Oncology Registered Dietitian Nutritionists’ Knowledge, Attitudes, and Practices Related to Food Insecurity among Cancer Survivors: A Qualitative Study

Published:December 09, 2021DOI:



      Understanding the knowledge, attitudes, and practices pertaining to food insecurity among oncology registered dietitian nutritionists (RDNs) is critical to ensuring that cancer survivors have adequate nutrition—a fundamental component of successful treatment and recovery.


      To qualitatively assess oncology RDNs’ knowledge, attitudes, and practices regarding the food access needs of their patients using a qualitative semantic approach to thematic analysis.


      The qualitative cross-sectional study was conducted from September 2018 to January 2019.

      Participants and setting

      Forty-one oncology RDNs working with cancer survivors in various clinical settings across the United States participated.

      Main outcome measures

      Participants completed a semistructured, in-depth interview via telephone, lasting an average of 49 minutes.

      Statistical analyses performed

      Two coders (primary and secondary) trained in qualitative thematic data analysis methods used a semantic approach to thematic analysis to analyze transcripts. A qualitative and mixed methods online coding program Dedoose was used to organize and analyze the data.


      Participants defined food insecurity (FI) as a lack of access to nutritious foods and a lack of resources to purchase nutritious foods. RDNs stated they believe FI is a serious problem in the United Staes, has a greater influence on cancer survivors than healthy individuals and they have specific concerns about FI among their own patients. Despite their concerns, most expressed that they do not use a validated tool to identify FI, nor were they aware that any exists. Only a small proportion of the RDNs stated that they regularly ask patients about their food access needs.


