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Food insecurity: A concept analysis

Krista Schroeder, BSN, RN, CCRN [Pre-doctoral Fellow] and
Columbia University School of Nursing

Arlene Smaldone, PhD, CPNP, CDE [Associate Professor of Nursing]
Assistant Dean of Scholarship and Research, Columbia University School of Nursing

Abstract

Aim—To report an analysis of the concept of food insecurity, in order to 1) propose a theoretical
model of food insecurity useful to nursing and 2) discuss its implications for nursing practice,

nursing research, and health promotion.

Background—Forty eight million Americans are food insecure. As food insecurity is associated
with multiple negative health effects, nursing intervention is warranted.

Design—Concept Analysis

Data sources—A literature search was conducted in May 2014 in Scopus and MEDLINE using
the exploded term “food insecur*.” No year limit was placed. Government websites and popular

media were searched to ensure a full understanding of the concept.

Review Methods—Iterative analysis, using the Walker and Avant method

Results—Food insecurity is defined by uncertain ability or inability to procure food, inability to
procure enough food, being unable to live a healthy life, and feeling unsatisfied. A proposed

theoretical model of food insecurity, adapted from the Socio-Ecological Model, identifies three

layers of food insecurity (individual, community, society), with potential for nursing impact at

each level.

Conclusion—Nurses must work to fight food insecurity. There exists a potential for nursing
impact that is currently unrealized. Nursing impact can be guided by a new conceptual model,

Food Insecurity within the Nursing Paradigm.

Keywords

concept analysis; food insecurity; nursing; conceptual model

Concerns about hunger in the United States arose during the Great Depression and

intensified in the 1960s during the Johnson administration’s Great Society initiative (Kregg-

Byers and Schlenk, 2010, Johnson, 1964). Since that time, concern about hunger in America

has received increasing attention from both government and the public (Bickel et al., 2000),

Corresponding author: Krista Schroeder, BSN, RN, CCRN, Columbia University School of Nursing, 617 West 168th Street, New
York, NY 10032, [email protected]

No conflict of interest has been declared by the author(s).

HHS Public Access
Author manuscript
Nurs Forum. Author manuscript; available in PMC 2016 July 21.Au

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leading to passage of the “National Nutrition Monitoring and Related Research Act of 1990”

(United States Department of Agriculture Economic Research Service, 2013). This

legislation required a standard metric for identifying and obtaining data on the prevalence of

“food insecurity” (United States Department of Agriculture Economic Research Service,

2013). Following passage of the act, the United States Department of Agriculture [USDA]

began working towards the creation of a practical way to measure and monitor food

insecurity (United States Department of Agriculture Economic Research Service, 2013),

with the most recent measurement tool being the Food Security Survey Module (Bickel et

al., 2000). Concern about food insecurity continued to grow, with leaders representing

academia, private research centers, and federal agencies meeting in 1994 at the National

Conference on Food Security Measurement and Research (United States Department of

Agriculture Economic Research Service, 2013). Food insecurity remains a focus of

government health leaders, with the Institute of Medicine convening a workshop on food

insecurity in 2010, looking specifically at its relationship with obesity (Institute of Medicine,

2011). Currently, the USDA Economic Research Service is responsible for routine

assessment and measurement of the prevalence of food insecurity.

The USDA defines food security as “access by all people at all times to enough food for an

active, healthy life” (Coleman-Jensen et al., 2013). Food insecurity is identified by lack of

food security. It is currently estimated that 14.5% of American households, or 48,966,000

individuals, are food insecure (Coleman-Jensen et al., 2013). This problem is not unique to

America; food insecurity is a global crisis (Food and Agricultural Organization of the United

Nations, 2013). This should be of concern to nurses, as individuals living in food insecure

households lack access to a healthy diet.

Background

Food insecure Americans eat less nutritious diets than food secure Americans (Champagne

et al., 2007; Robaina & Martin, 2013), as low cost foods are often less nutritious (Wallinga,

Schoonover, & Muller, 2009). The relationship between food insecurity and poor health

persists across the lifespan, impacting infants (Cook et al., 2004), school children, women of

childbearing age (Olson, 1999), adults (Stuff et al., 2004), and the elderly (Lee & Frongillo

E.A, 2001). Poor nutrition is a risk factor for four of the top ten causes of death in America

(Hoyert & Xu, 2012): cancer (Key, Allen, Spencer, & Travis, 2002; Pietinen et al., 1999;

Tsugane & Sasazuki, 2007; Voorrips et al., 2000), stroke (Boden-Albala & Sacco, 2000;

Fung et al., 2008; Larsson, Åkesson, & Wolk, 2014), cardiovascular disease (Krauss et al.,

2000; Mann, 2002), and diabetes (Hu et al., 2001; Mann, 2002; Parillo & Riccardi, 2004).

