Nutrition and Food Security Among Veterans: Operationalizing Nutritional Functioning

Abstract

Objective:

To assess injured military veterans’ experiences, beliefs, and daily physical and psychosocial functioning in relation to food and nutrition.

Design:

We used a convergent mixed-methods study design and the International Classification of Functioning, Disability, and Health to operationalize the core constructs and influencing factors related to physical and psychosocial functioning, food, and nutrition.

Setting:

Three Veterans Affairs polytrauma rehabilitation centers.

Participants:

Veterans who served in the United States military on or after September 11, 2001, and whose medical diagnoses met the criteria for polytrauma; at least 1 mild traumatic brain injury and at least 1 associated comorbidity (eg, posttraumatic stress disorder, chronic musculoskeletal pain, vestibular disturbances), for a total N of 43.

Interventions:

None.

Main Outcome Measures:

Themes from survey responses and semistructured interview data were pooled into core constructs and influencing factors.

Results:

Thirty-seven veterans completed all surveys and participated in recorded interviews. Based on qualitative and quantitative data, veterans’ relation to food and nutrition (ie, nutritional functioning) was found to be characterized by 5 core constructs, including food background, nutrition knowledge, meal aptitude, resource navigation, and navigation to/of food spaces. Nutritional functioning was found to be shaped by 5 influencing factors, including injuries and health conditions, ideological and cultural exposures, relations, current beliefs, and current behaviors.

Conclusions:

Nutritional functioning (food background, nutrition knowledge, meal aptitude, resource navigation, navigation to/of food spaces) among injured veterans is complex and shaped by multiple physical, psychosocial, economic, and cultural factors.

The effects of functional limitations on daily life can be complex and difficult to characterize. The International Classification of Functioning, Disability, and Health (ICF)^1,2 is a widely adopted framework for evaluating health conditions and their effect on functioning. In a nutritional context, ICF includes categories within the Body Functions and Structures domain, (eg, chewing), as well as in the Activities domain, (eg, eating). In focusing solely on mobility- or gastrointestinal-related aspects of nutrition, however, a gap remains. Nutrition-related behaviors, encompassing what and how people feed themselves, are complicated and ever-changing, shaped not only by economic and sociocultural considerations but also by the health conditions that influence daily psychosocial functioning. Specifically, a more holistic conceptualization of nutrition in people living with complex injuries is lacking.

Among post-9/11 veterans, the combination of mild traumatic brain injuries (mTBIs) sustained during service and the ensuing comorbidities exert a significant effect on veterans’ psychosocial functioning. “Polytrauma,” defined by the US Department of Veterans Affairs² as a diagnosis of at least 1 mTBI with at least 1 comorbidity (eg, chronic pain, posttraumatic stress disorder [PTSD], vestibular difficulties), affects more than 30% of post-9/11 veterans.³ Although polytrauma can manifest as a variety of symptoms, it most commonly includes cognitive difficulties, proneness to social isolation, depression/anxiety, headaches/dizziness, and chronic/recurring musculoskeletal pain, among others.³ The subsequent effect on veterans’ psychological and socioeconomic functioning, relations, employment, housing, and overall integration into civilian life can be profound.^4–6

Among veterans, there is growing evidence to suggest that food insecurity, the condition of not having access to sufficient food, or food of an adequate quality to meet one’s needs⁷ is strongly correlated with mental health disorders and functional limitations.^8–10 Historically considered an economic issue, food insecurity affects approximately 25% of post-9/11 veterans¹⁰ (compared with approximately 13% of Americans in general),¹¹ although this is likely a low estimate given the post–coronavirus disease 2019 pandemic rise in food insecurity.¹² Food insecurity is increasingly understood to be a multifactorial issue, closely correlated with disability,¹³ and veterans with complex medical burdens are at a disproportionately higher risk, even after accounting for income.^14,15 As a result, researchers and clinicians are increasingly calling for more comprehensive evaluations of psychosocial and cultural factors shaping nutritional behaviors, beyond economic definitions of food insecurity.^16,17 Although there is a growing body of evidence examining these complexities among veterans in general,^14,15,18 there has yet to be such a study of how veterans’ polytraumatic injuries affect their nutritional behaviors, henceforth known as “nutritional functioning.”

