Lead Article

Food insecurity and nutritional status among older

adults: a systematic review
Marlus H.Q. Pereira , Maria L.A.S. Pereira, Glaucia C. Campos, and Maria C.B. Molina

Context: Food insecurity (FI), characterized by difficulty or inability to access ade-

quate food, has become a public health problem. Objective: To analyze studies re-

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lating FI with nutritional status (NS) among older adults and the associated factors.
Data search: Articles published up to June 2020 were investigated in 5 databases:
PubMed, Embase, Scopus, LILACS, and Web of Science. The search, selection, extrac-
tion, and quality evaluation were carried out by 2 reviewers. Data extraction: The
authors identified characteristics of the studies and the main data regarding the re-
lationship of interest. Results: Twenty-two studies were included in the review and
their characteristics are summarized and presented using narrative synthesis. In 10
studies (45.4%), a relationship was observed between FI and malnutrition; in an-
other 6 (27.3%), a relationship was observed between FI and being overweight.
Conclusion: A relationship was identified between FI, especially severe forms, and
malnutrition, as well as between FI, especially mild forms, and people being over-
weight. Thus, FI among older adults relates to a 2-fold burden of nutritional out-
comes, depending on the level. Systematic Review Registration: PROSPERO reg-
istration no. CRD42020185086.

INTRODUCTION process.1 In other stages of life, FI is determined by pov-

Food insecurity (FI) is a condition related to difficulty
or inability to access an adequate food, in terms of both
quality and sufficient quantity to meet nutritional
needs.1–3 FI can cause various effects, ranging from psy-
chological symptoms, such as anxiety and worry about
a lack of food, to nutritional disorders, such as malnu-
trition and being overweight.3
FI occurs more severely among older adults, given
the backdrop of social, economic, physiological, and
pathological changes that occur during the ageing
erty, whereas among older adults, other factors are just
as important as the economic one, such as multimor-
bidity, the greater cost of managing the treatment of
chronic diseases, physical and functional limitations,
and neurologic and mental diseases.2,4
FI in older adults results in modifications in the
quantity of food consumed, with a reduction in the
number of meals and volume of each and an overall re-
duction in nutrients, especially proteins, vitamins, and
minerals. In addition, there is an alteration in the qual-
ity of meals, with the tendency being to consume tastier,

Affiliation: M.H.Q. Pereira and M.L.A.S. Pereira are with Center of Biological and Health, Science, Federal University of the Western of Bahia,
Barreiras, Bahia, Brazil. M.H.Q. Pereira, M.L.A.S. Pereira, and M.C.B. Molina are with the Postgraduate Program in Collective Heath, Federal
University of Espırito Santo, Vitoria, Brazil. G.C. Campos is with the Federal University of Espırito Santo, Vitoria, Brazil. M.C.B. Molina is with
the Postgraduate Program in Health and Nutrition, Federal University of Ouro Preto, Ouro Preto, Brazil.
Correspondence: M.H.Q. Pereira, Center of Biological and Health Science, Federal University of the Western of Bahia, St. Professor Jose
Seabra de Lemos, 316, Recanto dos Passaros, Barreiras, Bahia CEP 47808-021, Brazil. E-mail: marlus.pereira@ufob.edu.br .
Key words: ageing, food insecurity, malnutrition, nutritional status, overweight
C The Author(s) 2021. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved.
V
For permissions, please e-mail: journals.permissions@oup.com.

