Document Type : Original Article
Authors
- . Janette Bedoyan
- . Jade McNamara 1
- . Melissa D. Olfert 2
- . Carol Byrd‑Bredbenner 3
- . Geoffrey W. Greene
1 School of Food and Agriculture, University of Maine, Orono, ME, USA
2 Division of Animal and Nutritional Sciences, Davis College of Agriculture, Natural Resources, and Design, West Virginia University, Morgantown, WV, USA,
3 Department of Nutritional Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
Abstract
BACKGROUND: Critical nutrition literacy (CNL) plays an important role in how college students make
everyday decisions about nutrition choices. Increasing CNL is an aim of many introductory nutrition
courses, but there are limited instruments measuring this construct. This study aimed to assess the
changeability of CNL and the relationship between CNL and markers of diet quality in young adults.
DESIGN: This was a two‑phase research project consisting of a nonexperimental, pre–post study
and a cross‑sectional assessment from 2018 to 2019. Participants were U.S. college students,
18‑24 years old, recruited from introductory‑level courses from three participating universities, located
in Rhode Island, West Virginia, and New Jersey.
SUBJECTS AND METHODS: Interventions consisted of (1) a 4‑credit, 13‑week nutrition course
and (2) a cross‑sectional, online behavior, environment, and perception survey. CNL was measured
using the Revised CNL Tool (CNLT‑R) instrument across both phases. Measures for phases
include: (1) the changeability of CNL and (2) the relationship between CNL and markers of diet quality.
ANALYSIS: Paired t‑tests and multivariate analysis of variance were utilized through SPSS
version 25.0.
RESULTS: CNL score significantly increased from baseline to postintervention from 3.38 ± 0.48 to
3.61 ± 0.55 (P = 0.014). There was an overall significant effect of CNL on markers of diet quality, such
as cups of fruits and vegetables (F/V) and teaspoons of added sugar (F [2,1321] = 3.12, P < 0.05;
Wilks’ Λ = 0.99).
CONCLUSIONS: This research found that an introduction to nutrition course was associated with
an increase in CNL and that CNL is related to diet quality. The instrument could be used by nutrition
educators as an outcome assessment. Future research should investigate other components of the
CNL construct as well as predictive validity.
Keywords
- Sørensen K, van Den Broucke S, Fullam J, Doyle G, Pelikan J,
Slonska Z, et al. Health literacy and public health: A systematic
review and integration of definitions and models. BMC Public
Health 2012;12:80.
2. Nutbeam D. Defining, measuring and improving health literacy.
Heal Eval Promot 2015;42:450‑6.
3. Nutbeam D, McGill B, Premkumar P. Improving health literacy
in community populations: A review of progress. Health Promot
Int 2018;33:901‑11.
4. Van den Broucke S. Health literacy: A critical concept for public
health. Arch Public Heal 2014;72:10.
5. National Center for Health Statistics. Healthy People 2010: Final
Review. Hyattsville, MD: National Center for Health Statistics;
2012.
6. Osborn CY, Paasche‑Orlow MK, Bailey SC, Wolf MS. The
mechanisms linking health literacy to behavior and health status.
Am J Health Behav 2011;35:118‑28.
7. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K.
Low Health Literacy and Health Outcomes: An Updated
Systematic Review. Ann Intern Med 2011;155:97‑07.
8. Homamodin Javadzade S, Sharifirad G, Radjati F, Mostafavi F,
Reisi M, Hasanzade A. Relationship between health literacy,
health status, and healthy behaviors among older adults in
Isfahan, Iran. J Educ Health Promot 2012;1:31.
9. Bahramian M, Najimi A, Omid A. Association between health
literacy with knowledge, attitude, and performance of health‑care
providers in applying health literacy education strategies for
health education delivery. J Educ Health Promot 2020;9:10.
10. Karimi N, Saadat‑Gharin S, Tol A, Sadeghi R, Yaseri M,
Mohebbi B. Problem‑based learning health literacy intervention
program on improving health‑promoting behaviors among girl
students. J Educ Health Promot 2019;8:251.
11. Reisi M, Javadzade H, Heydarabadi AB, Mostafavi F, Tavassoli E,
Sharifirad G. The relationship between functional health literacy
and health promoting behaviors among older adults. J Educ
Health Promot 2014;3:119.
