Low health literacy and excess body weight: a systematic review

Relationships among Sleep Time, Physical Activity Time, Screen Time, and Nutrition Literacy of Adolescents: A Cross-Sectional Study in Chongqing, China

Background: Unhealthy lifestyles among adolescents are reaching alarming levels and have become a major public health problem. This study aimed to assess the relationship between sleep time, physical activity (PA) time, screen time (ST), and nutritional literacy (NL). Methods: This cross-sectional online study involving adolescents aged 10-18 years was conducted in September 2020 in 239 schools in Chongqing, China. NL was measured using the "Nutrition Literacy Scale for middle school students in Chongqing (CM-NLS)". According to the recommended by the Chinese dietary guidelines (2022), we divided the sleep time of junior high school students into <9 h and ≥9 h, high school students into <8 h and ≥8 h, divided the workdays into weekend PA time < 1 h and ≥1 h, and divided the workdays into weekend ST < 2 h and ≥2 h. The multinomial logistic regression model was used to examine the association. Results: A total of 18,660 adolescents (50.2% males) were included. The proportion of participants that were junior high school students and attended boarding schools was 57.2% and 65.3%, respectively. Compared with senior high school students, junior high school students had a higher level of NL. Whether on workdays or weekends, participants with sleep time ≥ 8/9 h, PA time ≥ 1 h, and ST < 2 h per day had higher levels of NL. On weekdays, participants who met the sleep time ≥ 8 h/9 h (OR = 1.48, 95% CI: 1.36, 1.62) and PA time ≥ 1 h (OR = 1.69, 95% CI: 1.59, 1.81) had higher reporting of NL levels. Conclusions: Sleep time, PA time, and ST were positively correlated with NL among adolescents, especially junior high school students.

Association of Obesity With Health Literacy and Weight Perception Among Women Merchants in Abidjan, Côte d'Ivoire: A Cross-Sectional Study

BACKGROUND

In Abidjan, Côte d'Ivoire's largest city, obesity rates among women are increasing, posing a major health challenge, especially for the working generation. Merchants represent 64.3% of working women and are a typical occupation for women with low- and middle-income. Health literacy is used to prevent and overcome chronic diseases and can be used as anti-obesity measures.

OBJECTIVE

The aim of this study was to examine the relationship between obesity, health literacy, and weight perception among women merchants in Abidjan.

METHODS

In this cross-sectional study, we conducted a complete enumeration survey among women merchants in a market in Abidjan from December 2020 to December 2021. In addition to anthropometric measurements, structured face-to-face interviews were conducted. The participants were asked about their weight perception, weight management behaviors, and sociodemographic attributes. They also responded to the Health Literacy Questionnaire (HLQ). Data were tabulated using descriptive statistics, and multiple logistic regression analysis was performed to examine obesity's association with HLQ scales, weight perception, and weight management behaviors.

KEY RESULTS

Of the 873 participants, 259 (29.7%) were obese; 82% of them underestimated their weight. Obesity was associated with a higher rate of HLQ1 (Feeling understood and supported by health care providers) (odds ratio [OR] = 2.926, confidence interval [CI]:1.450-5.901, p = .03), a lower score of HLQ3 (Actively managing my health) (OR = 0.343, CI:0.165-0.716, p = 0.004), a lower rate of accurate weight perception (OR = 0.145, CI: 0.093-0.224, p < .001), and a lower rate of eating at least three meals per day (OR = 0.401, CI:0.260-0.617, p < .001).

CONCLUSIONS

Findings from this study of Abidjan women merchants include obese participants' lack of a proactive attitude toward personal health management, and the association of factors such as inaccurate weight perception and eating fewer than three meals per day with obesity. These finding have important implications for future anti-obesity measures. [HLRP: Health Literacy Research and Practice. 2024;8(2):e102-e112.].

Physicians' and Patients' Expectations From Digital Agents for Consultations: Interview Study Among Physicians and Patients

BACKGROUND

Physicians are currently overwhelmed by administrative tasks and spend very little time in consultations with patients, which hampers health literacy, shared decision-making, and treatment adherence.

OBJECTIVE

This study aims to examine whether digital agents constructed using fast-evolving generative artificial intelligence, such as ChatGPT, have the potential to improve consultations, adherence to treatment, and health literacy. We interviewed patients and physicians to obtain their opinions about 3 digital agents-a silent digital expert, a communicative digital expert, and a digital companion (DC).

METHODS

We conducted in-depth interviews with 25 patients and 22 physicians from a purposeful sample, with the patients having a wide age range and coming from different educational backgrounds and the physicians having different medical specialties. Transcripts of the interviews were deductively coded using MAXQDA (VERBI Software GmbH) and then summarized according to code and interview before being clustered for interpretation.

RESULTS

Statements from patients and physicians were categorized according to three consultation phases: (1) silent and communicative digital experts that are part of the consultation, (2) digital experts that hand over to a DC, and (3) DCs that support patients in the period between consultations. Overall, patients and physicians were open to these forms of digital support but had reservations about all 3 agents.

CONCLUSIONS

Ultimately, we derived 9 requirements for designing digital agents to support consultations, treatment adherence, and health literacy based on the literature and our qualitative findings.

Association between ecological footprint awareness and health literacy in adults: a population-based study from Turkey

This study aimed to determine the relationship between health literacy and ecological footprint which is an indicator of sustainability and environmental impact and to examine the factors that may affect them. It was found that 20.3% of individuals have inadequate, 43.7% problematic, 26.1% sufficient and 10.0% excellent health literacy levels. There were differences in age, education level and BMI classification according to Ecological Footprint Awareness Scale score quartiles and health literacy levels (p < 0.05). It was determined that age and Turkey Health Literacy Scale score had effect on ecological footprint awareness. Individuals with a high level of health literacy have a high awareness of their ecological footprint. The increase in people's health literacy levels and ecological footprint awareness with age can be interpreted as the increase in people's education and knowledge levels and their awareness levels against the protection of nature and the environment.

Don't forget the veggies! Identifying and addressing a lack of vegetable education in physiology

Ninety-five percent of Westerners do not consume the recommended daily vegetable intake, exacerbating the incidence of obesity, malnutrition, and nutritional deficiencies such as fiber. This article reviews the literature from PubMed, ERIC, and Web of Science, as well as Internet sites and government resources, to identify what should be considered important inclusions relating to dietary vegetable (including legumes and pulses) intake content in university physiology subjects. The primary aim is to advance the competency relating to good nutrition knowledge for future health professionals to enable them to guide and counsel patients and clients toward better health. A review of the literature provides scant nutritional content relating to vegetable intake, particularly across physiology subjects and health professional programs in general. A review of country dietary guidelines yielded discrepancies and ambiguity around recommended daily vegetable intake, including what constitutes essential vegetables. Educators responsible for embedding nutritional information in the curriculum would therefore be challenged to find reliable, evidence-based resources. Adding quality curriculum content on the importance of vegetable intake also promotes some of the Sustainable Development Goals (SDGs), including SDG 2 (Zero Hunger), thereby contributing to SDG 3 (Good Health and Well-Being). This article offers recommendations on how to embed content relating to the importance of dietary vegetables for good health and guidance for educators of health professions programs wanting to improve their curriculum content relating to adequate nutrition.NEW & NOTEWORTHY Is nutritional literacy an important concept in physiology? This article identifies a paucity of content and addresses the need for vegetable intake education.