doi: 10.1093/nutrit/nuab044
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industrialized foods with a higher energy density.5,6
That is, among older adults, FI can cause both malnutri-
tion and nutritional deficiencies, as well as overweight,
obesity, and an increased risk for cardiovascular dis-
eases, producing a 2-fold burden on nutritional out-
comes.7–9
As a result of FI, malnutrition and the risk of mal-
nutrition among older adults constitute a serious public
health problem because of its multiple causes, high
prevalence, and its impacts on the quality of life of this
population.10,11 Characterized by an insufficient dietary
intake and by a loss of nutrients, malnutrition in older
adults exposes these individuals to a greater risk of
death, hospital readmission, susceptibility to infections,
and loss of autonomy and independence.12–15
On the other hand, there is another, equally impor-
tant nutritional disorder among older adults related to
FI conditions: being overweight, primarily due to physi-
cal inactivity and inadequate dietary habits.16,17 Often
because of difficulties accessing, preparing, and con-
suming healthier foods, the older adult has a monoto-
nous diet, involving practical and more accessible
foods, and which, most of the time, provides a higher
quantity of fat, salt, sugar, and a high energy density. A
decline in resting energy expenditure also is recorded
with ageing.4,18
Despite the various studies in which the association
between FI and nutritional status (NS) has been investi-
gated, the multifactorial mechanism of this association
remains to be found, possibly because there is no a sys-
temization of the findings on the topic. Although find-
ings of some studies indicate an association between FI
and overweight, others show a relationship with malnu-
trition or with the risk of malnutrition. Thus, it is im-
portant to understand the relationship between FI and
the NS of elderly individuals. Interventions are needed
that can reduce the negative impact this condition can
have on NS, manage the therapeutic itinerary in the
health and welfare system, and thus improve the quality
of life of this population. Therefore, our aim for this re-
view was to identify the relationship between FI and NS
in the elderly population and the associated factors.
METHODOLOGY
We conducted a systematic review based on the norms
of the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses,19 whose checklist is available in
Appendix 1 in the Supporting Information online. The
review involves studies that have related FI with NS in
older adults. A protocol was produced with details of
the main study items and was registered in PROSPERO
(registration no. CRD42020185086).
632
To help in this investigation, the following ques-
tions were asked: What is the relationship between food
insecurity and nutritional status in older adults? Is FI
related to overweight or malnutrition (manifested by
low weight or protein-energy malnutrition)? What are
the associated factors that can explain these conditions?
Search strategy
The search for articles was carried out in the PubMed,
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LILACS, Embase, Web of Science, and Scopus elec-
tronic databases. The following descriptors were used
for the database search: “food insecurity,” “food
security,” “nutritional status,” “nutritional assessment,”
“malnutrition,” “obesity,” “older adults,” “elderly,” and
“aged.” These were combined with the Boolean opera-
tors AND and OR and grouped in order to exhaust all
the possibilities and to give the search greater sensitivity
and specificity. We chose to use the title/abstract/key-
words filters for all the descriptors. According to each
database, adaptations were made to the descriptors to
maximize the article search (Appendix 2 in the
Supporting Information online). The studies identified
in each research database were imported to the Zotero
8 references management software (www.zotero.org),
where the next steps were carried out.
Inclusion and exclusion criteria
Included in the review were cross-sectional studies con-
ducted in any country that investigated the relationship
between FI and NS among elderly individuals
( 60 years old) who live in the community. Moreover,
the studies needed to have evaluated FI using validated
scales, questionnaires, or indicators. For the NS evalua-
tion, we considered articles that used the body mass in-
dex (BMI), the Mini Nutritional Assessment, body
composition indicators, the Subjective Global
Assessment, and the Nutrition Screening Initiative,
among other instruments validated for evaluating NS in
this population. The details of the inclusion and exclu-
sion criteria are listed in Table 1. We followed the
PICOS (participant, intervention, comparison, result,
study design) guidelines.20
Dissertations, theses, abstracts in congress annals,
censuses, and documents or reports from national and
international organizations were excluded. We also ex-
cluded articles repeated in different databases and
articles that repeated information from a previously in-
cluded population.
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 Table 1 Determination of the eligibility of the studies using inclusion and exclusion criteria, according to the PICOS
strategy
Parameter Inclusion Exclusion
Population Elderly residents in the community, both Children, adolescents, adults and preg-
sexes nant women, hospitalized older adults,
and institutionalized older adults
Intervention/exposure FI evaluated using validated or adapted FI analyzed in isolation, without tracing
scales, questionnaires, or indicators, the relationship with NS
based on the family’s or individual’s ex-
perience of FI
Comparison Does not apply
Outcome Evaluation of NS using BMI, MNA, NSI, SGA, NS evaluated through indicators that as-
body composition indicators, among sess bodily behaviors in isolation (ie,
other validated instruments calf circumference, triceps skin fold,

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bioimpedance)
Type of study Cross-sectional studies Case-control
Cohort study
Literature review
Systematic review
Qualitative studies
Ecological studies
Case report
Experimental studies

Abbreviations: BMI, body mass index; FI, food insecurity; MNA, Mini Nutritional Assessment; NS, nutritional status; NSI, Nutrition
Screening Initiative; SGA, Subjective Global Assessment.