12. Mohebbi B, Tol A, Sadeghi R, Yaseri M, Somar NA, Agide FD.
The efficacy of social cognitive theory‑based self‑care
intervention for rational antibiotic use: A randomized trial. Eur
J Public Health 2018;28:735‑9.
13. Carbone ET, Zoellner JM. Nutrition and health literacy:
A systematic review to inform nutrition research and practice.
Acad Nutr Diet 2012;112:254‑65. - 14. Velardo S. The nuances of health literacy, nutrition literacy, and
food literacy. Nutr Educ Behav 2015;47:385‑9.
15. Truman E, Bischoff M, Elliott C. Which literacy for health
promotion: Health, food, nutrition or media? Health Promot Int
2020;35:432‑444.
16. Gibbs HD, Ellerbeck EF, Gajewski B, Zhang C, Sullivan DK. The
nutrition literacy assessment instrument is a valid and reliable
measure of nutrition literacy in adults with chronic disease. Nutr
Educ Behav 2018;50:247‑257.
17. ZoellnerJ, You W, Connell C, Smith‑Ray RL, Allen K, Tucker KL,
et al. Health literacy is associated with healthy eating index scores
and sugar‑sweetened beverage intake: Findings from the rural
lower mississippi delta. Am Diet Assoc 2011;111:1012‑20.
18. Tallant A. First‑year college students increase food label‑reading
behaviors and improve food choices in a personal nutrition
seminar course. Am J Heal Educ 2017;48:331‑7.
19. Ha EJ, Caine‑Bish N. Effect of nutrition intervention using a
general nutrition course for promoting fruit and vegetable
consumption among college students. Nutr Educ Behav
2009;41:103‑9.
20. Nani M, Gordon K, Caine‑Bish N. P45 Impact of a college
nutrition course on nutrition knowledge and dietary intake of
undergraduate students. Nutr Educ Behav 2019;51:S52.
21. McNamara J, Kunicki ZJ, Olfert MD, Byrd‑Bredbenner C,
Greene G. Revision and psychometric validation of a survey tool
to measure critical nutrition literacy in young adults. Nutr Educ
Behav 2020;52:726‑31.
22. Kurtzman ET, Greene J. Effective presentation of health care
performance information for consumer decision making:
A systematic review. Patient Educ Counsel 2016;99:36.
23. Demiris G. Consumer health informatics: Past, present, and
future of a rapidly evolving domain. Yearb Med Inform 2016;
Suppl 1(Suppl 1):S42‑7.
24. McNamara J, Sweetman S, Connors P, Lofgren I, Greene G. Using
interactive nutrition modules to increase critical thinking skills
in college courses. Nutr Educ Behav 2020;52:343‑50.
25. Kong LN, Qin B, Zhou Y qing, Mou S yu, Gao HM. The
effectiveness of problem‑based learning on development of
nursing students’ critical thinking: A systematic review and
meta‑analysis. Int J Nurs Stud 2014;51:458‑69.
26. Mogford E, Gould L, Devoght A. Teaching critical health literacy
in the US as a means to action on the social determinants of health.
Health Promot Int 2011;26:4‑13.
27. Guttersrud O, Dalane JO, Pettersen S. Improving measurement
in nutrition literacy research using Rasch modelling: Examining
construct validity of stage‑specific “critical nutrition literacy”
scales. Public Health Nutr 2014;17:877‑83.
28. Harlow LL. The Essence of Multivariate Thinking. 2nd ed.
New York, NY: Routledge; 2014.
29. McNamara J, Olfert MD, Sowers M, Colby S, White A,
Byrd‑Bredbenner C, et al. Development of an instrument
measuring perceived environmental healthfulness: behavior
environment perception survey (BEPS). Nutr Educ Behav
2020;52:152‑61.
30. Dietary Screener Questionnaires (DSQ) in the NHANES 2009‑10:
DSQ. National Cancer Institute Website. Accessed December 6,
2020. Available from: https://epi.grants.cancer.gov/nhanes/
dietscreen/questionnaires.html.
