Nutrition Literacy and Health Status of Medical Students: A Systematic Review | ||
| Health Education and Health Promotion | ||
| Article 9, Volume 11, Issue 2, 2023, Pages 231-238 PDF (849.06 K) | ||
| Document Type: Systematic Review | ||
| DOI: 10.58209/hehp.11.2.231 | ||
| Authors | ||
| Sh. Vahidi; A. Ramezankhani* | ||
| Department of Public Health, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran | ||
| Abstract | ||
| Aims: Health literacy is considered a fundamental ability needed when making difficult health-related decisions. Also, people with nutrition literacy can convert nutrition messages into knowledge and tend to make healthier eating choices. This systematic review aimed to summarize the literature on nutrition and health literacy to enhance the medical students’ knowledge about the importance of health and nutrition literacy. Information & Methods: In this study systematic review, research articles published in English were reviewed using relevant terms in PubMed, CINAHL, Web of Science, EMBASE, Scopus, and CINAHL databases. The articles were selected based on the inclusion and exclusion criteria, repetition, purpose, and relevance to the topic. Furthermore, the “Consensus-based Standards for the selection of health Measurement Instruments” checklist was used to select and evaluate the reviewed articles. Findings: A total of 2978 articles were reviewed. Ultimately, 15 articles were approved and included in the study. Six studies were conducted on nursing students, six were on students of pharmacy and other clinical fields, and three studies examined medical students. The average nutrition and food literacy scores were sufficient, whereas the nutrition knowledge score was moderate. Conclusion: In the reviewed studies, nutrition literacy is evaluated to be at a low to medium level. Most students have insufficient nutrition knowledge. | ||
| Keywords | ||
| Literacy; Health Literacy; Health Status; Medical students; Systematic Review | ||
| Full Text | ||
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Introduction Health literacy is defined as the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions [1, 2]. It is essential to a person's ability to make wise health choices and regarded as a fundamental ability required when making difficult health-related decisions [3, 4]. According to the healthcare community, poor health literacy can impede the proper treatment of preventable diseases [5]. Individuals with low levels of literacy struggle to understand health-related information and take actions that can reduce risks and symptoms [6]. Consequently, inadequate health literacy interferes with provider-patient dialogue and affects the overall healthcare experience [7]. Meanwhile, evidence suggests deficiencies in people's knowledge and self-management skills, particularly in relation to nutrition and health literacy [8, 9]. The ability to access, process, and comprehend fundamental nutrition information is known as nutrition literacy [10-12]. According to literature, nutrition literacy can be developed or influenced by various factors, such as adhering to dietary guidelines, interpreting food labels, and making wise dietary decisions [13-16]. Skilled individuals in nutrition literacy can recognize and convert nutrition messages into knowledge. Generally, those with adequate nutritional understanding tend to make healthier eating choices [17, 18]. Factors such as poor utilization of health care services, inferior health status, noncompliance with medical advice, the inability to manage chronic diseases, lack of self-care, frequent hospitalizations, rising health costs, and higher mortality rates have been associated with low levels of health and nutrition literacy [19]. It is estimated that more than 19% of gastrointestinal cancers, 13% of heart diseases, and 10% of strokes worldwide are related to improper nutrition [3]. A high level of health and nutrition literacy among medical doctors can optimally promote healthy nutrition to prevent certain diseases, assist patients when recovering from illnesses and surgeries, and teach patients how to manage chronic illnesses with healthy food choices. Healthy nutrition helps to prevent obesity and chronic diseases, such as diabetes mellitus and cardiovascular diseases [20]. Medical students have received less research attention on food literacy and nutrition knowledge. It is especially important, as they will eventually appear in the public arena as therapists or paramedics and gain social trust and scientific status. This systematic review aimed to summarize the literature on nutrition and health literacy to enhance the medical students’ knowledge about the importance of health and nutrition literacy in practice and define the shortcomings and opportunities found in certain scientific researches [13, 21]. Information and Methods Search strategy and article selection Research articles published in English were analyzed using relevant terms in PubMed, CINAHL, Web of Science, EMBASE, Scopus, CINAHL databases, and the Google Scholar motor engine. The search was conducted using keywords and Medical Subject Headings (MeSH). Search terms applied in the screening of articles included “nutrition literacy”, “food literacy”, “Nutrition Knowledge”, “Nutritional”, “Food Knowledge”, “Students”, “Medical Students”, and “Clinical Students”. Combinations with the operators "and" and "or" were also examined. All articles related to the topic were reviewed. Inclusion and exclusion criteria The inclusion criteria included articles in which the levels of literacy and knowledge of both nutrition and food among healthcare students was examined regardless of age, income, study design, gender, and sample size (Healthcare, medical, and basic science students were selected as the target community because of their close connection to nutrition science). Also included in the study were