      Although Oncology RDNs have heard of FI, they do not routinely assess patients’ food security status with a validated tool, nor do they consistently ask patients directly about their food access needs. These findings suggest there is a need for developing education and training opportunities for oncology RDNs to enhance their ability to screen for and address FI with their patients.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Coleman-Jensen A.
        • Rabbitt M.P.
        • Gregory C.A.
        • Singh A.
        Household food security in the United States in 2019.
        US Department of Agriculture, Economic Research Service, 2020 (Publication No. ERR-275)
        • Gundersen C.
        • Ziliak J.P.
        Food insecurity and health outcomes.
        Health Aff (Millwood). 2015; 34: 1830-1839
        • Gundersen C.
        • Ziliak J.
        Food insecurity research in the United States: where we have been and where we need to go.
        Appl Econ Perspect Policy. 2018; 40: 119-135
        • Mariotto A.
        • Enewold L.
        • et al.
        Medical care costs associated with cancer survivorship in the United States.
        Cancer Epidemiol Biomarkers Prev. 2020; 29: 1304-1312
      1. National Cancer Institute. Survivor.
        (December 17, 2021)
        • American Cancer Society
        Cancer Treatment & Survivorship Facts & Figures 2019-2021.
        American Cancer Society, 2019
        • Desai A.
        • Gyawali B.
        Financial toxicity of cancer treatment: moving the discussion from acknowledgement of the problem to identifying solutions.
        E Clin Med. 2020; 20: 100269
        • National Cancer Institute
        Financial toxicity (financial distress) and cancer treatment (PDQ®)–patient version.
        • Ramsey S.
        • Blough D.
        • Kirchhoff A.
        • et al.
        Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis.
        Health Aff (Millwood). 2013; 32: 1143-1152
        • Bernard D.S.
        • Farr S.L.
        • Fang Z.
        National estimates of out-of-pocket health care expenditure burdens among nonelderly adults with cancer: 2001 to 2008.
        J Clin Oncol. 2011; 29: 2821-2826
        • Guy Jr., G.P.
        • Ekwueme D.U.
        • Yabroff K.R.
        • et al.
        Economic burden of cancer survivorship among adults in the United States.
        J Clin Oncol. 2013; 20: 3749-3757
        • Ekwueme D.U.
        • Yabroff K.R.
        • Guy Jr., G.P.
        • et al.
        Medical costs and productivity losses of cancer survivors—United States, 2008–2011.
        MMWR Morb Mortal Wkly Rep. 2014; 63: 505-510
        • Ramsey S.D.
        • Bansal A.
        • Fedorenko C.R.
        • et al.
        Financial insolvency as a risk factor for early mortality among patients with cancer.
        J Clin Oncol. 2016; 34: 980-986
        • Kudre D.
        • Chen Z.
        • Richard A.
        • et al.
        Multidisciplinary outpatient cancer rehabilitation can improve cancer patients’ physical and psychosocial status-a systematic review.
        Curr Oncol Rep. 2020; 22: 122
        • O’Connor J.M.
        • Sedghi T.
        • Dhodapkar M.
        • Kane M.J.
        • Gross C.P.
        Factors associated with cancer disparities among low-, medium-, and high-income US counties.
        JAMA Netw Open. 2018; 1e183146
        • Thompson K.L.
        • Elliott L.
        • Fuchs-Tarlovsky V.
        • et al.
        Oncology evidence-based nutrition practice guideline for adults.
        J Acad Nutr Diet. 2016; 117: 297-310 e47
        • Wiseman M.
        The second World Cancer Research Fund/American Institute for Cancer Research expert report. Food, nutrition, physical activity, and the prevention of cancer: a global perspective.
        Proc Nutr Soc. 2008; 67: 253-256
        • Rock C.L.
        • Doyle C.
        • Demark-Wahnefried W.
        • et al.
        Nutrition and physical activity guidelines for cancer survivors.
        CA Cancer J Clin. 2012; 62: 243-274
        • Ravasco P.
        • Monteiro-Grillo I.
        • Vidal P.M.
        • et al.
        Cancer: disease and nutrition are key determinants of patients’ quality of life.
        Support Care Cancer. 2004; 12: 246-252
        • Gundersen C.
        • Hake M.
        • Dewey A.
        • Engelhard E.
        Food insecurity during COVID-19.
        Appl Econ Perspect Policy. 2021; 43: 153-161
        • Denlinger C.S.
        • Sanft T.
        • Baker K.S.
        • et al.
        Survivorship, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology.
        J Natl Compr Canc Netw. 2018; 16: 1216-1247
        • Harris J.E.
        • Gleason P.M.
        • Sheean P.M.
        • et al.
        An introduction to qualitative research for food and nutrition professionals.
        J Am Diet Assoc. 2009; 109: 80-90
        • Goodell L.S.
        • Stage V.C.
        • Cooke N.K.
        Practical qualitative research strategies: training interviewers and coders.
        J Nutri Educ Behav. 2016; 48: 578-585.e1
      2. Audacity. The Audacity Team, 2018
        Version: Version 2.3.4
        • Braun V.
        • Clarke V.
        What can “thematic analysis” offer health and wellbeing researchers?.
        Int J Qual Stud Health Well-being. 2014; 9: 26152
      3. Dedoose. SocioCultural Research Consultants, LLC, 2018
        Version: Version 8.0.35
        • Lincoln Y.
        • Guba E.G.
        Naturalistic Inquiry.
        Sage Publications, 1985
      4. US Dept of Agriculture. Survey tools.
        • US Dept of Agriculture, Economic Research Service
        SNAP policy data sets.
        • Patel K.G.
        • Borno H.T.
        • Seligman H.K.
        Food insecurity screening: a missing piece in cancer management.
        Cancer. 2019; 125: 3494-3501
        • van Bokhorst-de van der Schueren M.A.
        Nutritional support strategies for malnourished cancer patients.
        Eur J Oncol Nurs. 2005; 9: S74-S83
        • Van Blarigan E.L.
        • Fuchs C.S.
        • Niedzwiecki D.
        • et al.
        Association of survival with adherence to the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors After Colon Cancer Diagnosis: The CALGB 89803/Alliance Trial.
        JAMA Oncol. 2018; 4 ([published correction appears in JAMA Oncol. 2019 Apr 1;5(4):579]): 783-790
        • Kenkhuis M.-F.
        • van der Linden B.W.A.
        • Breedveld-Peters J.J.L.
        • et al.
        Associations of the dietary World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations with patient-reported outcomes in colorectal cancer survivors 2–10 years post-diagnosis: a cross-sectional analysis.
        Br J Nutr. 2020; : 1-13
        • Inoue-Choi M.
        • Robien K.
        • Lazovich D.