Previous research has described how polytrauma in veterans affects day-to-day functioning, relations, income, and reintegration.^5,19,20 At the same time, increasing evidence shows that while post-9/11 veterans express reluctance to engage in traditional care for polytrauma,^5,21,22 they are interested in integrative/complementary therapies in general and nutrition in particular.^23,24 We argue, therefore, that there is a need for an evaluation of nutritional functioning in veterans with polytrauma that accounts for psychosocial and/or cognitive factors that shape their relations with food. To that end, we conducted a mixed-methods study of injured veterans’ daily physical and psychosocial functioning and assessed how their functioning relates to nutrition. Using the ICF as a framework, we characterized common themes from veterans’ experiences, habits, values, and preferences that shape their use of food. We also evaluated how veterans perceive their polytrauma, and if/how these injuries affect their dietary habits. Lastly, results were used to operationalize the constructs and contextual factors that define nutritional functioning.

Methods

We used a convergent mixed-methods design²⁵ consisting of semi-structured interviews and quantitative questionnaires.

Participants

The Department of Veterans Affairs Corporate Data Warehouse was used to identify potential participants. Veterans were considered eligible if they: (1) served after September 11, 2001; (2) received care at a VA polytrauma rehabilitation center; (3) were cognitively and physically able to access a computer and participate in an English-language interview; and (4) met criteria for a diagnosis of service-related polytrauma. Polytrauma was established using diagnostic codes (International Classification of Diseases–9th/10th Revision): (1) at least 1 mTBI; and (2) at least 1 TBI-related comorbidity (ie, PTSD, depression, anxiety, spinal cord injury, chronic pain, amputation, burns, bone fractures, visual damage, auditory damage). We mailed recruitment materials to eligible veterans, and those who completed data collection were financially compensated. This study was conducted according to the guidelines in the Declaration of Helsinki, and all procedures involving human participants were approved by the Colorado Multiple Institutional Review Board.

Procedures

Semistructured interview protocol

Using classification codes from the 5 ICF domains and postulating psychosocial factors that related to nutrition (supplemental fig S1, available online only at http://www.archives-pmr.org/), we developed a semistructured interview for veterans (supplemental appendix S1, available online only at http://www.archives-pmr.org/). Each script was piloted with 3-5 test participants and refined for content, clarity, and brevity. All interviews were conducted by the first author (D.P.B.), were digitally recorded with participants’ permission, and took place over the phone between January and September 2021, lasting 1-2 hours. Veteran interviews were collected until saturation was reached,²⁶ beyond the point at which new major themes were identified within the transcripts.

Quantitative surveys

Participants completed 15 surveys assessing demographics, military history, nutrition-related factors, physical health, psychological health, and quality of life (descriptions in table 1).^27–40 Surveys were administered using a Research Electronic Data Capture system, a Health Insurance Portability and Accountability Act–compliant web-based application for collecting and storing survey-based data.⁴¹

Table 1.

Quantitative surveys administered to veterans with polytraumatic injuries.