Of concern, food insecurity is also more common in populations known to suffer from

health disparities, such as the disabled (Coleman-Jensen and Nord, 2013) and racial/ethnic

minorities (Coleman-Jensen et al., 2013).

The negative health effects of food insecurity suggest a need for nursing intervention to help

individuals attain optimal health. Although there have been calls for increased nursing

involvement (Kregg-Byers and Schlenk, 2010), food insecurity is largely absent from the

nursing literature. A stronger nursing voice is needed in the ongoing international discussion

about food insecurity and health. To our knowledge, the nursing paradigm lacks an

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operational definition, conceptual model, or theoretical framework of food insecurity. To

address those gaps, utilizing the concept analysis method of Walker and Avant (2005), the

purpose of this paper is to 1) explore the meaning of food insecurity, 2) propose a theoretical

model of food insecurity relevant to nursing, and 3) discuss its implications for nursing

practice, nursing research, and health promotion.

Methods

We utilized the method of Walker and Avant (2011). The steps in this method include 1)

determine the aims or purpose of analysis, 2) identify all uses of a concept, 3) determine the

defining attributes, 4) construct a model case, 5) construct borderline, related, and contrary

cases, 6) identify antecedents and consequences, and 7) define empirical referents. Of note,

Walker and Avant note the need for the concept analysis process to be iterative in order to

result in a “cleaner, more precise analysis” (Walker and Avant, 2011). Although the steps

are presented sequentially, they occurred in a circular manner or, at times, simultaneously.

Data Sources

A literature search was conducted to identify primary research studies relating to food

insecurity. Scopus and MEDLINE were searched using the exploded term “food insecur*.”

Searches were limited to English language articles relating to food insecurity in the United

States. No year limit was placed, as a thorough understanding of the concept and its use over

time was desired. In addition, government websites, such as USDA.gov, were searched to

inform understanding of the concept. A Google search was also performed to better

understand the use of the term in general discourse and popular culture.

Results

The search of MEDLINE and Scopus resulted in 1,492 articles, and 1,480 after removal of

duplicates. These were screened by title for relevance to conceptual understanding of food

insecurity within the United States. After title screen, 57 articles remained. The 57 articles

were further screened first by abstract. Of these, fifteen were deemed relevant and read by

full text. A manual search of reference lists and government websites resulted in an

additional 24 articles and 9 web documents, resulting in a total of 48 resources.

Uses of the Concept

The use of the concept of food insecurity is relatively consistent throughout the literature. Of

the 29 resources that defined food insecurity, 27 used the USDA’s definition and two used

the United Nations’ [UN] definition. Authors of the remaining resources did not specify their

use of the concept; they proceed directly to discussion of other aspects of food insecurity,

such as antecedents or consequences. Of note, none of the resources identified by the search

came from nursing literature or arose from the nursing paradigm.

The USDA defines food insecurity as “limited or uncertain availability of nutritionally

adequate and safe food or limited or uncertain ability to acquire acceptable foods in socially

acceptable ways” (United States Department of Agrictulture Economic Research Service,

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2014b). The USDA’s definition attaches key characteristics to this concept. First, it specifies

“limited or uncertain availability” of food. Therefore, food insecurity includes having a

finite (“limited”) amount of food, as well as lack of guaranteed access (“uncertain

availability”). Although these two aspects of the definition are related, the difference is

important to note. Food insecurity is not just about quantity of food; it also pertains to

certitude of access. The definition is illustrative in its specification of “nutritionally adequate

and safe” food. These terms illustrate two different aspects of food security. Safe food is

more straightforward and can be considered food that is safe for consumption. For example,

safe food is produced under sanitary conditions and is not spoiled. However, nutritionally

adequate has a separate meaning. One could argue that having access to endless amount of

soda, potato chips, processed sweets, and other nutritionally deplete items may qualify as

“nutritionally inadequate,” as it may result in lack of vitamins, minerals, phytochemicals, or

protein. Therefore, according to this definition, it is possible to have a ubiquitous amount of

food and still be food insecure. Furthermore, the USDA’s definition qualifies the concept by

noting that food insecurity includes obtaining food in socially unacceptable ways. Therefore,

if one is able to acquire food, but does so by begging on subway cars, (s)he could be

considered food insecure, as the method of obtaining food is not socially acceptable. This

relates to the aspect of “limited access,” but adds the qualifier of social norms. Of note, the

USDA categorizes food insecurity by level of severity: low and very low (Coleman-Jensen

et al., 2013). Households with low food security report “reduced quality, variety, or

desirability of diet [with] little or no indication of reduced food intake.” Households with

very low food security report “multiple indications of disrupted eating patterns and reduced

food intake” (United States Department of Agrictulture Economic Research Service, 2014a).