Study selection enabled a better visualization of the relationships

Two researchers (M.H.Q.P and M.L.A.S.P) simulta-
neously and independently identified and selected the
articles in all the databases searched between May 2020
and June 2020. Disagreements between the reviewers
were resolved by consensus and, if necessary, discussed
with another reviewer (G.C.C). In this stage, there were
no language or period restrictions for choosing the pub-
lications. The studies were selected by evaluating the
titles, then by reading the abstracts and subsequently
reading the studies in full, observing the inclusion crite-
ria. In addition, the reference lists of the chosen articles
were analyzed to identify any study that had not been
captured using the search strategy.
Data extraction
Data were extracted independently by 2 researchers
(M.H.Q.P and M.L.A.S.P) and included in an Excel
(https://products.office.com/) spreadsheet containing
the following items: authors, year of publication, coun-
try of the study, number of people investigated, charac-
teristics of the population studied, method used to
evaluate NS, instrument used for evaluating FI/sam-
pling unit, prevalence of FI and NS, main results of the
relationship between FI and NS, and the aspects associ-
ated with these conditions. The information extracted
from the articles was used to build an explanatory
model regarding the factors associated with FI, NS, and
the relationship between both conditions, which
investigated.
Evaluation of the quality of the articles
The methodological quality of the selected articles was
evaluated according to the checklist from the Joanna
Briggs Institute.21 This is a specific instrument for eval-
uating cross-sectional studies22; it considers 8 methodo-
logical aspects: inclusion criteria, information on the
population, adequate measurement of exposure, valida-
tion of the method used to evaluate the outcomes, iden-
tification of confoundment, strategies for overcoming
the confounding factors, reliability of the results, and
adequate statistical analysis.
For each item of the study analyzed, a response and
a code were attributed: yes (1), no (0), not applicable
(X), and confounding (?). A total quality score was cal-
culated for each study. Scores between 7 and 8 points
were classified as having low risk of bias; those between
5 and 6 were classified as having moderate risk of bias;
and those between 0 and 4 were classified as having
high risk of methodological bias. The quality classifica-
tion was carried out independently by 2 researchers
(M.H.Q.P and M.L.A.S.P), and any differences were re-
solved through discussion.
RESULTS
In the first search, 2625 articles were identified in the
databases. Of these, 1064 were initially discarded because

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they were repeated; then, 1231 studies were excluded af-
ter reading the titles. In the subsequent screening that in-
volved reading and analyzing the abstracts, 276 articles
were excluded, resulting in 54 articles being chosen to be
read in full. After this evaluation, 19 studies were selected
for inclusion in the review. The reference lists of the se-
lected articles were subsequently searched, using the
descriptors and inclusion criteria, to identify original
published articles not located in the databases we used.
Via this process, we identified 3 additional articles; thus,
the systematic review ultimately covered 22 articles.
A diagram representing the search and the number
of studies found and eligible is presented in Figure 1.
The publications included are organized into tables
(Tables 2 and 3).5,7,16,23–41
Characteristics of the studies
Among the main characteristics of the 22 cross-
sectional studies selected (Table 2), 45.4% (n ¼ 10) were
published between 2017 and 2019.16,23–31 There were
studies of European (18.2%),16,24,25,32 Asian
27,30,33
(13.6%), African (9.1%),29,34 and Latin American
(13.6%)7,35,36 populations, but there was a predomi-
nance of studies of elderly North American individuals
N = 2625
Figure 1 Preferred reporting items for systematic reviews and meta-analysis (PRISMA) flow diagram of systematic review on food in-
security (FI) and nutritional status (NS).
634
(45.4%).5,23,26,28,31,37–41 The sample size varied from 49
to 9309 individuals.31,34 Half of the studies (n ¼ 11)
used samples of older adults from the general popula-
tion within their contexts, without restrictions regard-
ing specific groups,5,16,23–26,29–31,36,38 but other studies
used populations with their own particularities, such as
participants in social programs or with a low income
(8),7,28,32,33,35,37,39,41 only women (n ¼ 2),34,38 only those
with a chronic pathology (n ¼ 1),40 or only older adults
living in rural areas (n ¼ 3).27,34,40
In relation to the instruments for evaluating FI,
there was a predominance (n ¼ 17; 77.3%) of the use of
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FI scales based on household experience.7,16,23–31,33–
36,39,40
BMI was the most used method to evaluate NS
and was present in 18 studies (82%),5,7,16,23–27,29–31,34–
36,38–41
followed by the Mini Nutritional Assessment
(n ¼ 4; 18%).24,25,28,32
The prevalence of FI varied between 1.7% (United
States)5 and 76.3% (Greece).25 Moreover, half of the
studies (n ¼ 11) presented a FI prevalence of
< 25%.5,16,23,26,31,32,35,38–41 On the other hand, 7 studies
indicated a high prevalence (> 50%).24,25,30,33,34,36,37 In
the NS analysis, the prevalence of malnutrition varied
from 0% (United States)23,26,39 to 41% (Ghana),34
according to BMI. Using the Mini Nutritional
because
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 Table 2 Characteristics of the included studies (n 5 22) that relate FI with NS in older adults
Reference Country No. in sample Population FI measure; sam- NS measure Prevalence of NS Prevalence Study quality
pling unit of FI, %
Blankson Ghana 59 Women from rural Modified Radimer/ BMI (WHO) Underweight, 41%; nor- 75a þ8/8
(2012)34 areas Cornell Scale; mal weight 42%;

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individuals overweight 15%; obe-
sity, 2% BMI (mean),
20.5 kg/m2 (95%CI,
19.5–21.6)
Brewer United States 621 Social-program par- US household Food BMI (WHO) Normal weight, 24.6%; 18.7 þ7/8
(2010)39 ticipants (OAANP) Security Survey overweight, 35.4%;