Prevalence of overweight and its associated factors among Malaysian adults: Findings from a nationally representative survey

The World Health Organization has reported that the prevalence of overweight is a growing problem in many countries, including middle- and lower-income countries like Malaysia. This study aimed to determine the prevalence of overweight and its associated factors among Malaysian adults. A total of 9782 Malaysian adults aged 18 and above were included in this study, representing states and federal territories from the National Health and Morbidity Survey 2019. Sociodemographic data (sex, locality, age, marital status, ethnicity, educational level, income level, and health literacy), non-communicable disease status (hypertension, diabetes, and hypercholesterolemia), and lifestyle behaviours (physical activity level, smoking status, and also fruit and vegetable consumption) were collected and analysed to identify factors associated with overweight. The study found that the prevalence of overweight among Malaysian adults was 50.1%. Multivariate analyses showed that several factors, including female gender [aOR (95% CI) = 1.33 (1.11, 1.58); p = .002], ages 30-59 years [aOR (95% CI) = 1.61 (1.31, 1.97); p < .001], being Malay [aOR (95% CI) = 1.68 (1.36, 2.07); p < .001], Indian [aOR (95% CI) = 2.59 (1.80, 3.74); p < .001] or other Bumiputera [aOR (95% CI) = 1.82 (1.38, 2.39); p < .001], being married [aOR (95% CI) = 1.23 (1.00, 1.50); p = .046], and having adequate health literacy [aOR (95% CI) = 1.19 (1.01, 1.39); p = .033], were significantly associated with an increased risk of overweight. Additionally, overweight individuals had a significantly higher risk of non-communicable diseases such as diabetes [aOR (95% CI) = 1.47 (1.23, 1.75); p < .001] and hypertension [aOR (95% CI) = 2.60 (2.20, 3.07); p < .001]. The study suggests that intervention programs should be implemented in an equitable and cost-effective manner to target these high-risk populations and address the burden of overweight in Malaysia.

Self-management interventions for adults living with obesity to improve patient-relevant outcomes: An evidence map

OBJECTIVES

To conduct an evidence map on self-management interventions and patient-relevant outcomes for adults living with overweight/obesity.

METHODS

Following Arksey and O'Malley methodology, we searched in five electronical databases including randomized controlled trials (RCTs) on SMIs for overweight/obesity. We used the terms "self-management", "adult" and "obesity" for content. Two independent reviewers assessed eligible references; one reviewer extracted data, a second checked accuracy.

RESULTS

We identified 497 RCTs (58% US, 20% Europe) including 99,741 (median 112, range 11-5145) adults living with overweight/obesity. Most research evaluated clinical outcomes (617, 55%) and behaviors adherence (255, 23%). Empowerment skills, quality of life and satisfaction were less targeted (8%, 7%, 0.2%, respectively). The most frequent techniques included sharing information (858, 99%), goal setting (619, 72%) and self-monitoring training (614, 71%), provided face-to-face (386, 45%) or in combination with remote techniques (256, 30%). Emotional management, social support and shared-decision were less frequent (18%, 26%, 4%). Socio-economic status, minorities or health literacy were seldom reported.

CONCLUSION

There is a need of widening the scope of research by focusing on outcomes important to patients, assessing emotional/social/share-decision support, exploring remote techniques and including vulnerable populations.

Perceived Physical Literacy Is Associated with Cardiorespiratory Fitness, Body Composition and Physical Activity Levels in Secondary School Students

BACKGROUND

Overweight and obese adolescents are often associated with lower Physical Activity (PA) levels and low Cardiorespiratory Fitness (CRF). Recently, the concept of Physical Literacy (PL), has been suggested to be associated with higher levels of active behavior and better health in adolescents. The purpose of this study is to investigate the relationships between PL, body composition, cardiorespiratory fitness and physical activity levels in French secondary school students.

METHODS

The level of PL was assessed in 85 French adolescents using a French version of the Perceived Physical Literacy Instrument (F-PPLI). Cardiorespiratory fitness was measured by the "20 m adapted walk/shuttle run test". The PA level was assessed by the Youth Risk Behavior Surveillance System questionnaire. Weight status was measured by the Body Mass Index (BMI) and the body composition data.

RESULTS

We find a significant association between the PL and the percentage Fat Mass (%FM) (r = -0.43; p ≤ 0.01), between the PL and moderate to vigorous PA (MVPA) per week (r = 0.38; p ≤ 0.01). The PL was associated (r = 0.36; p ≤ 0.01) with the percentage of Skeletal Muscle Mass (%SMM) and cardiorespiratory fitness (r = 0.40; p ≤ 0.05).

CONCLUSIONS

Developing the PL for the most disadvantaged secondary school students in a PA program could be a suitable strategy to increase their PA level, reduce their adiposity, and promote better long-term health.

Parents' Experiences Using Digital Health Technologies in Paediatric Overweight and Obesity Support: An Integrative Review

This study aimed to explore parents' perspectives regarding the use of digital health technologies in paediatric overweight and obesity weight support. A systematic search in 'Academic Search Premier', 'British Nursing Index', 'Cumulative Index to Nursing and Allied Health', and 'Health Research Premium Collection' was conducted in November 2021. Inclusion criteria were English or Nordic peer-reviewed articles published after 2010, overweight and obese children aged 2-10, weight support using digital health technologies, and parental experiences examined. An integrative review was conducted using Joanna Briggs Institute quality appraisal checklists and a constant comparison analysis method. In total, 14 articles were analysed that included SMS, telephone, apps, websites, and social media as the main technology groups. A limitation of this review was the heterogenicity of the studies. The results indicate that parents, mostly mothers, had a positive experience, finding technologies helpful and easy to use, and expressed optimism toward future use. An option for interacting with others and the possibility of personalising support were enjoyed or requested. In conclusion, digital health technologies can be a suitable tool to empower the parents of children with overweight and obesity concerns, whose perspective should be considered during the design and support phases.

Preventing chronic disease in overweight and obese patients with low health literacy using eHealth and teamwork in primary healthcare (HeLP-GP): a cluster randomised controlled trial

OBJECTIVES

To evaluate a multifaceted intervention on diet, physical activity and health literacy of overweight and obese patients attending primary care.

DESIGN

A pragmatic two-arm cluster randomised controlled trial.

SETTING

Urban general practices in lower socioeconomic areas in Sydney and Adelaide.

PARTICIPANTS

We aimed to recruit 800 patients in each arm. Baseline assessment was completed by 215 patients (120 intervention and 95 control).

INTERVENTION

A practice nurse-led preventive health check, a mobile application and telephone coaching.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were measured at baseline, 6 and 12 months, and included patient health and eHealth literacy, weight, waist circumference and blood pressure. Secondary outcomes included changes in diet and physical activity, preventive advice and referral, blood lipids, quality of life and costs. Univariate and multivariate analyses of difference-in-differences (DiD) estimates for each outcome were conducted.

RESULTS

At 6 months, the intervention group, compared with the control group, demonstrated a greater increase in Health Literacy Questionnaire domain 8 score (ability to find good health information; mean DiD 0.22; 95% CI 0.01 to 0.44). There were similar differences for domain 9 score (understanding health information well enough to know what to do) among patients below the median at baseline. Differences were reduced and non-statistically significant at 12 months. There was a small improvement in diet scores at 6 months (DiD 0.78 (0.10 to 1.47); p=0.026) but not at 12 months. There were no differences in eHealth literacy, physical activity scores, body mass index, weight, waist circumference or blood pressure.

CONCLUSIONS

Targeted recruitment and engagement were challenging in this population. While the intervention was associated with some improvements in health literacy and diet, substantial differences in other outcomes were not observed. More intensive interventions and using codesign strategies to engage the practices earlier may produce a different result. Codesign may also be valuable when targeting lower socioeconomic populations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN 12617001508369) (http://www.ANZCTR.org.au/ACTRN12617001508369.aspx).