Survey	Concepts or Behaviors Measured	Interpretation
General
Demographic Questionnaire	Personal and socioeconomic characteristics; military service history	Cohort characteristics
Food-related behaviors
Eating Attitudes Test (EAT-26)27	Disordered eating behaviors	A score >20 (out of 34) indicates possibility of clinically disordered eating
Rapid Eating Assessment for Participants, short version (REAPS)28	Dietary quality	A higher score (range of 13-39) indicates better adherence to national dietary guidelines
U.S. Household Food Security Survey Module (6-Item)29	Food security status	Categorizes respondents as having food security (high or marginal) or not having food security (low or very low)
Flexible Consumer Behavior Survey (FCBS)30	Food expenditures, use of nutrition assistance, income, expenses, awareness of national dietary guidelines	Frequencies (eg, times eating out in the previous week); expenditures (eg, grocery dollars spent in the previous month)
Physical health and related factors
Drug Use Disorders Identification Test (DUDIT)31	Substance use	A score ≥25 (out of 44) warrants further evaluation for a possible substance use disorder
Alcohol Use Disorders Identification Test (AUDIT)32	Alcohol use	A score ≥8 (out of 21) warrants further evaluation for potentially hazardous drinking. Scores above 13 (women) or 15 (men) indicate possible alcohol dependence
Patient-Reported Outcomes Measurement Information System Sleep Disturbance (PROMIS-SD)33	Sleep	Adjusted T-scores 60-69.9 indicate moderately impaired sleep; scores ≥70 indicate severely impaired sleep
Pain Intensity and Interference Scale (PEG-3)34	Pain	Higher scores (range of 0-10) indicate greater degree of pain and pain-related interference in daily functioning
Psychosocial factors
UCLA Loneliness Scale Version 3 (UCLA-3)35	Loneliness	Higher scores (range of 1-4) indicate higher degrees of loneliness
General Self-Efficacy Scale (GSE-6)36	Self-efficacy regarding personal goals	Higher scores (range of 10-40) indicate higher degrees of self-efficacy
Multidimensional Scale of Perceived Social Support (MSPSS)37	Subjective perceptions of social support	Categorizes respondents as having low, medium, or high perceived social support
Military to Civilian Questionnaire (M2CQ-16)38	Community-level participation and functioning in veterans (previous 30d)	Higher scores (range of 0-4) indicate higher degrees of difficulties with civilian integration
Outcomes Questionnaire (OQ-45.2)39	Psychological functioning	A total score ≥63 (out of 180), ≥36 (out of 100) for symptom distress, ≥15 (out of 44) for interpersonal relation, and ≥12 (out of 36) for social role all indicate clinical significance
RAND 36-Item Short Form Survey Instrument (RAND SF-36)40	Physical health and quality of life	Increasing scores on 8 subscales indicate greater well-being, functioning, and quality of life

Interview data analysis

Semistructured interviews were transcribed and then uploaded into NVivo software for analysis. We used a constant comparative method,⁴² a form of latent content analysis, to analyze data and identify themes in participants’ responses. D.P.B. and L.A.B. first coded transcripts independently, then combined and reached consensus (with K.B.D.) on codes to develop a shared coding scheme. Each transcript was subsequently reread to ensure referential adequacy. Codes were evaluated in relation to ICF domains and unique and related characteristics that shaped physical and psychosocial functioning in relation to food and nutrition. Codes were then clustered into broader themes and evaluated for internal homogeneity and external heterogeneity. This ensured that the themes were associated with, yet distinct from each other. We then synthesized the themes into constructs, which were reviewed by an expert advisory panel of polytrauma rehabilitation specialists, stakeholder clinicians, and post-9/11 veterans. A consensus-based process⁴³ was used to revise and agree on the central constructs of nutritional functioning.

Convergent synthesis

We created a joint display combining qualitative themes and quantitative data. The first author (D.P.B.) evaluated joint data to draw meta-inferences, which were then verified by coauthors (K.B-D. and L.A.B.).

Results

Quantitative results

Forty-three participants completed all quantitative surveys and 37 completed qualitative interviews (supplemental fig S2, available online only at http://www.archives-pmr.org/). Demographic characteristics are presented in table 2. Most participants identified as Caucasian/White (81%), men (74%), and non-Hispanic (74%), with a mean age of 44 years. Most served in the Army (79%) and were deployed a median of 3 times, with a median of 2 combat tours. Results from nutrition-related questionnaires are presented in table 3. Sixteen veterans (37%) were food-insecure (low or very low food security), and 5 of them were receiving government food assistance. On the Eating Attitudes Test-26, 4 veterans (9.3%) reported engaging in possibly clinically significant disordered eating behaviors (score, >20). Short-version Rapid Eating Assessment for Participants scores indicated an overall fair/middling dietary quality, with participants reporting modest intakes of nutritious foods such as vegetables and lean proteins and higher intakes of refined grains and added sugars. Flexible Consumer Behavior Survey results indicated relatively low awareness and low use of dietary guidelines when making food choices.

Table 2.

Demographic and military characteristics of post-9/11 veterans with polytrauma.