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module; obesity, 40%
household
Brostow United States 2868 National representa- US household Food BMI (WHO) Normal weight, 31.1%; 18.2 þ8/8
(2019)23 tive sample (HRS) Security Survey overweight, 38.5%;
module; obesity, 30.4%
household
Fernandes Portugal 1885 National representa- Scale adapted from BMI (WHO) Underweight, 1.04%; 23 þ7/8
(2018)16 tive sample the Brazilian Food normal weight,
(EpiDoc3) Insecurity Scale; 29.69%; overweight,
household 46.45%; obesity,
22.82%
Ganh~ao- Portugal 337 Participants in senior Food Insecurity BMI (WHO) and Underweight, 1.2%; 70 þ7/8
Arranhado centers Experience Scale; MNA normal weight,
(2018)24 individuals 25.2%; overweight,
45.1%; obesity,
23.7%; malnutrition,
4.7%; nutritional risk,
40.7%; normal
weight, 54.6%
Grammatikopo- Greece 207 Participants of recre- Household Food Mean BMI, mean Mean BMI, 30.1 (6 76.3 þ8/8
ulou (2019)25 ational centers for Insecurity Access WC, and MNA 8.0)bkg/m2; malnutri-
the elderly Scale; household tion, 5.3%; nutritional
risk, 48.3%; normal
weight, 46.4%
Hernandez United States 5506 Representative na- USDA food security BMI (WHO) Underweight, 0%; nor- 19 þ7/8
(2017)26 tional sample with survey module; mal weight, 32%;
low income (NHIS) household overweight, 36%;
obesity, 32%
Homenko United States 74 Older adults with di- USDA food security BMI (mean) Mean BMI, 31.6 (66.5) 23 þ2/8
(2010)40 abetes in rural survey module; kg/m2
areas household
Hudin (2017)27 Malaysia 289 Older adults in an Food security tool BMI (WHO) Underweight, 7.6%; 27.7 þ8/8
agricultural for elderly; normal weight,
settlement household 40.8%; overweight,
36.7%; obesity,
14.9%; mean BMI,

635
25.1 (6 4.7) kg/m2
(continued)
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 Table 2 Continued

636
Reference Country No. in sample Population FI measure; sam- NS measure Prevalence of NS Prevalence Study quality
pling unit of FI, %
Jung (2019)28 United States 372 Social-program US household food MNA No information No
participants security survey
module;
household
information þ7/8
Kwon (2007)33 South Korea 458 Low-income older Adapted version of Nutritional man- No information 63.4 þ5/8
adults the USDA short- agement skills
form Household questionnaire
Food Insecurity
scale; household
Lee (2001)5 United States 7041 Representative sam- Food insecurity BMI (mean) and BMI, 26.8 kg/m2 (older 1.7d þ8/8
ple (NHANES and questions of NSICc adult with FS);
NSENY) NHANESIII; house- 27.1 kg/m2 (older
hold, and food in- adult with FI)
security measure
of NSENY;
individuals
Legesse Ethiopia 892 Representative sam- Household Food BMI (WHO) Underweight, 17.6% 25.7 þ8/8
(2019)29 ple: Censos Insecurity Access (95%CI, 15.0–20.20)
Scale/household
Park (2017)30 South Korea 5409 Representative sam- USDA’s core food se- BMI (mean) No information 62.5 þ5/8
ple (KNHANES) curity module;
household
Petersen United States 9309 National representa- USDA food security BMI (WHO) and No information 19 þ7/8
(2019)31 tive sample survey module; BMI (mean)
(NHANES) household
Porter (2011)41 United States 120 Social-program par- Adapted version of BMI (obesi- Obese, 51.6%; nonob- 23 þ8/8
ticipants (OAANP) NSI; individuals ty > 30 kg/m2) ese, 48.3%
Rivera-Marquez Mexico 6790 Representative Latin American and BMI (WHO) Underweight, 1.5%; 67 þ7/8
(2014)36 sample Caribbean scale of normal weight,
food security; 28.2%; overweight,
household 40.2%; obesity, 30.1%
Sharkey United States 908 Social-program par- Indicator of food in- NHSe No information 58 þ6/8
(2004)37 ticipants (OAANP) security: do not al-
ways have
enough money to
buy food.
Indicator of food

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security: always
have enough
money to buy
food; individuals
(continued)

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 Table 2 Continued
Reference Country No. in sample Population FI measure; sam- NS measure Prevalence of NS Prevalence Study quality
pling unit of FI, %
Simsek Turkey 650 Low-income older Food insecurity MNA Malnutrition, 2.7%; nu- 21.7 þ6/8
(2013)32 adults measure of tritional risk, 28.0%;

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NSENY; normal weight, 69.3%
individuals
Souza (2013)35 Brazil 427 Social-program Brazilian Food BMI (PAHO) Underweight, 16.9%; 21.8 þ8/8
participants Insecurity Scale; normal weight,
household 45.4%; obesity, 37.7%
Townsend United States 1139 Representative sam- Question of continu- BMI (NIH) Overweight, 43.8% 17.3 þ7/8