TRIAL PROTOCOL

The protocol for this trial has been published (open access; https://bmjopen.bmj.com/content/8/6/e023239).

The Relationship Between Health Literacy, Self-Efficacy, and Self-Care Behaviors in Older Adults With Hypertension in the North of Iran

BACKGROUND

Hypertension is the main risk factor for cardiovascular disease. Low level of health literacy is more common in people with hypertension. Evidence suggests that hypertension is preventable and can be controlled by modifying lifestyle and improving self-care behaviors.

OBJECTIVE

This study aimed to determine the relationship between health literacy, self-efficacy, and self-care behaviors in older adults with hypertension.

METHODS

The present study was a cross-sectional study conducted with 150 older adult patients with hypertension admitted to the Cardiac Care Unit (CCU) and post-CCU wards in East Guilan public hospitals in the north of Iran in 2020. Sampling was conducted using a convenience method based on inclusion criteria (age 60 years and older, high blood pressure and taking antihypertensive drugs for at least 6 months, ability to speak and communicate, having the suitable physical condition (not ill) to participate in research and answer questions, and having informed consent to participate in the study). The research instruments included a Health Literacy Questionnaire for Iranian Adults, a self-efficacy questionnaire in patients with hypertension, and a self-care behavior questionnaire for patients with hypertension. Descriptive statistics and multiple linear regression were used to analyze the data using SPSS software version 19.

KEY RESULTS

The results showed that most patients had adequate health literacy with a mean score of 116.77 (standard deviation [SD] = 8.34), excellent self-efficacy with a mean score of 23.06 (SD = 1.99) and relatively desirable self-care behaviors with a mean score of 51.79 (SD = 4.37). Findings also indicated that health literacy can predict self-efficacy (beta = 0.262, p = .001) and self-care behaviors (beta = 0.639, p = .000).

CONCLUSIONS

Based on results, health literacy is a predictor of self-efficacy variables and self-care behaviors. Therefore, planning to improve the health literacy of the older adult to promote self-efficacy and self-care behaviors and ultimately their health is recommended. [HLRP: Health Literacy Research and Practice. 2022;6(4):e262-e269.] Plain Language Summary: This study sought to determine the role of health literacy in predicting self-efficacy and self-care behaviors in older adults with hypertension admitted to CCU and post-CCU wards in East Guilan public hospitals in the north of Iran. Findings of this research demonstrate health literacy can predict self-efficacy and self-care behaviors.

Views of patients with obesity on person-centred care: A Q-methodology study

INTRODUCTION

To better accommodate patients with obesity, the adoption of a person-centred approach to healthcare seems to be imperative. Eight dimensions are important for person-centred care (PCC): respect for patients' preferences, physical comfort, the coordination of care, emotional support, access to care, the continuity of care, the provision of information and education, and the involvement of family and friends. The aim of this study was to explore the views of patients with obesity on the relative importance of the dimensions of PCC.

METHODS

Q methodology was used to study the viewpoints of 21 patients with obesity on PCC. Respondents were asked to rank 31 statements about the eight dimensions of PCC by level of personal significance. Using by-person factor analysis, distinct viewpoints were identified. Respondents' comments made while ranking were used to verify and refine the interpretation of the viewpoints.

RESULTS

Five distinct viewpoints were identified: (1) 'someone who listens in an unbiased manner', (2) 'everything should run smoothly', (3) 'interpersonal communication is key', (4) 'I want my independence', and (5) 'support for myself and my loved ones'. Viewpoint 1 was supported by the largest number of respondents and explained the most variance in the data, followed by viewpoint 3 and the other viewpoints, respectively.

CONCLUSION

Our findings highlight the need for tailored care in obesity treatment and shed light on aspects of care and support that are most important for patients with obesity.

PATIENT CONTRIBUTION

Our sample consisted of patients. Patients were also involved in the development of the statement set through pilot testing.

Health literacy as a key to improving weight status among Palestinian adolescents living in chronic conflict conditions: a cross-sectional study

OBJECTIVE

To examine the moderating role of health literacy in the association between direct exposure to violence and weight status among Palestinian adolescents.

DESIGN

A household cross-sectional study conducted in 2017.

SETTING

A Palestinian district of the West Bank.

PARTICIPANTS

Palestinian adolescents aged 11-16 years.

RESULTS

After excluding underweight adolescents from the 1200 who were initially recruited, the data of 1173 adolescents were analysed. A high proportion (62%) of adolescents were directly exposed to violence. The prevalence of obesity and overweight was 6.5% and 17.1%, respectively. The odds of obesity and overweight were 2.8 and 1.8 times higher among adolescents who were not exposed to domestic and school violence when they had low health literacy in the communication subscale. The odds of obesity were 62% and 57% lower among adolescents with high functional health literacy when exposed to domestic and school violence and to any form of violence, respectively. Among adolescents who were not exposed to any form of violence, those who had high health literacy in the communication subscale were 72% less likely to be obese compared with those who had low health literacy.

CONCLUSIONS

Health literacy moderated the association between direct exposure to violence and weight status. When health literacy levels were higher, lower obesity rates were observed among adolescents who were directly exposed to any form of violence or exposed either to political violence only or domestic and school violence only. The results warrant further investigation of the role of health literacy in adolescent health. It is recommended that policy-makers integrate the health literacy concept into both education and health systems.

Body mass index, body fat percentage, and visceral fat as mediators in the association between health literacy and hypertension among residents living in rural and suburban areas

Background

Hypertension is a major cause of death and disability worldwide. Enhancing health literacy (HL) may help to alleviate the risk of hypertension and its burden. However, evidence on the association between HL and hypertension and potential mechanisms remain to be explored.

Objectives

This study examined the association between HL and hypertension; and explored whether body mass index (BMI), body fat percentage (PBF), and visceral fat (VF) were mediators of this association in people who resided in rural and suburban areas in Vietnam.

Methods

A cross-sectional survey was conducted from 1st July to 31st December 2019, involving 1655 residents and exploring participants' sociodemographic characteristics, HL, health-related behaviors, comorbidities, body composition, and blood pressure (BP). People with systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg or using antihypertensive medication were classified as having hypertension. Multiple logistic regression and mediation analyses were used to explore associations.

Results

The hypertension prevalence was 41.9% (694/1,655). In adjusted models, a higher HL score was associated with a lower hypertension likelihood (OR = 0.96; 95%CI = 0.95–0.97; p < 0.001). Factors associated with a higher odd of hypertension were overweight/obese (OR = 1.69; 95%CI = 1.24–2.29; p = 0.001), high PBF (OR = 2.35; 95%CI = 1.85–2.99; p < 0.001), and high VF (OR = 2.27; 95%CI = 1.63–3.16; p < 0.001). Notably, PBF significantly mediated the association between HL and hypertension (indirect effect, OR = 0.99; 95%CI = 0.98–0.99; p = 0.009; percent mediated = 8.56%). The mediating roles of BMI and VF were not found.

Conclusion

The prevalence of hypertension was relatively high. People with better HL were less likely to have hypertension. The association between HL and hypertension was partially explained by PBF. Strategic approaches are required to improve people's HL and body fat which further help to manage hypertension in rural and suburban areas.

Socioeconomic differences in metabolic syndrome development among males and females, and the mediating role of health literacy and self-management skills

BACKGROUND

Our aim was to investigate sex differences in the associations between socioeconomic position (SEP) and metabolic syndrome (MetS) development, and to what extent these associations are mediated by health literacy and self-management skills.