The UN, including the World Health Organization and the Food and Agriculture

Organization, utilizes the definition that was determined at the World Food Summit in

Rome, Italy in 1996 (Food and Agricultural Organization of the United Nations, n.d.):

“when all people at all times have access to sufficient, safe, nutritious food to maintain a

healthy and active life” (World Health Organization, 2014). The WHO literature notes that

this issue is linked to health through malnutrition, yet globalization, development, and trade

also play key roles in this complex concept (World Health Organization, 2014). The WHO’s

perspective focuses on problems of distribution and nationwide food security, with special

attention paid to agricultural work in developing countries and how current global trends

impact those nations’ agriculture and food security (World Health Organization, 2014).

Both the USDA and the UN play key roles in tackling food insecurity, guided by their

definitions. Although these definitions have similarities, such as their identification of

sufficiency of amount, safety, and nutrition, there are significant differences, as they address

different problems. The UN focuses on food security issues in developing countries,

whereas the United States is considered a developed nation (United Nations, n.d.). Issues of

food insecurity present differently in developed versus developing nations (Kregg-Byers and

Schlenk, 2010). For example, the severe malnutrition common in certain developing nations,

of significant concern to the UN, has been essentially eradicated from the United States

(Bickel et al., 2000). Furthermore, the definitions differ in scope, as the USDA focuses

attention to a problem that entails only one nation and has the governmental authority to

approach the problem more directly through policy change. The UN’s approach to food

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insecurity is necessarily broader, as it deals with diverse nations and is unable to directly

establish policy within its member states.

Even though the UN and USDA both define food insecurity, the meanings of global food

insecurity and American food insecurity differ significantly. Thus, the role of nurses in

addressing global food insecurity versus American food insecurity would differ

significantly. A concept analysis of this issue within the nursing paradigm must focus on one

of these approaches. This paper concerns itself with food insecurity in the United States, as a

representation of food insecurity in developed nations.

Defining Attributes

Defining attributes are those that identify a concept as separate and distinct from related

concepts (Walker and Avant, 2011). Four defining attributes of food insecurity emerged

from the literature. They include 1) uncertain ability or inability to procure 2) enough food

3) to feel satiated 4) and/or live a healthy life.

Uncertain ability or inability to procure food—The literature demonstrates that the
inability to procure food is often due to financial constraints. Findings of several studies

suggest a positive association between increasing food prices and increased prevalence of

food insecurity (Zhang et al., 2013, Gregory and Coleman-Jensen, 2013). In addition, it is

known that poverty is associated with food insecurity (Coleman-Jensen et al., 2013),

particularly among households who have limited assets and liquidity constraint (lack

sufficient liquid assets and/or have difficulty borrowing) (Chang et al., 2013). However,

financial constraints are not the only contributors to procuring food. Researchers have

examined non-financial barriers contributing to food insecurity. Ramadurai and colleagues,

in their qualitative study of food insecure individuals living in rural Texas, reported that

food insecure adults perceived lengthy travel to food stores as a significant barrier to

procuring food (Ramadurai et al., 2012). Findings of a cross-sectional study conducted in an

urban pediatric clinic suggest that individuals residing in food insecure households were

more likely to report transportation as a barrier to procuring food that those in food secure

households (Demartini et al., 2013).

Inability to procure enough food—Individuals can have access to food, but when the
amount of food is inadequate, they become food insecure. This reflects the episodic nature

of food insecurity; households often waver between food insecurity and food security

(LeBlanc et al., 2005) based upon food supply. The USDA’s food insecurity screening tool

also demonstrates that individuals in food insecure households have access to food, yet not

in sufficient quantity. The tool assesses reduced food intake, running out of food, and intake

of less food than normal (Bickel et al., 2000).

Feeling unsatisfied—The presence of food insecurity is often defined by lack of enough
food to feel satisfied. Individuals living in food insecure households do not eat to satiety. For

example, in food insecure households, children may express feelings of hunger but parents

are unable to adequately respond due to insufficient supply of food in the home (Sano et al.,

2011). Food insecure individuals may engage in acts to minimize appetite, such as smoking

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cigarettes, ignoring mealtimes, or drinking caffeinated beverages (Mammen et al., 2009).

The USDA’s screening tool for food insecurity also identifies lack of satiety as a key factor,

by connecting food insecurity with eating less than desired or not eating enough to satisfy

hunger (Bickel et al., 2000).