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(2001)38 ple of women ing survey of food
(CSFII) intake by individ-
uals (CSFII) ;
household
Vargas Puello Chile 344 Low-income older Household Food BMI (Chilean Underweight, 9.1%; 40.4 þ5/8
(2013)7 adults Insecurity Access Ministry of normal weight,
Scale; household Health) 42.4%; overweight,
25.1%; obesity,
23.4%; mean BMI,
27.8 (95%CI, 25.0–
31.6) kg/m2
Abbreviations: BMI, body mass index; CSFII, Continuing Survey of Food Intake of Individuals; EpiDoc3, Epidemiology of Chronic Diseases Cohort Study 3; FI, food insecurity; FS, food security;
HRS, Health and Retirement Study; KNHANES, Korea National Health and Nutrition Examination Survey; MNA, Mini Nutritional Assessment; NHANES, National Health and Nutrition
Examination Survey; NHIS, National Health Interview Survey; NIH, National Institutes of Health Development Conference on the Health Implications of Obesity; NS, nutritional status; NSENY,
Nutrition Survey of the Elderly in New York State; NHS, Nutritional Health Screen; NSI, Nutrition Screening Initiative; OAANP, Older Americans Act Nutrition Program; PAHO, Pan American
Health
a
Organization; USDA, US Department of Agriculture; WC, waist circumference; WHO, World Health Organization.
Presented some level of FI.bStandard deviation.cAdaptation of Nutritional Risk Screening (NSIC).dPrevalence of NHANES III.eNutritional Health Screen, a modified version of the NSI.

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 Table 3 Main results of the studies (n 5 22) regarding the relationship between FI and NS in older adults
Reference Relationship between NS and FI Relationship between FI and the nutritional
outcomea
Blankson (2012)34 Among women with a low weight, 83.8% (RR ¼ 1.70; There was no statistical significance
P ¼ 0.238) presented some level of FI
Brewer (2010)39 72.5% of elderly individuals experiencing FS and 87.0% Overweight
of those experiencing FI were overweight
(P < 0.001).
Brostow (2019)23 After adjusting for other factors, being overweight or There was no statistical significance
obese was not associated with higher chances of FI
among older adults.
Fernandes (2018)16 The elderly in families experiencing FI had higher chan- Overweight
ces of pre-obesity (pre-obesity vs normal weight, OR,
1.364; 95%CI, 1.353–1.376) and obesity (obesity vs

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normal weight, OR, 1.493; 95%CI, 1.477–1.508), be-
fore and after adjusting for age group, sex, educa-
tional level, and health region.
Ganh~ao-Arranhado (2018)24 Malnutrition was greater among older adults with Malnutrition and risk of malnutrition
higher FI scores (OR, 1.728; 95%CI, 1.20–2.475; P <
0.05).
Grammatikopoulou (2019)25 There was an association between FI and risk of malnu- Malnutrition and risk of malnutrition
trition (OR, 2.63; 95%CI, 1.21–5.75; P ¼ 0.015) in the
multivariate analysis.
Hernandez (2017)26 FI and obesity coexist among older adult women on a Overweight
low income. In the bivariate analysis, a greater pro-
portion of the older adults experiencing FI were
obese (40%) compared with those experiencing FS
(32%) (P < 0.05). Nonetheless, after analyzing the
adjusted models, this condition was not statistically
significant.
Homenko (2010)40 The older adults who reported mild FI (23%) had a BMI Overweight
> 35.5(6 7.1 )b kg/m2 vs older adults with FS, 30.5
(6 6.0)b kg/m2, P ¼ 0.01.
Hudin (2017)27 BMI was a predictive factor for FI (OR, 0.91 P < 0.05); Malnutrition and risk of malnutrition
that is, the older adults experiencing FI had lower
BMI values. Malnutrition was associated with FI (b
coefficient, 0.153; P ¼ 0.022).
Jung (2019)28 An indirect association was observed between FI and Malnutrition and risk of malnutrition
NS through depressive symptoms (b coefficient,
0.02; P ¼ 0.04).
Kwon (2007)33 FI was linearly and negatively associated with the level Malnutrition and risk of malnutrition
of nutritional management abilities. Among the
older adults with positive nutritional management
abilities, 33.3% experienced FS, 15.1% experienced
FI/no hunger, and 15.2% experienced FI/with hunger
(P ¼ 0.000).
Lee (2001)5 The older adults experiencing FI had, on average, a Malnutrition and risk of malnutrition
1.59-point higher nutritional risk score than the older
adults experiencing FS (P ¼ 0.001), even after con-
trolling for confounding factors.
Legesse (2019)29 The probability of chronic energy deficiency (malnutri- Malnutrition and risk of malnutrition
tion) among the older adults was strongly associated
with household FI (gross OR, 2.63; 95%CI, 1.84–3.78);
adjusted OR, 1.95 (95%CI, 1.26–3.00).
Park (2017)30 No statistically significant differences were observed in There was no statistical significance
the means between the older adults experiencing FS
and FI in the BMI analysis: FS, 24.0 (60.1) kg/m2;
mild FI, 24.1 (60.1) kg/m2; moderate and severe FI,
23.9 (60.3) kg/m2; P ¼ 0.740.
Petersen (2019)31 In the comparison between the groups, the mean BMI The statistical significance was not
increased as FS worsened. BMI: FS: 28.8 (60.1) kg/ analyzed.
m2; marginal FI, 29.8 (60.4) kg/m2; low FI, 30.1
(60.5) kg/m2; very low FI, 30.4 (60.6) kg/m2.
(continued)