METHODS

A subsample (n = 88,384, 59.5% female) of the adult Lifelines Cohort Study was used. MetS development according to NCEP-ATPIII criteria was assessed on average 3.8 years after baseline. SEP-MetS associations were assessed for moderation by sex, and sex-stratified accordingly. Associations between SEP measures (education, income and occupational prestige), health literacy and self-management skills, and MetS development were investigated using logistic regression analyses. The mediating effects of health literacy and self-management skills on the SEP-MetS associations were investigated using the Karlson-Holm-Breen method.

RESULTS

Among males and females, respectively 9.4% and 7.1% developed MetS. For males, education was inversely associated with MetS development; health literacy (7.1%) and self-management skills (1.9%) mediated a proportion of these educational differences. For females, education, income and occupational prestige were inversely associated with MetS development; health literacy (respectively 5.9% and 6.4%) and self-management skills (respectively 4.1% and 3.7%) mediated a proportion of the educational and occupational differences in MetS development. Neither health literacy nor self-management skills mediated female income differences in MetS development.

CONCLUSIONS

Socioeconomic differences in MetS development differ between males and females. Both for males and females, health literacy and self-management skills mediated a small proportion of socioeconomic differences in MetS development.

The role of family structure in health literacy in children and adolescents: a narrative review

Childhood and adolescence are the periods in which children shape their character and behavior. This is also the period for children to adopt good health behaviors and to gain health knowledge- to gain health literacy (HL). Several factors play an important role in this. Among them are the person's characteristics, family and social environment, literacy in general, cultural influences, and technological advances. The present study reviews the recent scientific evidence on the role that the family structure plays in HL in children and adolescents. A literature search was performed, until July 2019, in PubMed and Scopus. Appropriate keywords, related to HL and family structure, were used. Titles and abstracts were screened independently, and full-text manuscripts meeting inclusion criteria were extracted. Ten studies were included in this literature review. Several aspects of family structure (e.g., marital status, members of family, parental educational level, etc.) seemed to play a positive role in children's HL status in the sense that children improve their HL when raised in families whose members have better HL. Although there is good evidence that HL positively affects children's and adolescents' health behavior, the role of family structure in children's HL has not been well studied and understood.

Validation and measurement invariance of the Arabic Health Literacy Questionnaire

Health literacy plays a key role in empowering individuals and enabling them to make health-related decisions. Despite the advances in health literacy research, there are gaps in the literature that require further inquiry, and establishing comprehensive and valid measurements is one of them. Thus, this research was conducted to examine the psychometric properties of the Arabic Health Literacy Questionnaire (HLQ), including the reliability, validity, and measurement invariances of the nine HLQ scales. A cross-sectional design was used in this study. A sample of university students (N = 1011) was recruited, the mean of age was 21.1 years old (SD = 2.28). The Arabic HLQ and a demographics questionnaire were completed by the participants. Confirmatory factor analyses (CFA) and measurement invariances were performed for each HLQ scale. The values of Cronbach's α and composite reliability were above .70 for all HLQ scales. The CFA analyses showed that all HLQ scales meet the criteria that were set a priori: RMSEA ≤.07, CFI ≥.95, and Chisq/df < 5. In addition, all standardized factor loadings were above .50. Regarding the measurement invariance, the results supported the equal form measurement invariance for all HLQ scales. The equality of factor loadings measurement invariance across gender was also supported for all HLQ scales. Measurement invariance of factor loadings and equality of indicator intercepts was partially supported. These results show that the internal consistency, convergence, and factor structure of the HLQ are all supported. The Arabic HLQ is a reliable, valid tool to measure health literacy among Arabic-speaking populations.

Do Children and Adolescents with Overweight or Obesity Adhere to the National Food-Based Dietary Guidelines in Greece?

Childhood obesity increases the risk for metabolic disorders, but is also related to nutritional deficiencies, such as anemia and hypovitaminosis D. Although children/adolescents with overweight/obesity may have higher energy intake, their diet quality and diversity may be low. The present study aimed to evaluate the consumption of foods against the national food-based dietary guidelines in children and adolescents with overweight or obesity in Greece. Sociodemographic, anthropometric and lifestyle data were collected from a sample of 1467 children 2–18 years old (962 obese, 505 overweight, 51.2% females) in 2014–2017. The results of this study show that the consumption of dairy products, fruit, vegetables, legumes and fish by children/adolescents with overweight or obesity was lower than the national recommendations (ranging from a minimum of 39.5% for fish, to a maximum of 75.5% for cereal/potato/rice). Only the consumption of meat/poultry was found to exceed the national recommendation (estimated coverage of 131.3%). Moreover, a large proportion of participants regularly consumed various unhealthy foods/beverages. The present findings indicate that the majority of children/adolescents with overweight/obesity do not comply with the national food-based dietary guidelines in Greece. The implementation of new strategies to promote healthy diets among children/adolescents with overweight/obesity are urgently required.

Associação entre letramento em saúde, ameaça pela COVID-19 e intenção vacinal de adolescentes brasileiros

Resumo Objetivo: investigar a influência do letramento em saúde na avaliação da ameaça à saúde pela COVID-19 e sobre a intenção de não se vacinar de adolescentes brasileiros. Método: estudo transversal com 526 adolescentes brasileiros de 14 a 19 anos. Aspectos socioeconômicos, perfil saúde-doença, letramento em saúde, ameaça à saúde pela COVID-19 e intenção de não se vacinar foram analisados por associação bivariada e regressão linear múltipla com resposta Poisson. Resultados: maior pontuação de letramento em saúde (p=0,010), doença cardíaca (p=0,006), menor renda (p=0,000) e morar na região norte (p=0,007) foram fatores que contribuíram para o sentimento de maior ameaça pela COVID-19. O letramento em saúde não influenciou a intenção de não se vacinar (p=0,091), cuja prevalência foi menor entre os adolescentes do Sudeste quando comparados aos do Norte (p=0,010), entre os que cursavam o ensino superior (p=0,049) e entre aqueles com maior renda (p=0,000). Conclusão: letramento em saúde influenciou a percepção da ameaça da doença, mas não a intenção de não se vacinar. Avaliação da ameaça à saúde pela COVID-19 e a prevalência da intenção de não se vacinar foram influenciadas pela região de residência, renda e escolaridade, o que reforça a importância dos determinantes sociais da saúde nesse contexto.

Relación entre alfabetización en salud, amenaza por COVID-19 e intención de vacunación entre los adolescentes brasileños

Resumen Objetivo: investigar la influencia de la alfabetización en salud sobre la evaluación de la amenaza por COVID-19 y sobre la intención de los adolescentes brasileños de no vacunarse. Método: estudio transversal con 526 adolescentes brasileños entre 14 y 19 años. Se analizaron aspectos socioeconómicos, perfil epidemiológico, alfabetización en salud, amenaza a la salud por COVID-19 y la intención de no vacunarse mediante una relación bivariada y regresión lineal múltiple de respuesta de Poisson. Resultados: una elevada puntuación de alfabetización en salud (p=0,010), enfermedades cardiovasculares (p=0,006), menor nivel de renta (p=0,000) y vivir en la región norte (p=0,007) fueron factores que ayudaron a la sensación de mayor amenaza por COVID-19. La alfabetización en salud no influyó en la intención de no vacunarse (p=0,091), cuya prevalencia fue más baja entre los adolescentes del Sudeste en comparación con los del Norte (p=0,010), entre los que cursaban estudios superiores (p=0,049) y mayor nivel de renta (p=0,000). Conclusión: la alfabetización en salud influyó sobre la percepción de la amenaza de la enfermedad pero no en la intención de no vacunarse. La evaluación de la amenaza a la salud por COVID-19 y la prevalencia de la intención de no vacunarse fueron condicionadas por la región de residencia, nivel de renta y educación, acentuando la importancia de los determinantes sociales de la salud en este contexto.