Participant Characteristic	N (%) or Mean±SD
Age (y), mean ± SD	44.15±8.73
Sex, n (%)
Male	32 (74.4)
Female	11 (25.6)
Other	0 (0.00)
Racial background, n (%)
Caucasian/White	35 (81.4)
Black or African American	6 (14.0)
Native American/Alaskan Native	3 (7.0)
Asian	1 (2.3)
Pacific Islander	1 (2.3)
Other	4 (9.3)
Hispanic	11 (25.6)
Highest level of education, n (%)
No high school diploma	0 (0.00)
High school diploma or equivalent	5 (11.6)
Some college	11 (25.6)
Associate’s or bachelor’s degree	20 (46.5)
Postgraduate degree	7 (16.3)
Employment Status, n (%)
Part time or full time	14 (32.6)
Unemployed	14 (32.6)
Retired	15 (34.9)
Military service history
Former branch of service, n (%)
Army	34 (79.1)
Air Force	4 (9.3)
Navy	6 (14.0)
Marine Corps	1 (2.3)
Number of times deployed, median	3.00±4.00
Number of combat tours, median	2.00±2.00
Experience of military sexual trauma, n (%)
Sexual harassment	13 (30.2)
Sexual assault	9 (20.9)
Declined to respond	1 (2.3)
Household characteristics
Any previous experience of homelessness, n (%)	17 (39.5)
Marital status, n (%)
Married or cohabitating	26 (60.5)
Single	6 (14.0)
Divorced/Separated	11 (25.6)
Total annual household income (n=1 missing), n (%)
<$10,000	1 (2.3)
$10,000-$24,999	2 (4.7)
$25,000-$49,999	16 (37.2)
$50,000-$74,999	9 (20.9)
$75,000-$99,999	7 (16.3)
$100,000+	7 (16.3)
Number of children cohabitating at least part time in household, mean ± SD	0.91±1.15

Table 3.

Nutrition-related questionnaire results (N=43).

Questionnaire	Mean or n	SD or %	Range
USDA 6-Item Food Security Module*:
Current low food security	n=9	21%	—
Current very low food security	n=7	16%	—
Current high/marginal food security	n=27	63%	—
Eating Attitudes Test-26†	9.84	7.11	0-34
Rapid Eating Assessment for Participants, short version‡	17.74	2.29	13-39
Flexible Consumer Behavior Survey§:
Use of food assistanceǁ:
Current SNAP	n=1	2.33%	—
Current WIC	n=4	9.3%	—
Ever WIC	n=9	21%	—
My Plate¶ knowledge:
Yes, have heard of My Plate	n=16	37%	—
Yes, have tried to follow guidelines	n=10	23%	—
Eating out frequency (previous 7d)	2.5	4.00	1-18
Use of convenience foods (previous 30d)	4.0	13.00	1-56
Food expenditures (previous 30d):
Grocery stores	$1200	$2100	$25-$5280
Nongrocery stores	$400	$300	$5-$2000
Eating out	$400	$700	$12-$4000
Take-out/delivery	$250	$380	$5-$2000
Transportation to grocery shopping:
Personal vehicle	n=39	91%	—
Taxi/other paid driver	n=2	4.7%	—
Bicycle	n=1	2.33%	—
Someone else delivers	n=1	2.33%	—
Household income:
≤185% Federal poverty level	n=6	14%	—
≤130% Federal poverty level	n=3	7%	—

Abbreviations: SNAP, Supplemental Nutrition Assistance Program; USDA, US Department of Agriculture; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

^*The USDA 6-Item Food Security Module categorizes respondents’ scores as food-secure (high or marginal) or food-insecure (low or very low food security).

^†An Eating Attitudes Test-26 score of >20 (out of a range of 0-34) indicates clinically significant disordered eating symptoms. Four participants scored >20.

^‡The range of possible scores on the short-version Rapid Eating Assessment for Participants is 13-39; higher scores indicate better dietary quality and better adherence to dietary guidelines.

^§The Flexible Consumer Behavior Survey assesses respondents’ grocery expenses, eating occasions away from home, modes of transportation to buy food, use of food assistance, use and awareness of nutritional guidelines, and total income and assets.

^ǁFood assistance in the Flexible Consumer Behavior Survey assesses current/previous use of the 2 federal programs; SNAP and WIC.

^¶MyPlate is the USDA’s nutrition guide that establishes the proportional intakes of vegetables, fruits, grains, proteins, and dairy products recommended for most Americans.