        Adherence to the WCRF/AICR guidelines for cancer prevention is associated with lower mortality among older female cancer survivors.
        Cancer Epidemiol Biomarkers Prev. 2013; 22: 792-802
        • Gany F.
        • Leng J.
        • Ramirez J.
        • et al.
        Health-related quality of life of food-insecure ethnic minority patients with cancer.
        J Oncol Pract. 2015; 11 ([published correction appears in J Oncol Pract. 2016;12(1):98]): 396-402
        • Leung C.W.
        • Tester J.M.
        The association between food insecurity and diet quality varies by race/ethnicity: an analysis of National Health and Nutrition Examination Survey 2011-2014 results.
        J Acad Nutr Diet. 2019; 119: 1676-1686
        • Altice C.K.
        • Banegas M.P.
        • Tucker-Seeley R.D.
        • Yabroff K.R.
        Financial hardships experienced by cancer survivors: a systematic review.
        J Natl Cancer Inst. 2016; 109 (Published 2016 Oct 20): djw205
        • Zafar S.Y.
        • Peppercorn J.M.
        • Schrag D.
        • et al.
        The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience.
        Oncologist. 2013; 18: 381-390
        • Jefford M.
        • Ward A.C.
        • Lisy K.
        • et al.
        Patient-reported outcomes in cancer survivors: a population-wide cross-sectional study.
        Support Care Cancer. 2017; 25: 3171-3179
        • Zheng Z.
        • Jemal A.
        • Han X.
        • et al.
        Medical financial hardship among cancer survivors in the United States.
        Cancer. 2019; 125: 1737-1747
        • Ekwueme D.U.
        • Zhao J.
        • Rim S.H.
        • et al.
        Annual out-of-pocket expenditures and financial hardship among cancer survivors aged 18-64 years - United States, 2011-2016.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 494-499
        • Yabroff K.R.
        • Dowling E.C.
        • Guy Jr., G.P.
        • et al.
        Financial hardship associated with cancer in the United States: findings from a population-based sample of adult cancer survivors.
        J Clinical Oncol. 2016; 34: 259-267
        • Ziliak J.
        • Gundersen C.
        The State of Senior Hunger in America 2018: An Annual Report. 2020.
        • Simmons L.A.
        • Modesitt S.C.
        • Brody A.C.
        • Leggin A.B.
        Food insecurity among cancer patients in kentucky: a pilot study.
        J Oncol Pract. 2006; 2: 274-279
        • Gany F.
        • Lee T.
        • Ramirez J.
        • et al.
        Do our patients have enough to eat?: Food insecurity among urban low-income cancer patients.
        J Health Care Poor Underserved. 2014; 25: 1153-1168
        • Trego M.L.
        • Baba Z.M.
        • DiSantis K.I.
        • Longacre M.L.
        Food insecurity among adult cancer survivors in the United States.
        J Cancer Survivorship. 2019; 13: 641-652
        • McDougall J.A.
        • Anderson J.
        • Adler Jaffe S.
        • et al.
        Food insecurity and forgone medical care among cancer survivors.
        JCO Oncol Pract. 2020; 16: e922-e932
        • Council On Community Pediatrics, Committee On Nutrition
        Promoting food security for all children.
        Pediatrics. 2015; 136: e1431-e1438
        • Berkowitz S.A.
        • Karter A.J.
        • Corbie-Smith G.
        • et al.
        Food insecurity, food “deserts,” and glycemic control in patients with diabetes: a longitudinal analysis.
        Diabetes Care. 2018; 41: 1188-1195
        • Pooler J.
        • Levin M.
        • Hoffman V.
        • Karva F.
        • Lewin-Zwerdling A.
        Implementing Food Security Screening and Referral for Older Patients in Primary Care: a resource guide and toolkit.
        (Published 2016)
        • Hager E.R.
        • Quigg A.M.
        • Black M.M.
        • et al.
        Development and validity of a 2-item screen to identify families at risk for food insecurity.
        Pediatrics. 2010; 126: e26-e32
        • Gundersen C.
        • Engelhard E.E.
        • Crumbaugh A.S.
        • Seligman H.K.
        Brief assessment of food insecurity accurately identifies high-risk US adults.
        Public Health Nutr. 2017; 20: 1367-1371
        • Goldman N.
        The hunger vital sign: a new standard of care for preventive health.
        Children’s Health Watch, 2014
        • Gundersen C.
        The right to food in the U.S.: the role of the Supplemental Nutrition Assistance Program (SNAP).
        Am J Agric Econ. 2019; 101: 1328-1336
        • Gundersen C.
        • Kreider B.
        • Pepper J.
        Partial identification methods for evaluating food assistance programs: a case study of the causal impact of SNAP on food insecurity.”.
        Am J Agric Econ. 2017; 99: 875-894
        • Kreider B.
        • Pepper J.
        • Gundersen C.
        • Jolliffe D.
        Identifying the effects of SNAP (Food Stamps) on child health outcomes when participation is endogenous and misreported.
        J Am Stat Assoc. 2012; 107: 958-975
        • Gany F.
        • Melnic I.
        • Ramirez J.
        • et al.
        Food insecurity among cancer patients enrolled in the Supplemental Nutrition Assistance Program (SNAP).
        Nutr Cancer. 2021; 73: 206-214
        • Lee E.W.J.
        • Viswanath K.
        Big data in context: addressing the twin perils of data absenteeism and chauvinism in the context of health disparities research.
        J Med Internet Res. 2020; 22e16377
        • Hoffman K.M.
        • Trawalter S.
        • Axt J.R.
        • Oliver M.N.
        Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.
        Proc Natl Acad Sci U S A. 2016; 113: 4296-4301
        • Lund A.
        • Latortue K.Y.
        • Rodriguez J.
        Dietetic training: understanding racial inequity in power and privilege.
        J Acad Nutr Diet. 2021; 121: 1437-1440
        • Ojinnaka C.O.
        • Bruening M.
        Black-White racial disparities in health care utilization and self-reported health among cancer survivors: The role of food insecurity.
        Cancer. 2021; 127: 4620-4627


      A. A. Burton-Obanla is a doctoral degree student, Division of Nutritional Sciences, University of Illinois, Urbana.


      S. Sloane is a research scientist, Family Resiliency Center, University of Illinois, Urbana.


      B. Koester is associate director, Family Resiliency Center, University of Illinois, Urbana.


      C. Gundersen is a distinguished professor, Agricultural and Consumer Economics, University of Illinois, Urbana.


      B. Fiese is with the Family Resiliency Center and the Department of Human Development and Family Studies, University of Illinois, Urbana.


      A. Arthur is with Division of Nutritional Sciences and Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana; and an assistant professor, Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City.