Association of health literacy, COVID-19 threat, and vaccination intention among Brazilian adolescents

Objective:

investigate the influence of health literacy on the assessment of COVID-19 threat to health and the intention not to be vaccinated among Brazilian adolescents.

Method:

cross-sectional study with 526 Brazilian adolescents aged 14 to 19 years. Socioeconomic aspects, health-disease profile, health literacy, health threat by COVID-19 and intention not to be vaccinated were analyzed by bivariate association and multiple linear regression with Poisson response.

Results:

higher health literacy score (p=0.010), cardiovascular disease (p=0.006), lower income (p=0.000), and living in the North region (p=0.007) were factors that contributed to feeling more threatened by COVID-19. Health literacy did not influence the intention not to be vaccinated (p=0.091), whose prevalence was lower among adolescents in the Southeast region when compared to those in the North region (p=0.010), among those who attended higher education (p=0,049) and those with higher income (p=0.000).

Conclusion:

health literacy influenced the perception of COVID-19 threat, but not the intention not to be vaccinated. Assessment of COVID-19 threat to health and prevalence of the intention not to be vaccinated were influenced by the region of residence, income, and education, which reinforces the importance of social determinants of health in this context.

The causal model of health literacy and health behavior for obesity prevention among primary school students in Bangkok, Thailand

Background: The aim of the study was to develop a research instrument to study the levels of health literacy for obesity prevention (HLFOP), as well as health behavior for obesity prevention (HBFOP). In addition, we investigated the causal model between health literacy and health behavior for obesity prevention among primary school students in Bangkok, Thailand. Methods: A cross-sectional study among 600 participants who were primary school students (aged 9-13 years) was conducted. The participants were selected from schools in all parts of Bangkok using multi-stage random sampling technique. The research instrument to assess HLFOP and HBFOP, constructed by the researchers, were utilized for data collection. Data were analyzed using descriptive statistics, exploratory and confirmatory factor analyses, and structural equation model through linear structural relationship. Results: We found that HBFOP was directly influenced by heath literacy in the category of Critical Literacy with an effect size of 0.65 (p < 0.01), and was indirectly influenced in the category of Basic Literacy and Interactive Literacy through Critical Literacy with effect sizes of 0.46 and 0.58 (p<0.01), respectively. The model was consistent with the empirical data, with Chi-Square=13.68, df=7, p=0.05721, RMSEA (root mean square error of approximation)= 0.040,  SRMR (standardized root mean square residual)= 0.017 NFI (normal fit index)=0.99, GFI (goodness of fit index)=0.99, and AGFI (adjusted goodness of fit index)=0.97. Conclusions: HLFOP was influential on HBFOP in primary school students in the Bangkok Metropolis. The categories that were particularly influential were: 1) Basic Literacy: accessing health information skills; 2) Interactive Literacy: communication skills; and 3) Critical Literacy: media literacy and self-management skills.

Sociodemographic disparities and contextual factors in obesity: updated evidence from a National Survey of Risk Factors for Chronic Diseases

OBJECTIVE

To assess the association of sociodemographic and environmental factors with the obesity occurrence in Argentina from a sex- and age-comparative perspective and a multilevel approach.

DESIGN

Cross-sectional study based on secondary data from the National Survey of Chronic Diseases Risk Factors (CDRF) 2018, Argentina. Two-level logistic regression models stratified by sex and age were used.

SETTING

The nationwide probabilistic sample of the CDRF survey and twenty-four geographical units.

PARTICIPANTS

16 410 adult people, living in Argentine towns of at least 5000 people, nested into 24 geographical units. Sex and age groups were defined as young (aged 18-44 years), middle-aged (45-64 years) and older (65 years and older) men and women.

RESULTS

Single men (all age groups) and divorced/widowed men (aged 45 years or older) had a lower obesity risk compared to married ones. In the middle-aged group, men with higher education showed a lower risk than men with incomplete primary education. In young women, a marked social gradient by educational level was observed. A low-income level coupled with highly urbanised contexts represents an unfavourable scenario for young and middle-aged women. Having a multi-person household was a risk factor for obesity (OR = 1·26, P = 0·038) in middle-aged women. Contextual factors linked to the availability of socially constructed recreational resources and green spaces were associated with obesity among young adults.

CONCLUSIONS

Socio-environmental determinants of obesity seem to operate differently according to sex and age in Argentina. This entails the need to address the obesity epidemic considering gender inequalities and the socio-environmental context at each stage of life.

The Role of Health Literacy in Health Behavior, Health Service Use, Health Outcomes, and Empowerment in Pediatric Patients with Chronic Disease: A Systematic Review

About 8% of all children and adolescents worldwide are affected by chronic diseases. Managing chronic conditions requires pediatric patients to be health literate. The purpose of this review is to examine the existing evidence on the links between health literacy and its outcomes proposed by the model by Sørensen et al. in chronically ill pediatric patients. Four electronic databases (PubMed, Scopus, CINAHL, PsycINFO) were searched to identify pertinent articles published up to November 2021. The search was conducted independently by two researchers and restricted to observational studies. Of 11,137 initial results, 11 articles met eligibility criteria. Overall, 6 studies identified a significant association between health literacy and one of the considered outcomes. Regarding health behavior, none of the studies on adherence found significant associations with health literacy. The results in terms of health service use were inconclusive. Regarding health outcomes, health literacy did not affect most physiological parameters, but it significantly improved health-related quality of life. Overall, evidence remains inconclusive but suggests that health literacy is associated with self-efficacy, health-related quality of life, and health service use in pediatric patients. Further research should be undertaken to strengthen the evidence.

Nutrition-Exercise Behaviors, Health Literacy Level, and Related Factors in Adolescents in Turkey

BACKGROUND

Health behaviors of adolescents affect their health and well-being into adulthood. This study was conducted to determine the nutrition-exercise behaviors, health literacy level, and related factors in adolescents.

METHODS

A cross-sectional design was used for this study. Overall, 810 students in grades 6-8 in a Turkish school completed the study. A personal information form, the Nutrition-Exercise Behaviors Scale, and the Health Literacy for School-Aged Children Scale were used for data collection.

RESULTS

According to the mean score of the Health Literacy Scale, 21% of the students had a low level of health literacy, 63.8% had a medium level, and 15.2% had a high level. A positive correlation was found between health literacy level and healthy nutrition-exercise behavior (r = 0.345, p < .001), and a positive correlation between health literacy level and meal pattern (r = 0.230, p < .001). A positive correlation (r = 0.385, p < .001) was found between meal pattern and healthy nutrition-exercise behavior. A moderate positive correlation (r = 0.510, p < .001) was found between unhealthy nutrition-exercise behavior and psychological/addicted eating behavior.

CONCLUSION

The present study revealed that nutrition-exercise behaviors and the health literacy of adolescents were at a moderate level and, there was a relationship between nutrition-exercise behaviors and health literacy levels in adolescents. Interventions should be planned and followed through with parents to help adolescents adopt healthy nutrition and exercise behaviors from an early age and to increase their health literacy level. In this context, it is recommended to implement training and intervention programs for adolescents and their families.

