analysis
to transcribe, code, and analyze participant interviews. Three themes emerged
from the authors’ analysis of participants’ experiences of living with food inse-
curity and diabetes: (1) barriers to accessing and preparing food, (2) social
isolation, and (3) enhancing agency and resilience. Food insecurity appears to
negatively impact diabetes self-management. Healthcare professionals need to
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