May 31, 2018
By Greg Peters
They say necessity is the mother of invention, and that adage holds especially true for a University of Kansas Medical Center nutrition researcher. After finding there was no good method to assess nutrition literacy, Heather Gibbs, Ph.D., an assistant professor in the KU Department of Dietetics and Nutrition, developed an original tool to test a person's ability to obtain, process and understand dietary information, all of which are keys to making healthy food choices.
Sparked by the absence of such an invaluable tool needed as a clinical outpatient dietitian years ago, she has created the Nutrition Literacy Assessment Instrument (NLAI or NLit). She is currently using NLit, or adaptations of the tool, to assess the health and nutrition of various populations, including one of the fastest-growing immigrant groups in the country.
"The immediate goal of nutrition education is to improve diets," said Gibbs. "That's pretty hard if people don't have the knowledge and the skills, such as nutrition literacy, to do so. A lack of diet improvement can impede efforts to improve a person's overall health."
While practicing as an outpatient dietitian, including time with the Telehealth Clinic at KU Medical Center, much of her time and energy was spent educating and counseling patients about how diet could play a role in their disease therapy. From there she moved to the classroom teaching undergraduate coursework and during that time she realized there was no formal standard measure of nutrition literacy. Without a common methodology to establish a baseline of knowledge, there is no meaningful way to look at the cause and effect of poor nutrition literacy.
"This realization is what launched my research into developing a measurement for nutrition literacy," she said.
Gibbs began creating her nutrition literacy tool in earnest as part of her doctoral work at the University of Illinois at Champagne-Urbana in 2012. The result was an assessment tool flexible enough to be adapted for a variety of populations, yet reliable enough to stand up to a variety of testing. Gibbs' dissertation laid the foundation for a paper published in July 2013 by the Centers for Disease Control and Prevention in which she and co-author Karen Chapman-Novakofski, Ph.D., provided the specifics for the Nutrition Literacy Assessment Instrument.
"After my dissertation work, I joined the faculty at KU Medical Center and worked with collaborators to look for audiences where nutrition literacy might be especially important," she said. "In my experience as a clinical educator and in higher education, I've found it's very useful to understand your audience in order to tailor the education to their specific needs."
Gibbs has put NLit to use in multiple population groups, including breast cancer survivors. NLit looks at six subscales or focus areas: nutrition and health; energy sources in food; food label and numeracy; household food measurement; food groups; and consumer skills. They found that scores on the NLit were strongly and positively related to diet quality. As a way to validate the reliability of NLit, she worked with her department chair, Debra Sullivan, Ph.D., R.D., and fellow KU Medical Center faculty members Edward Ellerbeck, M.D., Byron Gajewski, Ph.D., and Chuanwu Zhang, MS, on a study published in in the Journal of Nutrition Education and Behavior that examined nutrition literacy among 402 adults with chronic diseases.
With NLit's credibility and reliability established, she began working alongside Juntos: Center for Advancing Latino Health at KU Medical Center in its efforts to improve health and participation in health research for Spanish-speaking Latinos living in the Midwest. Gibbs is the principal investigator on a study published in November 2017 that used NLit-Spanish (NLit-S), a form of NLit with language and cultural modifications made to address the specific barriers faced by Spanish-speaking Latino immigrants.
This research is important because statistics show that In the United States, Latino immigrants face a greater number of barriers to living a healthy lifestyle compared to the general population. This is especially true when it comes to eating a nutritious diet. Poverty, food insecurity, a lack of formal education, a limited access to general health care and the assimilation of bad eating habits common in the U.S. population are among the difficulties they must overcome.
Nutrition literacy can be key to making the proper food choices. Research shows that a high-quality diet rich in fruits and vegetables and low in saturated fat decreases the death rate for all Americans, especially in deaths from cardiovascular disease and cancer. For some immigrants, adopting common American eating habits often leads to an increase in calorie-rich fast foods, snacks and foods with added salt and fat, while bypassing healthier choices like lean meats, and fresh vegetables and fruits.
To convert NLit both linguistically and culturally so it was appropriate for the immigrant population being studied, Gibbs' team, called on three experts, two of whom were dietitians working in clinic-based nutrition education in the Latino community and the third had extensive experience in creating adaptive learning methods for Latinos. The resulting questions were then tested by three native Spanish speakers from within the community for accuracy and appropriateness for the target audience. NLit-S is the first comprehensive nutrition literacy measurement tool created to provide insights into the abilities of Latino immigrants who primarily speak Spanish or little or no English to apply nutrition information.
The results of the 51-person study showed that NLit-S is a reliable tool to measure the six domains of nutrition literacy, and it correlates well to the Short Assessment of Health Literacy Spanish (SAHL-S), a validated measure of health literacy in Spanish.
Gibbs and her team hope their tool can help improve nutrition literacy, ultimately resulting in a reduction in the mortality rate, especially from heart disease and cancer. And now that she has proven that the NLit concept can be translated and culturally assimilated to meet the needs of a variety of populations, including Spanish-speaking immigrants, the options seem to abound for future uses of the tool. She hopes others will pick up the mantle of responsibility and continue spreading the lessons that can be learned through nutrition literacy. Her team is also in the process of developing a smart phone app for NLit.
"Good nutrition is important for absolutely everyone, so I envision many applications of this work," Gibbs said. "My hope is that other researchers will also study nutrition literacy in their specific populations of interest."