Health Literacy and Health Behavior: Associated Factors in Surabaya High School Students, Indonesia

(1) Background: The health behavior (HB) of adolescents develops in the school or family setting and plays an important role in their future health status. Health literacy (HL) has been identified as an important factor in modifying health behavior in addition to socioeconomic factors. health-promoting school (HPS) programs also have a significant role in providing students with the means of learning the importance of knowledge, behavior, and skills for a healthy lifestyle. (2) Method: This study aims to identify the association between HB, HL measured in comprehensive health literacy (CHL) and functional health literacy (FHL), HPS programs, and socioeconomic factors among high school students in Surabaya, Indonesia. A cross-sectional study was conducted, and 1066 students were evaluated as respondents. (3) Result: The results of multivariate analyses showed that following factors were associated with better health behavior: female, better academic performance, higher grade, higher father’s education, lower allowance, and better CHL and FHL. The strongest association for HB was gender. CHL was especially associated with handwashing, physical activity, and drug abuse. FHL was associated with smoking and drug abuse. The implementation of HPS programs did not reach an optimum level and only influenced physical activity. (4) Conclusions: The findings confirm that CHL and FHL have a significant association with several HBs. HB intervention in the HPS program is recommended to incorporate the CHL and FHL for a better health impact.

Food and health promotion literacy among employees with a low and medium level of education in the Netherlands

BACKGROUND

Prior research indicates a positive association between socioeconomic position and health literacy levels. We hypothesize comparable socioeconomic gradients for food literacy. This study aims to determine the level of self-perceived food literacy and health promotion literacy among adults with a low and medium level of education and from various subgroups, as well as the association between these food and health literacy levels. Furthermore, this study aims to explore the associations of self-perceived food literacy (SPFL) and health promotion literacy (HPL) in BMI.

METHODS

A cross-sectional study was conducted among employees with a low and medium level of education. Descriptive analyses were performed to compute SPFL and HPL levels. Analyses of variance were performed to test differences between subgroups. The correlation between SPFL and HPL was computed by Pearson's r. Multivariate linear regression analyses were used to explore 1) the association between SPFL and HPL adjusted for demographic characteristics 2) the associations between SPFL and HPL in BMI.

RESULTS

The majority (63.1%) of all participants (n = 222) scored low on SPFL and 34.5% scored inadequate or problematic on HPL. No significant educational or weight-status differences were found in SPFL or HPL levels. On most levels, women compared to men and older compared to younger employees scored significantly higher. A small positive correlation between the two mean levels was found, r = .25, P < .001 (n = 203). Multivariate linear regression analyses showed a significant association between SPFL and HPL (B = .31, 95% CI = .15-.48). No significant associations between SPFL and HPL in BMI were found.

CONCLUSIONS

This study suggests there is room for improvement in SPFL and HPL among adults with a low and medium level of education. Future research should consider comparing low and middle socioeconomic with high socioeconomic groups when exploring food and health literacy. Regarding health promotion activities for adults with a low and medium level of education, it is recommended to focus on improving both food and health literacy. Furthermore, more research is needed to explore direct proxies of weight-status to better understand the role of food and health literacy in overweight patterns.

Application of the eHealth Literacy Model in Digital Health Interventions: Scoping Review

BACKGROUND

Digital health interventions (DHIs) are increasingly being adopted globally to address various public health issues. DHIs can be categorized according to four main types of technology: mobile based, web based, telehealth, and electronic health records. In 2006, Norman and Skinner introduced the eHealth literacy model, encompassing six domains of skills and abilities (basic, health, information, scientific, media, and computer) needed to effectively understand, process, and act on health-related information. Little is known about whether these domains are assessed or accounted for in DHIs.

OBJECTIVE

This study aims to explore how DHIs assess and evaluate the eHealth literacy model, describe which health conditions are addressed, and which technologies are used.

METHODS

We conducted a scoping review of the literature on DHIs, based on randomized controlled trial design and reporting the assessment of any domain of the eHealth literacy model. MEDLINE, CINAHL, Embase, and Cochrane Library were searched. A duplicate selection and data extraction process was performed; we charted the results according to the country of origin, health condition, technology used, and eHealth literacy domain.

RESULTS

We identified 131 unique DHIs conducted in 26 different countries between 2001 and 2020. Most DHIs were conducted in English-speaking countries (n=81, 61.8%), delivered via the web (n=68, 51.9%), and addressed issues related to noncommunicable diseases (n=57, 43.5%) or mental health (n=26, 19.8%). None of the interventions assessed all six domains of the eHealth literacy model. Most studies focused on the domain of health literacy (n=96, 73.2%), followed by digital (n=19, 14.5%), basic and media (n=4, 3%), and information and scientific literacy (n=1, 0.7%). Of the 131 studies, 7 (5.3%) studies covered both health and digital literacy.

CONCLUSIONS

Although many selected DHIs assessed health or digital literacy, no studies comprehensively evaluated all domains of the eHealth literacy model; this evidence might be overlooking important factors that can mediate or moderate the effects of these interventions. Future DHIs should comprehensively assess the eHealth literacy model while developing or evaluating interventions to understand how and why interventions can be effective.

Dietary agrobiodiversity for improved nutrition and health outcomes within a transitioning indigenous Solomon Island food system

Indigenous food systems of Pacific Small Island Developing Countries contain vast biological and cultural diversity. However, a nutrition transition is underway, characterized by shifts away from traditional diets in favour of imported and modern foods, contributing to some of the highest rates of obesity and Diabetes Type 2 Mellitus in the world. Using a mixed method approach, this study aimed to assess dietary agrobiodiversity’s relationship with nutrition indicators related to diet quality and anthropometrics within the context of the rural and Indigenous food system of Baniata village, located in the Western Province of Solomon Islands (Melanesia). A secondary aim was to evaluate the contribution of agrobiodiversity from the local food system to diet quality. A comprehensive nutrition survey was administered to the women primarily responsible for cooking of randomly selected households (n = 30). Additionally, 14 participatory focus group discussions captured the historical narrative of food system transitions, were hosted over a period of seven days, and included men, women and youth. Dietary intakes of the participants were reported below the estimated average requirement (EAR) for several essential nutrients, including protein (53%), calcium (96.6%), vitamin B1 (86.6%), vitamin B2 (80%), vitamin A (80%), zinc (40%) and fibre (77%). Focus group participants built a timeline of key historical and climatic transitions perceived to be drivers of dietary shifts away from traditional foods and towards imported and processed foods. Participants identified 221 species and varieties of agrobiodiverse foods available for cultivation or wild collection. Based on 24 h diet recalls, 87 were found to be utilised. Participants who consumed foods of a wider diversity of species richness had a higher probability of achieving recommended nutrition intakes and a lower body fat percentage (r2 = 0.205; p = 0.012). Our results suggest a nutrition transition is underway, and strategies harnessing traditional knowledge of nutrient-dense, agrobiodiverse foods can help improve food and nutrition security.

Parental health literacy and nutrition literacy affect child feeding practices: A cross-sectional study

BACKGROUND

Health literacy (HL) and nutrition literacy (NL) are important issues to consider, in the provision of health care to children and the establishment of healthy eating behaviors.

AIM

The study investigates the possible role of HL and NL levels of Greek parents, in parental Feeding Practices (PFP).

METHODS

This is a cross-sectional study which was conducted in the urban area of the Attica region, Greece. The sample consisted of 402 parents (68.4% mothers). Parents completed the Greek version of Comprehensive Parental Feeding Questionnaire, the European Health Literacy Questionnaire 47 and the Greek version of the Nutrition Literacy Scale. Sociodemographic and anthropometric characteristics were also assessed. The non-parametric tests Mann-Whitney and Kruskal Wallis, the chi-square test and linear regression models were applied.