Results from other survey measures are presented in table 4. Participant responses to the RAND 36-Item Short Form Health Survey and the Pain Intensity and Interference Scale-3 indicated a mild-to-moderate degree of perceived disability, particularly regarding pain and fatigue, and responses to the Patient-Reported Outcomes Measurement Information System indicated a relatively high burden of sleep disturbance. Veterans also expressed a high degree of loneliness (UCLA Loneliness-3) and low levels of social support (Multidimensional Scale of Perceived Social Support). Results from the Outcomes Questionnaire-45 indicated a high burden of poor mental health, with clinically significant symptom distress (n=36, 83.7%), poor interpersonal relations (n=36, 83.7%) and poor social role functioning (n=30, 70%). Veterans scored as having mild role limitations in an emotional context (RAND 36-Item Short Form Health Survey) and moderate difficulties with civilian reintegration (Military to Civilian Questionnaire-16). None of the participants reported current substance abuse (Drug Use Disorders Identification Test), but 14 veterans (35%) screened as having hazardous drinking habits on the Alcohol Use Disorders Identification Test, with 4 veterans (9.3%) screened as being potentially alcohol dependent. Lastly, General Self-Efficacy Scale-6 survey scores indicated a very high degree of self-efficacy.

Table 4.

Nonnutrition quantitative survey results, N=43.

Questionnaire	Mean	SD	Range
AUDIT* (alcohol)	5.39	5.96	0-26
DUDI† (drug use)	3.26	5.85	0-21
PROMIS‡ Sleep Disturbance Scale	53.37	3.38	44.2-59.4
PEG-3§ (pain)	5.25	2.15	0-9.33
UCLA Loneliness Scaleǁ	2.79	0.59	1.4-3.7
GSE-6¶ (self-efficacy)	30.16	5.26	15-39
MSPSS# (perceived social support)	4.43	1.49	1.33-7.0
M2CQ-16** (civilian reintegration)	2.13	0.94	0.25-4.0
0Q-45††
Total score	96.86	27.90	42-156
Symptom distress	50.86	16.59	19-81
Interpersonal relations	21.23	8.50	3-38
Social role	14.77	6.07	4-29
RAND SF-36‡‡
Total score	39.53	19.19	4.17-87.5
Pain	38.60	24.21	0-100
Energy/fatigue	26.86	18.90	0-70
Physical functioning	59.06	26.24	5-100
Role limitations, physical	27.9	37.48	0-100
Social functioning	41.57	29.22	0-100
Role limitations, emotional	21.433	35.93	0-100
Emotional well-being	47.72	21.37	8-84

Abbreviations: AUDIT, Alcohol Use Disorders Identification Test; DUDIT, Drug Use Disorders Identification Test; PROMIS, Patient-Reported Outcomes Measurement Information System; PEG-3, Pain Intensity and Interference Scale-3; GSE-6, General Self-Efficacy Scale-6; MSPSS, Multidimensional Scale of Perceived Social Support; M2CQ-16, Military to Civilian Questionnaire-16; 0Q-45, Outcomes Questionnaire-45; SF-36, 36-Item Short Form Health Survey.

^*AUDIT; 10 participants had scores indicating harmful or hazardous drinking habits; 4 participants had scores indicating possible alcohol dependence.

^†DUDIT; no participants scored ≥25, indicating possible drug/substance dependence.

^‡PROMIS Sleep Disturbance; no participants scored 60-69.9 or >70 (adjusted T-scores), indicating moderately or severely impaired sleep, respectively.

^§PEG-3; the range of possible scores is 0-10, with higher scores indicating greater burden of pain.

^ǁUCLA Loneliness-3; the range of possible scores is 1-4, with higher scores indicating higher levels of loneliness.

^¶GSE-6; the range of possible scores is 10-40, with higher scores indicating greater self-efficacy.

^#MSPSS; 7 participants had scores indicating low perceived social support, compared with 22 having scores indicating medium support and 14 having scores indicating high support.

^**M2CQ-16; the range of possible scores is 0 to 4, with higher scores indicating greater difficulty with reintegration.

^††0Q-45; total score ≥63 (n=38, 88.4%), ≥36 for symptom distress (n=36, 83.7%), ≥15 for interpersonal relation (n=36, 83.7%), and ≥12 for social role subscales (n=30, 70%) all indicate clinical significance.

^‡‡The RAND SF-36 is a survey of quality of life, with 8 subscales relating to physical and emotional functioning and well-being.