31. Dietary Screener Questionnaire (DSQ) in the NHANES 2009‑10:
Data Processing & Scoring Procedures. National Cancer Institute
Website. Accessed December 6, 2020. Available from: http://epi.
grants.cancer.gov/diet/screeners/fruitveg/scoring/allday.html.
32. Chinn D. Critical health literacy: A review and critical analysis.
Soc Sci Med 2011;73:60‑7.
33. Garcia AC, Sykes L, Matthews J, Martin N, Leipert B. Perceived
facilitators of and barriers to healthful eating among university
students. Can J Diet Pract Res 2010;71:e28‑33.
34. Halawah I. Factors influencing college students’ motivation to
learn from students’ perspective. Education 2011;132:379‑390.
35. Catalano A. Patterns of graduate students’ information seeking
behavior: A meta‑synthesis of the literature. J Document
2013;69:243‑274.
36. Greene GW, Schembre SM, White AA, Hoerr SL, Lohse B, Shoff S,
et al. Identifying clusters of college students at elevated health
risk based on eating and exercise behaviors and psychosocial
determinants of body weight. Am Diet Assoc 2011;111:394‑400.
37. Seguin R, Connor L, Nelson M, LaCroix A, Eldridge G.
Understanding barriers and facilitators to healthy eating and
active living in rural communities. Nutr Metab 2014;2014:146502.
38. Graham DJ, PelletierJE, Neumark‑Sztainer D, Lust K, Laska MN.
Perceived social‑ecological factors associated with fruit and
vegetable purchasing, preparation, and consumption among
young adults. Acad Nutr Diet 2013;113:1366‑74.
39. Greene GW, White AA, Hoerr SL, Lohse B, Schembre SM, Riebe D,
et al. Impact of an online healthful eating and physical activity
program for college students. Am J Health Promot 2012;27:47‑58.
40. World Health Organization. Sugars Intake for Adults and
Children. World Health Organization; 2015.
41. Jasti S, Rubin R, Doak CM. Sugar‑sweetened beverage knowledge
and consumption in college students. Heal Behav Policy Rev
2016;4:37‑45.
42. Yang CC, Bin CW. Substitution of healthy for unhealthy
beverages among college students. Health‑concerns and
behavioral‑economics perspective. Appetite 2010;54:512‑6.
43. Bawadi H, Khataybeh T, Obeidat B, Kerkadi A, Tayyem R,
Banks A, et al. Sugar‑sweetened beverages contribute significantly
to college students’ daily caloric intake in Jordan: Soft drinks are
not the major contributor. Nutrients 2019;11:1058.
44. Attila S, Çakir B. Energy‑drink consumption in college students
and associated factors. Nutrition 2011;27:316‑22.
45. Hawkins LK, Farrow C, Thomas JM. Do perceived norms of social
media users’ eating habits and preferences predict our own food
consumption and BMI? Appetite 2020;49:104611.
46. Spiteri Cornish L, Moraes C. The impact of consumer confusion
on nutrition literacy and subsequent dietary behavior. Psychol
Mark 2015;32:558‑74.
47. Naigaga DA, Pettersen KS, Henjum S, Guttersrud Ø. Assessing
adolescents’ perceived proficiency in critically evaluating
nutrition information. Int J Behav Nutr Phys Act 2018;15:1‑13.
48. Brownbill AL, Miller CL, Braunack‑Mayer AJ. The marketing of
sugar‑sweetened beverages to young people on Facebook. Aust
N Z J Public Health 2018;42:354‑60.
49. Zoellner J, Chen Y, Davy B, You W, Hedrick V, Corsi T, et al.
Talking Health, A pragmatic randomized‑controlled health
literacy trial targeting sugar‑sweetened beverage consumption
among adults: Rationale, design & methods. Contemp Clin Trials
2014;37:43‑57.
50. Gase LN, Robles B, Barragan NC, Kuo T. Relationship between
nutritional knowledge and the amount of sugar‑sweetened
beverages consumed in los Angeles county. Heal Educ Behav
2014;41:431‑9.
51. Mohebbi B, Tol A, Shakibazadeh E, Yaseri M, Sabouri M,
Agide FD. Testing psychometrics of healthcare empowerment
questionnaires (HCEQ) among Iranian reproductive age women:
Persian version. Ethiop J Health Sci 2018;28:341‑6.
)