RESULTS

The median for HL and NL were 33.69 and 24.00, respectively. Mothers applied the "child control" practice more frequently than fathers (p = 0.015). Linear regression analysis revealed that HL was associated positively with "healthy eating guidance" and "monitoring" (p = 0.009 and p < 0.0001, respectively) and negatively with "emotion regulation/food as reward" and "child control" (p = 0.037 and p = 0.015, respectively). NL was associated positively only with "healthy eating guidance" (p = 0.009), positively but marginally with "monitoring" (p = 0.051) and negatively with "emotion regulation/food as reward" (p = 0.020).

CONCLUSIONS

Higher parental levels of HL and NL are significantly positively associated with better parental feeding practices in Greece.

Exploring the Causes of Obesity Among Adults in the Kurdish Regions of Iran: A Qualitative Study

BACKGROUND

Obesity is one of the most important public health problems in the world, which is occurred by various factors. The purpose of this study is to explore the causes of obesity in the Kurdish regions of Iran with a qualitative approach.

METHODS

A qualitative content analysis study was conducted in the Kurdish regions of Iran from June 2019 to November 2019. The data were collected by holding focus group discussions and semi-structured interviews with 111 obese and thin men and women, and experts from different fields, who were selected through purposive sampling. Additionally, the data were analyzed by the conventional content analysis approach following the steps proposed by Graneheim and Lundman. The researchers used ATLAS.ti (Version 2019) software for data analysis and management. Lincoln and Guba's criteria were used to assess the quality of the research.

RESULTS

The results of the data analysis were classified into 5 categories and 16 sub-categories. The main categories included the modern lifestyle, sociocultural norms, indigenous culture of nutrition, lack of institutionalization of exercise, and low health literacy.

CONCLUSION

Changing people's beliefs and values ​​about obesity and thinness, changing the dietary habits of individuals, expanding and institutionalizing exercise and physical activity, and enhancing health literacy can prevent and control obesity.

What Role Does Body Image in Relationship between Level of Health Literacy and Symptoms of Eating Disorders in Adolescents?

(1) Background: The aim of this study was to explore the associations between health literacy and symptoms for eating disorders among adolescents, taking into consideration age and gender and whether this association is mediated by body image. (2) Methods: We used data on 5054 adolescents (mean age = 13.9, 51.7% boys) from the Health Behaviour in School-Aged Children study conducted in 2018 in Slovakia. We used logistic regression models to examine associations between level of health literacy and symptoms for eating disorders mediated by body image. (3) Results: Adolescents with low and medium levels of health literacy had a higher occurrence of reporting two or more symptoms of eating disorders (odds ratio (OR)/95% CI: 2.25/1.78-2.84 and 1.37/1.15-1.65). Adjustment for body image reduced the significance of association between low level of health literacy and symptoms for eating disorders by 26.4%, and association between medium level of health literacy and symptoms for eating disorders by 29.7%. (4) Conclusions: Adolescents who have a low health literacy level were found to have a higher probability of having symptoms for eating disorders, especially when they perceive themselves as fat. The study refers to potential theoretical frameworks for health literacy intervention that may provide guidelines for the intervention design and materials.

Parental health status in relation to the nutrition literacy level of their children: Results from an epidemiological study in 1728 Greek students

BACKGROUND: Children’s dietary behaviors seem tract into adulthood and as a result preventing strategies to establish healthy behaviors from early stages of life are needed. Nutrition knowledge is essential for behavioral change. OBJECTIVE: To examine whether the status of parental health related to their children’s nutrition literacy level through their perceptions mainly of healthy eating attitudes METHODS: A cross-sectional survey was conducted in Greece among 1,728 schoolchildren aged 10–12 years old. The sample was collected in the school setting during the school years of 2014–2016. Children completed anonymously a self-administered questionnaire about their knowledge and perceptions of a healthy diet while their parents completed another suitable questionnaire about family health status. RESULTS: Paternal BMI status and hypertension were inversely associated with the level of nutrition literacy of their children by b = –0.043 (95%CI: (–0.082, –0.003; p = 0.036) and by b = –0.600 (95%CI: –1.181, –0.019; p = 0.043), respectively. Parental health status, specifically, paternal diabetes and maternal dyslipidemia were associated with children’s higher level of nutrition literacy by b = 0.729 (95%CI: 0.002, 1.456; p = 0.049) and by b = 0.730 (95%CI: 0.086, 1.374; p = 0.026), respectively. CONCLUSIONS: Parental health status partially affects, either negatively or positively, the level of nutrition literacy of their children. This impact depends on whether parents follow nutritional recommendations to improve their health.

Health literacy as a determinant of childhood and adult obesity: a systematic review

OBJECTIVES

To assess whether Health Literacy (HL) acts as a determinant of obesity in adults and children by synthesizing the results of recent scientific evidence.

CONTENT

This is a systematic qualitative review following the MOOSE guidelines. A systematic, computer-assisted literature search via PubMed scientific database, between January 1st, 2000, and September 30th 2020, was conducted. Only cross-sectional epidemiologic research studies that were published in the English language, investigating HL's possible role as a determinant of childhood and adult obesity, were included.

SUMMARY

After screening 725 citations from the PubMed database, 39 (n=39) studies in total were included in this literature review; Four (n=4) studies were conducted in the children population, seven (n=7) studies were performed in children-parent/caregiver dyads, and 28 studies (n=28) enrolled adults. There is significant evidence that HL knowledge and skills determine the consequent management of obesity and BMI rates in children and adult populations.

OUTLOOK

Despite policies and action plans put in place by countries globally, overweight and obesity continue to be a pressing public health issue and one of the critical drivers of non-communicable diseases, constituting a health, social and economic burden worldwide. Health Literacy as an essential health policy and promotion agenda item and a critical empowerment strategy could increase children's and adults' control over their overall health and awareness to overcome obesity issues. Initiatives to improve HL levels could be useful tools in managing the obesity epidemic, starting from integrating HL in the school curriculum and further in family and community action plans.

Inverse Association Between Health Literacy and Obesity Among Children in Greece: A School-Based, Cross-Sectional Epidemiological Study

Children's health literacy is a crucial pillar of health. This study is aimed to examine the association between health literacy and weight status among Greek schoolchildren aged 10 to 12 years old. A population-based, cross-sectional observational study enrolling 1,728 students (795 boys), aged 10 to 12 years old, was conducted during school years 2014-2016. A health literacy index (range 0-100) was created through an item response theory hybrid model, by combining a variety of beliefs and perceptions of children about health. The mean health literacy score was 70.4 (±18.7). The majority of children (63.8%) had a "high" level (i.e., >67/100) of health literacy, 30.5% had a "medium" level (i.e., 34-66/100) of health literacy, while a small proportion of children (5.7%) had a "low" level (i.e., <33/100). Girls exhibited a higher level of health literacy than boys (71.7 ± 18.3 vs. 68.8 ± 19.1, p < .01). Regarding body weight status, 21.7% of children was overweight and 5.0% was obese. Linear regression models showed that the health literacy score was inversely associated with children's body mass index (regression coefficient [95% CI]: -0.010 [-0.018, -0.001]), after adjusting for dietary habits, physical activity levels, and other potential confounders. Health literacy seems to be a dominant characteristic of children's weight status; therefore, school planning, as well as public health policy actions should emphasize on the ability of children's capacity to obtain, process, and understand basic health information.