Unable to live a healthy life—Food insecurity prevents individuals from living a healthy
life. For example, food insecure individuals have difficulty affording nutritious diets

(Coleman-Jensen, Nord, & Singh, 2013) and experience increased psychological stress

(Laraia, Siega-Riz, Gundersen, & Dole, 2006). Poor nutrition and stress increase likelihood

of chronic disease (World Health Organization, 2005). Food insecurity also presents

significant problems for the chronically ill. For example, Seligman and colleagues reported

that low income adults with diabetes are more likely to be hospitalized for hypoglycemia

when their Supplemental Nutrition Assistance Program (food stamps) budget is exhausted

and food insecurity worsens (Seligman, Bolger, Guzman, López, & Bibbins-Domingo,

2014). Because food insecure individuals cannot live a healthy life due to poor nutrition and

increased stress, food insecurity is associated with many negative health consequences

(Olson, 1999, Lee and Frongillo, 2001, Cook et al., 2004, Stuff et al., 2004). For these

reasons, inability to live a healthy life may be considered both a defining attruibute and a

consequence of food insecurity. Food advocacy organizations and associations of dietary

health professionals have recognized this, responding with a call to action to reduce food

insecurity (American Dietetic Association, 2010, Feeding America, 2014).

Antecedents

Antecedents are “events or incidents that must occur prior to the occurrence of the concept”

(Walker and Avant, 2011). In simplest terms, lack of resources to procure food and lack of

access to food are key antecedents. However, antecedents do not occur in a vacuum and may

result from diverse contributing factors. For example, food insecurity has been associated

with high food costs (Gregory and Coleman-Jensen, 2013, Morrissey et al., 2014, Zhang et

al., 2013, Ramadurai et al., 2012), lack of access to food stores (Freedman et al., 2013,

Ramadurai et al., 2012, Jernigan et al., 2012), a lacking local food environment (i.e. food

stores sell unaffordable or undesirable products) (Chang et al., 2013, Demartini et al., 2013),

lack of or low income (Chang et al., 2013, Demartini et al., 2013, Anderson, 2013,

Langellier et al., 2013), being unable to find culturally appropriate food (Jernigan et al.,

2012), low acculturation (Iglesias-Rios et al., 2013), being a first-generation American or

immigrant (Langellier et al., 2013), lack of transportation (Demartini el al., 2013, Jernigan et

al., 2012), stigma associated with using resources such as federal “food stamps” – the

Supplemental Nutrition Assistance Program (SNAP) (Gundersen, 2013, Food Research and

Action Center, 2011) or SNAP for Women, Infants, and Children (WIC) (Huynh, 2013),

lack of awareness about resources such as SNAP (Food Research and Action Center, 2011),

inadequate policy to support food insecure individuals (Jernigan et al., 2012), and having a

disability (Coleman-Jensen and Nord, 2013).

Consequences—Walker and Avant describe consequences as “events or incident that
occur as a result of the occurrence of a concept” (2011). Many negative health consequences

may result from food insecurity. Gundersen (2013) provides one of the most through

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summaries of negative health outcomes. We share findings of his review here, as it is one of

the most comprehensive and supports the need to address food insecurity to promote optimal

health across the lifespan. Risks begin for the developing fetus, with food insecurity linked

to higher rates of birth defects such as spina bifida and anencephaly (Carmichael et al.,

2007). In children, risks of food insecurity include anemia (Eicher-Miller et al., 2009,

Skalicky et al., 2006), lower nutrient intakes (Cook et al., 2004), greater cognitive problems

(Howard, 2011), higher levels of aggression and anxiety (Whitaker et al., 2006), higher

probability of being hospitalized (Cook et al., 2006), poorer general health (Cook et al.,

2006), higher probability of mental health issues (Alaimo et al., 2002), higher probability of

asthma (Kirkpatrick et al., 2010), higher probability of behavioral problems (Huang et al.,

2010), and increased oral health problems (Muirhead et al., 2009). In addition, there is a

potential connection between food insecurity and childhood obesity, but this relationship is

not yet well understood (Dinour, Bergen, & Yeh, 2007; Eisenmann, Gundersen, Lohman,

Garasky, & Stewart, 2011; Food Research and Action Center, 2011; Franklin et al., 2012;

Larson & Story, 2011). In adults, risks include lower nutrient intakes (Kirkpatrick and

Tarasuk, 2008, McIntyre et al., 2003), mental health problems (Heflin et al., 2005) such as

depression (Whitaker et al., 2006), physical health problems (Tarasuk, 2001), type 2

diabetes (Seligman et al., 2007), higher levels of chronic disease (Seligman et al., 2010),

obesity, particularly in women (Dinour et al., 2007; Food Research and Action Center, 2011;

Franklin et al., 2012; Pan, Sherry, Njai, & Blanck, 2012), disordered eating (Kendall, Olson,

& Frongillo Jr, 1996), and poorer self-reported health status (Stuff et al., 2004). Food

insecure elderly have lower nutrient intakes (Lee and Frongillo, 2001, Ziliak J et al., 2008),

increased likelihood of reporting poor or fair health (Lee and Frongillo, 2001, Ziliak J et al.,

2008) and having limitations in activities of daily living (Ziliak J et al., 2008).