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 Table 3 Continued
Reference Relationship between NS and FI Relationship between FI and the nutritional
outcomea
Porter (2011)41 In the comparison between the obese and nonobese There was no statistical significance
groups, there was no statistically significant associa-
tion with FI. Nonobese older adults: 21% FI; obese:
26% FI; P ¼ 0.51.
Rivera-Marquez (2014)36 Positive associations between FI and low weight Malnutrition and risk of malnutrition
among the older adults. The prevalence of low
weight was higher in older adults belonging to
households experiencing severe FI, in contrast with
those living in households experiencing mild FI
(2.8% and 1.3%, respectively; P < 0.05). It was possi-
ble to observe a certain tendency that suggested

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weight loss generally increased as the household FI
intensified.
Sharkey (2004)37 The independent association between FI and nutri- Malnutrition and risk of malnutrition
tional risk factors and health and nutrition indicators
remained strong and significant, even after control-
ling for demographic circumstances.
Simsek (2013)32 The presence of FI significantly increased the risk of Malnutrition and risk of malnutrition
malnutrition (OR, 2.49; 95%CI, 1.48–4.16; P ¼ 0.001).
Souza (2013)35 A higher chance of mild FI (OR, 2.01; 95%CI, 1.04–3.87) Overweight
was observed among the older adults who were
obese, in the final model, which was adjusted for sex
and age.
Townsend (2001)38 The prevalence of overweight women increased with Overweight
increased FI, from 40.8% for those experiencing mild
FI, to 57.7% for those experiencing moderate FI and
to 84.2% for those experiencing severe FI (P <
0.0001).
Vargas Puello (2013)7 Relationship between FI and malnutrition and being Malnutrition/risk of malnutrition and
overweight (OR, 1.99; 95%CI, 1.22–3.25; P < 0.01) Overweight
Abbreviations:
a
BMI, body mass index; FI, food insecurity; FS, food security; NS, nutritional status; OR, odds ratio; RR, risk ratio.
Malnutrition: this is an imbalanced nutritional state resulting from insufficient consumption of nutrients to fulfill normal physiological
needs,
b
related with protein-energy malnutrition, weight loss, and low weight.
Standard deviation

Assessment, malnutrition and/or risk of malnutrition Appendix 3 in the Supporting Information online). These
varied from 30.7% (Turkey)32 to 53.6% (Greece).25 The associated factors were divided into 4 groups: (1) risk factors
prevalence of being overweight varied from 17% for the FI condition; (2) repercussions of FI in the older
(Ghana)34 to 75.4% (United States)39; of the 22 studies, adults; (3) factors related to malnutrition or risk of malnutri-
8 (36.7%) reported > 50% prevalence of this nutritional tion; and (4) factors related to being overweight.
outcome.16,23,24,26,27,36,39,41
Evaluation of the methodological quality
Relationship between FI and NS
In the evaluation of the methodological quality, a low or
Among the studies, 10 (45.4%) reported a relationship be-
moderate risk of bias was observed, given that 8 articles
tween FI and malnutrition or risk of malnutrition,5,24,25,27–
29,32,33,36,37 (36.5%) fulfilled 100% of the criteria featured in the check-
6 (27.3%) reported a relationship between FI and
list.5,23,25,27,29,34,35,41 Another 8 adhered to 87.5% of the items
people being overweight,16,26,35,38–40 and in 1 (4.5%), there
evaluated.16,24,26,31,36,38,39 Adequate evaluation of the exposure
was a relationship with both outcomes.7 Another 5 studies
and of the outcome, together with the statistical methods
did not report statistical significance between the varia-
used, were the best evaluated items. The aspects that had the
bles.23,30,31,34,41 It is worth highlighting that 13 studies
worse evaluations were: details of the criteria for inclusion in
(59.1%) used the odds ratio as a statistical measure for mea-
the sample and reliability of the data (Figure 3; Appendix 4
suring the relationship between FI and NS.
in the Supporting Information online).
Factors associated with FI and NS
DISCUSSION
After analyzing the 22 studies, a model was produced to ex-
plain the relationship between FI and NS and the other vari- Our findings in this review indicated a complex rela-
ables, based on the main results we found (Figure 2; tionship between FI and NS. FI is related with a 2-fold

Nutrition ReviewsV Vol. 80(4):631–644

R
639
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Figure 2 Model explaining the factors associated with food insecurity (FI), nutritional status, and the relationship between both
conditions.