Qualitative results

Although veterans reported a variety of cultural backgrounds, food preferences, and grocery shopping habits, an overall theme emerged, namely that veterans who reported having the most difficulties with accessing food, preparing meals, and eating the kinds of foods that they believed would support their well-being are also those that reported feeling the most affected by their military experiences. Specifically, veterans who felt like their military service negatively affected their mental and physical health, economic opportunities, and interpersonal relations were most likely to report experiencing significant obstacles to nutritional functioning. Moreover, these veterans repeatedly reported that they view the adverse effects of their military service to be permanent and immutable. In characterizing the themes we observed, we identified 5 key constructs that define nutritional functioning, and 5 core influencing factors. A convergent meta-inference table that combines qualitative and quantitative findings is presented in supplemental table S1 (available online only at http://www.archives-pmr.org/).

The first construct, food background, refers to the totality of childhood, military, and life experiences that shape current habits and preferences. Some veterans who experienced food insecurity during childhood reported that as adults they prioritize food over other necessities, whereas others reported that military service was the only time in their lives that they had consistent access to adequate food. A major recurring theme centered around food in military culture, namely that all foods are defined as “good” or “bad,” and the main purpose of food is to obtain or maintain an acceptable body weight. When they did not meet weight standards, many veterans reported feeling stigmatized:

…[they] will put you down. They say you’re worthless…They put me in what they call the ‘Food Blister’ platoon […] and we [ran].

Several veterans described learning from peers how to “make weight,” including fasting, all-liquid diets, and laxative abuse, among others. Overall, veterans overwhelmingly expressed that these experiences adversely shaped their current eating habits, with many reporting feeling like their depression and anxiety drive them to eat:

I keep on eating, and I keep on eating. I’m never hungry, it’s just a habit…;

I ate my feelings away. I didn’t realize that I was struggling […] I never cried about it. So what did I do? I went to food because it made me feel good.

The second construct, nutrition knowledge, refers to a veteran’s experiences with nutrition-related education, and to the ways in which a veteran interprets nutrition-related information that they encounter in daily life (eg, advertisements). Veterans described a variety of backgrounds in nutrition, ranging from primary school lessons to professional culinary experience. Frequently, veterans described that they know what they “should” be eating but that financial barriers preclude “healthy” eating:

I met with a dietitian like three or four times […] the hard part is — because I don’t get enough money. I can’t shop the way they want me to shop. I have to shop to survive for a whole month. Sorry, the healthy stuff is expensive…I can afford a head of lettuce. But I can’t afford a thing of kale.;

I want to just try to eat better…but honestly, that’s still a struggle.

The third construct, meal aptitude, refers to the degree of familiarity, comfort, and engagement in the process of planning and preparing meals. To a large degree, meal aptitude was informed by veterans’ early experiences, primarily, whether or not they had grown up with caregivers who taught them how to shop for and prepare meals. Although a few veterans reported that they enjoy cooking, a recurring theme was that their cognitive difficulties preclude engaging in meal-related tasks and frequently preclude learning new cooking skills altogether:

My wife cooks. I used to cook, but now with my forgetfulness getting as it is—I don’t feel comfortable cooking.;

I don’t really put myself in a position to learn new things.

The fourth construct, resource navigation, comprises the degree of education, experience, and comfort in managing resources to budget for food and/or obtain food assistance, as needed. As with nutrition knowledge, veterans reported a range of experiences:

I didn’t have much of a formal background in budgeting and how to balance a checkbook and how bank accounts work and stuff like that.;

I mean, the philosophy is keep the roof above your head and the lights on. That and the car. You know what I mean? After that, it’s like, oh, if I’ve only got $5 bucks for groceries, then so be it.

In terms of seeking nutrition assistance, veterans overwhelmingly reported that they had never been asked by a health care provider whether they had adequate funds for food, and many reported not knowing where they could go to ask for assistance:

Oh wow. No. I’ve never, nobody has ever asked me about food security.;

I know there’s a couple food banks here but that’s about it.

Despite a high prevalence of food insecurity among participants, veterans rarely acknowledged actually experiencing it, stating that it was a condition experienced by others and describing food assistance as a “handout” that a “real” veteran should not use. Among women veterans, several reported using the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits when their children were young:

When my kids were little, and I was recently divorced, I did apply for like, WIC…And it was really nice to be like: Okay, I can get peanut butter, I can get tuna fish, I can get vegetables. And even though it’s a pain…and people shame you and they look at you funny…it was really helpful to be able to have a program like that.