Case Studies

The following examples demonstrate potential implications of food insecurity for

individuals. Consistent with method of Walker and Avant (2011), the model case

exemplifies an individual who clearly meets the definition of food insecure, the borderline

case includes some but not all of the aspects of the definition, and the contrary case serves as

a contrast to this concept.

Model case—AB is a 30 year old Hispanic female living in Washington Heights, New
York City. She is a single mother with three school-aged children. She is employed as a

retail cashier, but has difficulty paying her bills despite working full-time at minimum wage.

After paying her rent, she has little income left for her and her children. She experiences

stress due to trying to balance the need to pay for rent and pay for groceries. She receives

SNAP benefits, but these funds generally do not last the entire month. In addition, it is

difficult for her to get to the grocery store, as the closest full service store is 10 blocks away

and she struggles to travel there with three children. As a result, by the last week of the

month she sometimes is forced to skip meals to ensure that there is enough food for her

children. She worries more on weekends, when her children are unable to participate in free

meals programs at school. She reports feeling “starving” by dinnertime, which is when she

has her first full meal. She often serves canned soup for dinner, which she waters down to

increase the volume, allowing her to use only two cans instead of three. Feeling that she

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lacks other options, she has considered asking strangers for money on the subway. She is

unaware of local food pantries and does not have any local family or friends who can assist

her.

Borderline case—CD is a 30 year old Hispanic female living in Washington Heights,
New York City. She is a single mother and has an eight month old infant. She left her job as

a retail clerk when her child was born, but is able to support herself through a small amount

of savings and financial assistance from her large family, who all live nearby. She

experiences stress about paying her bills but has always been able to afford essentials such

as rent. She purchases groceries on a weekly basis and never goes hungry, though she buys

sale items to keep costs low. She worries because her savings are almost exhausted, so she is

applying for government nutrition assistance for Women Infants and Children (WIC) with

the aid of her local community center. However, she is unsure if she wants to use these

benefits, as she has heard others refer to them as “hand-outs” for “lazy people.” In addition,

she has been using the local food pantry for rice cereal and baby formula for her child. She

worries about being able to afford enough food for her daughter, but her pediatrician says

her child is developing normally and is within healthy ranges for height and weight.

Contrary case—EF is a 30 year old Hispanic female living in Washington Heights, New
York City. She is married and lives with her husband and two school-age children. Both EF

and her husband work at an academic medical center; she is a unit clerk and he is a

registered nurse. They share the grocery shopping responsibilities and usually go to the store

twice a week. They never worry about their ability to afford groceries. They actively seek

out healthier foods to purchase, even if they are more expensive, with the aim of providing

nutritious meals for their children. The whole family usually goes to a restaurant

approximately two or three times a month.

Interpretation of cases—These cases serve as examples of the multiple factors that
impact the development and severity of food insecurity. For example, CD, the borderline

case, appears to be food secure because she has assistance from a local community center

and family. However, a social issue, the stigma of WIC as a “hand out,” may prevent her

from seeking and/or taking advantage of the service she needs. In addition, AB is impacted

by the inadequate minimum wage at her job, something that is determined by national and

state policy and therefore outside of her direct control.

Empirical referents

Empirical referents are “classes or categories of actual phenomena that by their existence

demonstrate occurrence of the concept” (Walker and Avant, 2011). Food insecurity is

assessed yearly using the Food Security Survey Module as part of the Current Population

Survey (Bickel et al., 2000). Survey responses are analyzed to determine the prevalence of

food insecurity. The empirical referents captured in this survey include inadequate amount

of food, unaffordability of food, meal skipping and portion cutting, hunger, unplanned

weight loss, not eating for a whole day, cutting or skipping children’s meals, and hunger

related to food affordability (Bickel et al., 2000).

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Theoretical implications

Though the role of concept analysis in theory development is debated, there is agreement on

the need for the connection between concept analysis and theory (Duncan et al., 2009,

Risjord, 2009, Paley, 1996). Our concept analysis has …