640 Nutrition ReviewsV Vol. 80(4):631–644

R

Yes
Figure 3 Evaluation of the quality of the articles included in the systematic review, according to the criteria of the Joanna Briggs
Institute checklist for evaluating cross-sectional studies
burden of nutritional disorders in older adults: malnu-
trition and overweight; each of these outcomes is associ-
ated with a different network of factors. Depending on
the level of FI, the nutritional outcomes can be differ-
ent. Most of the studies indicated a relationship be-
tween severe FI and malnutrition and risk of
malnutrition. This occurs because elderly people in this
condition, which is characterized by food scarcity, expe-
rience episodes of hunger and weight loss.24,25,30,34,36
The results also indicated that milder FI presents a rela-
tionship with being overweight. In this context, despite
their concern and uncertainty about the durability of
food and the scarcity of financial resources, older adults
are still able to access food, even though it is not of sat-
isfactory nutritional quality.30,33 Thus, these elderly
individuals are more likely to be overweight.24,36,38,40
Older adults who experience FI, both acutely and
chronically, try to create strategies to gain access to
foods.5,42 The aim of these individuals is to overcome
the basic need to feed themselves and escape from hun-
ger, even if their dietary choices are not based on a
health-promoting diet.43 These adaptations conse-
quently affect the NS and health of those individuals.
With these new dietary strategies, the following oc-
cur: a reduction in food expenses; a search for more ac-
cessible foods; a reduction in the number of meals;
lower consumption of fruits, vegetables, meat, and milk;
an increase in the consumption of simple carbohy-
drates; and a search to enroll in social programs for
food or income distribution.29,43 This new dietary pat-
tern causes a general reduction in nutrients consumed,
which establishes an imbalance between what is
Nutrition ReviewsV Vol. 80(4):631–644
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No Unclear Unclear
consumed and nutritional needs, often made worse by
pathological and psychological processes.5,30,33 The
results are nutritional deficits and unintentional weight
loss, which can lead to malnutrition.
Malnourished older adults experiencing FI present
a profile that goes beyond aspects related to poverty, as
shown in the explanatory model (Figure 2).44 That is, a
complex, multifactor network is concerned, associated
with female sex, low income, alcoholism, smoking,
chronic diseases, depression, the use of multiple phar-
maceuticals, alterations in appetite, a worse state of
health, a lower BMI, reduced waist circumference and
skin folds, dietary monotony, and few daily meals,
among others.45,46
The high prevalence of older adults who experience
FI who are overweight also drew our attention in this
review. In a study of elderly Americans participating in
1 social program, Brewer et al39 found that 35.4% were
overweight and 40% were obese (75.4% combined). In
another study of elderly Americans, Porter and
Johnson41 observed 51.6% of this population were
obese. The aforementioned strategies used by older
adults experiencing FI to gain access to food can lead
these people to have an obesogenic dietary pattern, cre-
ated by the need to make changes in the quality of the
food consumed. To fulfill energy needs, elderly people
experiencing FI tend to acquire lower-cost as well as in-
dustrialized foods, but with less nutritional quality.
These foods generally have a higher energy density and
greater fat, sugar, and salt content, and a lower quantity
of fibers and micronutrients. This leads to a diet with
little diversity and a reduced intake of fruits, vegetables,
641
and dairy products. This new consumption pattern can
sometimes exceed the energy needs of the elderly and
result in excess weight and obesity.36,43
Along these lines, in a cohort of British adults and
elderly individuals, Cheung et al47 found an association
between FI and increased BMI. A number of factors
may be associated with older adults who experience FI
being overweight: female sex, younger older adults,
l ower educational level, a reduction in or no physical
activity, health problems, emotional eating, uncon-
trolled eating, the presence of pathologies, and cognitive
alterations, among others, as presented in the explana-
tory model (Figure 2).
In this review, we also found a high prevalence of FI,
considering that more than one-third of the studies
reported > 50% prevalence of FI. The most critical sce-
narios were found by Grammatikopoulou et al,25 who
reported 76.3% FI in the elderly in recreation centers in
Greece; Blankson and Hall,34 who found 75% FI among
older adult women from rural communities in Ghana;
Ganh~ao-Arranhado et al,24 who reported 70% FI in el-
derly Portuguese individuals participating in centers for
the elderly; and Rivera-Marquez et al,36 who also found
70% FI in a sample representative of the older adult pop-
ulation of Mexico. These data indicate that older adults or
families with elderly individuals may be more vulnerable
to FI, and they may have more difficulty gaining access to
an adequate and healthy diet. Thus, there are various risk
factors that expose older adults to FI conditions.
This worrying scenario of high prevalence of FI in
the older adult population may have been influenced by
the major global recession that occurred between 2008
and 2012, including the global food crisis (in 2008),
with its impacts on many populations around the
world.48,49 Many countries have adopted fiscal austerity
policies and a reduction in investments in policies di-