The causal model of health literacy and health behavior for obesity prevention among primary school students in Bangkok, Thailand

Background: The aim of the study was to develop a research instrument to study the levels of health literacy for obesity prevention (HLFOP), as well as health behavior for obesity prevention (HBFOP). In addition, we investigated the causal model between health literacy and health behavior for obesity prevention among primary school students in Bangkok, Thailand. Methods: A cross-sectional study among 600 participants who were primary school students (aged 9-13 years) was conducted. The participants were selected from schools in all parts of Bangkok using multi-stage random sampling technique. The research instrument to assess HLFOP and HBFOP, constructed by the researchers, were utilized for data collection. Data were analyzed using descriptive statistics, exploratory and confirmatory factor analyses, and structural equation model through linear structural relationship. Results: We found that HBFOP was directly influenced by heath literacy in the category of Critical Literacy with an effect size of 0.65 (p < 0.01), and was indirectly influenced in the category of Basic Literacy and Interactive Literacy through Critical Literacy with effect sizes of 0.46 and 0.58 (p<0.01), respectively. The model was consistent with the empirical data, with Chi-Square=13.68, df=7, p=0.05721, RMSEA (root mean square error of approximation)= 0.040,  SRMR (standardized root mean square residual)= 0.017 NFI (normal fit index)=0.99, GFI (goodness of fit index)=0.99, and AGFI (adjusted goodness of fit index)=0.97. Conclusions: HLFOP was influential on HBFOP in primary school students in the Bangkok Metropolis. The categories that were particularly influential were: 1) Basic Literacy: accessing health information skills; 2) Interactive Literacy: communication skills; and 3) Critical Literacy: media literacy and self-management skills.

Obesity-related knowledge and body mass index: a national survey in Portugal

PURPOSE

Obesity-related knowledge predicts weight control but previous studies only comprise individuals with excessive weight and assess very specific aspects of knowledge. This study aims to evaluate several domains of obesity-related knowledge according to the body mass index (BMI) in a representative sample of Portuguese-speaking dwellers in mainland Portugal.

METHODS

A sample of 1624 participants aged 16-79 years was analyzed. Eighteen questions comprising eight obesity domains were asked: prevalence, physical activity, number of calories, adiposity location, causes, diagnosis, treatment and consequences; each one was dichotomized into correct/incorrect knowledge.

RESULTS

The majority of Portuguese-speaking dwellers recognized the benefits of physical activity, the risks of abdominal obesity and most consequences of excessive weight, independently of their BMI. However, knowledge gaps were identified regarding prevalence, calories and BMI diagnosis. BMI influenced specific obesity-related knowledge: participants with a normal BMI knew the BMI formula more often, identified 22 as normal BMI more frequently and had the highest proportion of correct knowledge regarding the number of calories an adult should eat; obese individuals identified natural products as not being good treatments for obesity more often. After adjusting for age, sex and educational level, obese individuals identified natural products and supplements as not being good obesity treatments more often.

CONCLUSIONS

Obesity-related knowledge gaps (prevalence, calories, and diagnosis) were identified among Portuguese adults. Moreover, correct knowledge does not necessarily translate into a healthier BMI. Besides the dissemination of accurate information, public health interventions should focus on the transfer of knowledge to behaviors that will guarantee better weight management.

EVIDENCE-BASED MEDICINE RANKINGS

Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

The Clinical Obesity Maintenance Model: A Theoretical Framework for Bariatric Psychology

Ranked highly in its association with serious medical comorbidities, obesity, a rapidly growing epidemic worldwide, poses a significant socio-economic burden. While bariatric procedures offer the most efficacious treatment for weight loss, a subset of patients risk weight recidivism. Due to the heterogeneity of obesity, it is likely that there are phenotypes or sub-groups of patients that require evidence-based psychological support to produce more sustainable outcomes. So far, however, characteristics of patients have not led to a personalized treatment algorithm for bariatric surgery. Maintenance of weight loss following bariatric surgery requires long-term modification of eating behaviors and physical activity. A recent Clinical Obesity Maintenance Model (COMM) proposed a conceptual framework of salient constructs, including the role of habit, behavioral clusters, emotion dysregulation, mood, health literacy, and executive function as interconnected drivers of obesity maintaining behaviors relevant to the field of bariatric psychology. The primary aim of this concise review is to bring together emerging findings from experimental and epidemiological studies relating to the COMM constructs that may inform the assessment and follow up of bariatric surgery. We also aim to explain the phenotypes that need to be understood and screened prior to bariatric surgery to enable better pre-surgery intervention and optimum post-surgery response.

Subjective Health Literacy among School-Aged Children: First Evidence from Lithuania

Health literacy as a set of competencies to promote and sustain health has received significant research attention, particularly in studies on adults. Improving health literacy at an early age is crucial to personal health and development, so there is a need to investigate the health literacy of school-aged children. The aims of this study were to determine the level of subjective health literacy among adolescents in Lithuania and to examine the association between health literacy, school achievement, health education in schools, and family affluence. Health literacy was assessed using a brief Health Literacy for School-Aged Children instrument on a representative sample of 2369 subjects (from the 7th to 10th grades). Overall, 12.1% of all respondents had low, 70.5% moderate, and 17.4% a high level of health literacy. School achievements were found to be a significant predictor of health literacy, as were the number of school-based health promotion events. Family affluence also predicted an increased level of health literacy. This study was the first nationally representative examination of this topic in Lithuania and it highlighted the alarming finding that less than one-fifth of adolescents had high health literacy.

Cardiovascular Health, Adiposity, and Food Insecurity in an Underserved Population

This study investigated associations between cardiovascular health (CVH), adiposity, and food insecurity by race, sex, and health literacy in a sample of 800 underserved patients with obesity (body mass index [BMI] ≥ 30 kg/m²). CVH was assessed using American Heart Association Life’s Simple 7 (LS7) and adiposity was estimated using BMI and waist circumference (WC). Mixed models including interaction terms between food insecurity and sex, race, and health literacy were analyzed for LS7, BMI, and WC. Stratified models were analyzed as indicated by significant interactions. Mean BMI and WC were 37.3 kg/m² (4.6 SD) and 113.5 cm (12.4 SD), respectively. Among patients, 31% were food insecure and 31% had low health literacy. There were significant positive associations between food insecurity and BMI (p = 0.03) and WC (p = 0.03) in the overall sample. In sex-stratified models, women who were food insecure had higher BMI (p = 0.02) and WC (p = 0.007) than their food secure counterparts. Further, food insecure patients with better health literacy had greater BMI (p = 0.004) and WC (p = 0.007) than their food secure counterparts. Results suggest that adiposity is a greater burden in food insecure patients, which may be an important consideration for obesity treatment in underserved populations.

Socioeconomic inequalities in relation to health and nutrition literacy in Greece

Poor health literacy (HL) is associated with poor health behaviours and outcomes. The aim of the study was to investigate the effect of socioeconomic status on HL and nutrition literacy (NL) in Greece. This is a cross-sectional study which took place in Attica, Greece. 1281 individuals, aged ≥18 years of both sexes, participated. The European Health Literacy Questionnaire and the Greek version of the Nutrition Literacy Scale were used. Linear regression analysis revealed that education was significantly positively associated with HL (p = 0.002) and medium annual income was significantly associated with higher HL (p = 0.024), in contrast to low annual income. Education (p < 0.001) was significantly positively associated with NL. Unskilled particpants had lower NL compared to skilled paricipants (p = 0.021) and participants with medium annual income had significantly higher NL (p = 0.003) in comparison to participants with low annual income. Socioeconomic inequalities seem to negatively associate with HL and NL in Greece.