Lastly, navigation to/of food spaces refers to the physical, cognitive, and psychological barriers and facilitators to navigating grocery stores and restaurants. Veterans reported significant cognitive challenges when buying food (eg, feeling “overwhelmed and confused” when trying to find specific items), as well as psychological barriers manifesting as PTSD-related anxiety and hypervigilance. Veterans particularly emphasized the latter, with many reporting that their PTSD symptoms can often preclude entering a public space altogether:

[1] don’t sit down anywhere [in a restaurant]. I don’t like, I can’t. I can’t. I can’t…I don’t want to be around people and the noise.;

…more so to me is the people gathering [in a grocery store], that’s what I don’t like…The waiting around and standing around. That to me is a threat. That’s a problem.;

There’s no lingering…here’s my grocery list, bang-bang-bang…If I don’t have to look up and, you know, and interact with anyone, even better.

Finally, we identified 5 core influencing factors that shape how veterans with polytrauma engage in nutritional functioning. To some degree, all veterans reported grappling with injuries and health conditions. As a result of chronic pain, headaches, and vestibular disturbances, nearly all veterans reported that their functioning is significantly affected when grocery shopping or meal planning. Ideological and cultural exposures also influenced nutritional functioning, comprising not just military exposures but also more broad societal factors. For example, many male veterans reported that even if they feel capable of planning and preparing meals (meal aptitude), they perceive these as gendered activities, generally performed by women. Relations were another influencing factor. Veterans reported that their social lives after military service became increasingly characterized by self-isolation and avoidance of people in general. Next, current beliefs were another influencing factor. Veterans overwhelmingly believe themselves to be “broken,” making them less able to acquire economic resources or find/maintain gainful employment. Lastly, current behaviors comprise the general daily habits that do not stem from cultural or socioeconomic factors but nevertheless shape veterans’ nutritional functioning, such as meal preferences, preferred grocery stores, and travel distances for groceries.

Discussion

In this convergent mixed-methods study, we assessed veterans with polytrauma; their experiences, beliefs, and daily physical and psychosocial functioning in relation to food and used findings to operationalize nutritional functioning. Although we found that some veterans encounter ICF barriers (eg, gastrointestinal conditions), most factors were related to psychosocial and cognitive challenges. Specifically, we found that in addition to veterans’ daily struggles arising from their polytrauma, they strongly identify with military cultural expectations that intrinsically shape their perceptions of their injuries and core identities. As a result, nutritional functioning in this population comprises far more than having an “adequate” grocery budget.

Implications for physical medicine and rehabilitation

In physical medicine and rehabilitation settings, the nutrition care process is well-established.^44,45 Our research suggests that patients with complex psychosocial and cognitive barriers to functioning require a different approach, and this study is a first step toward recognizing the gaps in our understanding. The core constructs and influencing factors will form the basis of a nutritional functioning survey measure, which will undergo validation testing and further refinement. In the long term, such a measure may be used in rehabilitation and integrative care settings, providing the necessary data for developing interdisciplinary tailored interventions that address veterans’ needs, such as learning strategies, food preparation/cooking education, financial literacy, and shopping strategies.

Study limitations

This study evaluated post-9/11 veterans with polytrauma who received care at specialized VA rehabilitation centers, and our findings may not be generalizable to other populations, including those with poor/no access to the internet and/or who have more severe functional, cognitive, or language difficulties. Of note however, food insecurity rates in this cohort are in line with rates observed in other cohorts with disabilities,⁴⁶ suggesting that our findings may be generalizable to such populations. Also, all data were collected at 1 time-point, precluding our ability to assess if/how nutritional functioning in veterans may vary over time.

Conclusions

We evaluated the experiences of veterans living with polytrauma regarding nutrition and food and found that nutritional functioning (food background, nutrition knowledge, meal aptitude, resource navigation, and navigation to/of food spaces) is complex, shaped by physical, psychosocial, economic, and cultural factors.

List of abbreviations:

ICF

International Classification of Functioning, Disability, and Health

mTBI

mild traumatic brain injury

PTSD

posttraumatic stress disorder