rectly or indirectly related to FI.50 Welfare system
reforms, frozen pensions and salaries, reduced coverage
of or exclusion from social programs, higher taxes, in-
creasing personal healthcare costs (eg, medicines, doc-
tor’s visits, health plans), as well as food prices have
contributed to a reduction in the incomes of older
adults and their families. This combination may have
made access to food more difficult and worsened FI
conditions even more.51,52
During the coronavirus pandemic, this scenario
has tended to worsen, with increased unemployment, a
reduction in families’ incomes, physical and economic
barriers to accessing foods, reduced consumption of
natural foods, increased consumption of industrialized
foods, and reduced access to healthcare services. This
scenario will increase the demand for food assistance
programs and income-transfer strategies even
more.53,54
642
The scales or indices based on the experience of FI
are the most used instruments for evaluating this phe-
nomenon. The most common ones in the studies we
reviewed were the US Household Food Security Survey
Module and the Household Food Insecurity Access
Scale. Used since the 1980s, they use families/house-
holds as the sampling unit, and generally classify house-
holds as secure or insecure; in the latter, these tools
categorize FI as mild, moderate, or severe.55 These
instruments are used to evaluate FI directly and al-
though they consider psychometric aspects (ie, percep-
tion and experience), they only analyze the access-to-
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food dimension. Despite being applied in populations
of elderly individuals or families with older adult mem-
bers, these instruments do not present any adaptation
that considers the specificities of that stage of life.
A heterogeneity of methods for evaluating nutri-
tional outcomes was perceived in this review, but the
BMI was the predominant method. Half (50%) of the
studies used the parameters of the World Health
Organization.56,57 Despite its limitations, the BMI has
been widely used as an indicator of NS in epidemiologi-
cal studies, especially because of the ease of obtaining
data, the low cost of carrying out the measures, and the
correlation with other anthropometric and body com-
position indicators.58 However, results of various stud-
ies already point to the need to use more suitable
parameters, when assessing older adults, that consider
all the alterations in body composition that occur with
ageing.59–63
In this review, we chose not to carry out a meta-
analysis, due to the heterogeneity of the methods and
parameters for evaluating both NS and FI and the wide
variability of the statistical analysis used in the studies,
which generated different statistical measures.
Moreover, the data found in the review cannot be ex-
trapolated to other scenarios, such as hospitals, ex-
tended care facilities, and rehabilitation centers,
because the studies only covered elderly individuals
who lived in the community.
In terms of its merits, this is, to our knowledge, the
first systematic review regarding FI and NS among
older adults. Moreover, we used consistent methodolog-
ical strategies, such as independent reviewers, a search
of 5 major databases, the possibility of including articles
in different languages published in any period, as well
as the application of a specific instrument for evaluating
the methodological quality of cross-sectional studies.
CONCLUSION
FI is related to malnutrition or risk of malnutrition, es-
pecially in its severe form, when older adults need to
create strategies to resolve the problem of food scarcity.
Nutrition ReviewsV Vol. 80(4):631–644
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These behaviors result in a reduction in the quantity
and quality of foods consumed and, consequently,
unintentional weight loss. Social determinants, eco-
nomic factors, functional aspects, lifestyle, mental disor-
ders, multiple morbidities, inadequate management of
chronic diseases, polypharmacy, dietary behavior, and a
debilitated state of health are among the main factors
associated with this condition.
On the other hand, and no less important, mild FI
exposes these individuals to an obesogenic consump-
tion profile, which causes them to be overweight. This
relationship is determined by: being younger, female,
have a low educational level; are physically inactive;
have health problems, stress, or cognitive decline; die-
tary behaviors; and engage in excessive screen time.
Acknowledgments
Author contributions. M.H.Q.P. conceived the study.
M.H.Q.P. and M.L.A.S.P. conducted the study selection,
extracted and analyzed the data, assessed the risk of
bias, and contributed to writing the manuscript. G.C.C.
and M.C.B.M. supervised the development of the work
and contributed to writing the manuscript. All the
authors revised and approved the manuscript for
publication.
Funding. No external funds supported this work.
Declaration of interest. The authors have no relevant
interests to declare.
SUPPORTING INFORMATION
The following Supporting Information is available
through the online version of this article at the publish-
er’s website.
S1. Appendix 1 Items from the PRIMA checklist in-
cluded in the systematic review
S2. Appendix 2 Details of the database search strategy
S3. Appendix 3 Factors associated with food insecurity
or nutritional status in the older adults
S4. Appendix 4 Evaluation of the quality of the articles
included in the systematic review, according to the
criteria of the Joanna Briggs Institute checklist for
evaluating cross-sectional studies
Nutrition ReviewsV Vol. 80(4):631–644
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