researches in which the literacy or knowledge of either nutrition or food was measured with appropriate tools, studies that had no limitations and deficiencies in research findings, and studies that examined graduate students in the fields of healthcare or basic social sciences. The exclusion criteria included studies in which people other than healthcare students were examined, and in which the mean or percentage of instruments was unclear. Furthermore, articles whose full text was not available were excluded from the study. Articles with review data, case reports, and manuscripts were also rendered as irrelevant and excluded from the study. Data extraction and screening Two trained authors assisted in the search for and extraction of data. The authors selected abstracts based on quality and the inclusion and exclusion criteria. After reviewing the abstracts, the results of the studies were analyzed. Consequently, the two authors consulted each other, reached a consensus, and then mentioned the reasons behind the inclusion or exclusion of articles with conflicting content. The method of the presented topics presented, including the analysis, interpretation and collection of findings, was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After the initial search, the articles were checked for the repetition and consistency of their titles and abstracts. The content and relevance of the text was then evaluated. Therefore, all selected articles were of high quality and based on the inclusion and exclusion criteria (Figure 1).  Figure 1) Article selection diagram Article quality evaluation The quality of the final articles was evaluated separately by two researchers with experience in systematic review research. The results were then discussed in a joint meeting. In cases where there was a difference of opinion, the discussion continued until a final agreement was reached between the two researchers. In order to select and check the quality of the articles, the “COnsensus-based Standards for the selection of health Measurement INstruments” (COSMIN) checklist was used. The articles were classified as poor (1-3), good (4, 5), and excellent (6) based on the score obtained for each criterion. Findings Article selection, article type and target population A total of 2978 articles were reviewed. Eventually, 15 articles were approved and included in the study (Figure 1). Twelve articles examined nutrition knowledge, one studied both nutrition literacy and nutrition knowledge [22], and two articles researched nutrition literacy [5, 6]. For the studied population, a total of 4108 students were examined. Six articles were on nursing students [5, 7, 10], three studies focused on medical students [6, 10, 13], and six studies examined students of pharmacy and other fields of clinical studies [23, 24] (Table 1). Article content and study design Two studies focused on nutrition literacy, both of which revealed an average level of nutrition literacy among the studied subjects. One study by Mengi and Semerci [7] examined both nutrition literacy and nutrition knowledge, demonstrating a sufficient level of nutrition literacy and good level of nutrition knowledge among the students. Twelve studies reviewed nutrition knowledge, two of which demonstrated low levels of nutrition knowledge [10, 22]. Overall, nutrition knowledge was average. Five studies showed that nutrition knowledge was higher than 50% [13, 17, 20, 25]. Most studies mentioned the positive role played by the related academic field and degree in nutrition literacy (Table 1). Among the reviewed studies, fourteen were cross-sectional, and one did not specify. Three studies were conducted before 2010. In all studies, the objectives and methodologies were well presented [8, 13, 26]. Table 1) Main nutritional findings of the reviewed articles  Nutrition assessment tools In two studies, the reliability levels of the tools were not determined. In six studies, the questionnaire was self-designed. The tools applied to evaluate nutrition literacy, were targeted at nursing students, whereas those used to measure nutrition knowledge were targeted at medical and clinical students. The “Evaluation Instrument of Nutrition Literacy on Adults” tool (EINLA) was applied to measure nutrition literacy [27]. However, in order to measure nutrition knowledge, most studies used either the “General Nutrition Knowledge Questionnaire” (GNKQ) [14] or other modified questionnaires [28] (Table 2). Table 2) Nutrition assessment tools  Article quality The qualities of the selected 15 articles were evaluated via the COSMIN checklist. Twelve studies were rated as good, while the remaining three studies received a positive score in only one area and were rendered as poor. In most of the studies, both the predictive validity and concurrent validity of the criteria were strong (Table 3). Table 3) Review of articles via the COSMIN checklist  Discussion In this systematic review, different aspects of studies associated with food and nutrition literacy and nutrition knowledge were examined. The evidences collected here indicate that medical students had inadequate health and nutrition literacy, whereas nursing students obtained an average score [29]. Accordingly, Bahramfard et al.'s study in Iran showed that the average nutrition literacy score of students was 24.9 out of 35. One percent of students had inadequate nutrition literacy, and the remaining 50.9% and 48.12% had borderline and adequate nutrition literacy, respectively. Nutrition literacy was related to effective factors in the nutritional health of the students [6]. A study by Mearns et al. was obtained results similar to our findings, showing that the nutrition literacy score of nursing students was average, and those who had proper literacy were more informed about healthy fats [5]. Nutrition literacy has also been associated with social differences between populations [30]. A research in Iran showed that about 23% of teachers had insufficient dietary literacy. Nevertheless, their average nutrition literacy score was sufficient [12]. The present study displayed that most clinicians had sufficient nutrition literacy. In support of these findings, the development of nutrition literacy can effectively prevent the increase of diet-related diseases and improve nurses' relationship with food [22]. Many nursing students with good nutrition literacy scores also obtained an average score in nutrition knowledge, revealing a direct relationship between nutrition knowledge and literacy [7]. Health professionals, including nurses, provide nutritional information to the community. A study on nutrition knowledge among nursing students found that the average nutrition knowledge score was low to moderate and around 60%, which can be improved through professional nutrition magazines and books [8]. In contrast to our study, another study showed that the nutrition knowledge score of nursing students was high (close to average) compared to other students [31]. According to Phillips' findings, most nursing students were unfamiliar with the basic principles of nutrition [32]. The collected evidence in this study showed that medical students had poor nutrition knowledge. Accordingly, another study showed many deficiencies in the nutrition knowledge of medical students [19]. Based on a survey in China, it was observed that nutrition knowledge among medical students was related to their nationality. The knowledge of Chinese students, especially that of seafoods and traditional foods, was more than that of international students in many cases [17]. According to another study, nutrition literacy was average among medical students. The nutrition and diabetes axis had the highest percentage of correct answers (55.6%), whereas the nutrition and heart disease axis had the lowest correct answers (44%) [20]. This systematic review showed that, based on a survey on different clinical students, dietetics students had significantly higher nutrition scores compared to other students. Young people and women scored higher in the nutrition knowledge questionnaire compared to older men and women [14]. Spexoto et al. reported that about 80% of pharmacy and biochemistry students had average nutrition knowledge, and 77.1% paid attention to their diet. Meanwhile, first-year students had less nutrition knowledge, low physical activity and did not pay attention to a healthy diet [25]. According to the findings of another survey, student groups had different strengths and weaknesses in terms of nutrition knowledge. Dental students were more concerned about dental erosion, and nutrition students were more focused on obesity. This study recommends oral and dental health nutrition classes for nutritionists and general health nutrition classes for dentists [23]. El-Ahmady & El-Wakeel stated that there is a positive correlation between nutrition literacy and healthy nutritional practice, and that nutrition knowledge alone is not a driver for nutritional practice and healthy food use. The study also noted that practicing healthy eating habits can affect nutritional practice [24]. It is important to know the factors that reliably affect food literacy. The evidence obtained in this study demonstrated that students' regular participation in food-related activities at home and with their parents increased their knowledge about food. Furthermore, students faced certain challenges with regard to food literacy acquisition, such as the lack of food and nutrition education (both at home and in schools), hindering time limitations, and complex food relationships [30, 33]. A systematic review demonstrated that students who had nutrition knowledge and healthier eating habits showed a significant relationship between food literacy and healthy diet behavior in the long term [34]. Surveys among teachers have shown that those with fewer years of work experience but higher education had a higher level of nutrition literacy [12, 35]. However, experience can also effectively increase nutrition literacy. According to a recent survey in Iran, it was determined that about 75% of the workers in a steel company had sufficient nutrition literacy. The average nutritional literacy score was significantly higher in people with higher education [35, 36]. Moreover, people with adequate monthly salaries obtained a higher average score in determining food groups and overall nutrition literacy [2, 11]. The information mentioned above is of vital importance because medical students, i.e., practicing doctors in the near future, will have to interact with people from all walks of life. Therefore, they must develop and enhance their nutrition literacy to provide proper service to the community [37]. In this systematic review, the COSMIN checklist provided information about the quality of the 15 selected studies, such that twelve studies rated good and the remaining three studies rated poor, as they received a positive score in only one area. Furthermore, in most of the studies, both the predictive validity and concurrent validity of the criteria were strong. According to literature, the COSMIN checklist is a standardized instrument used to assess the methodological quality of studies based on measurement properties [38-40]. This article is the first review to assess nutrition literacy among medical students. Evaluating the quality of the articles using the standard method and adhering to the PRISMA guidelines positively affected the reliability of the study results. As for the current study’s limitations, the cause of high or low nutrition literacy and health knowledge could not be investigated because most of the studies were cross-sectional. Presenting prospective studies can help better understand the causes. Another limitation was that there were many differences in the methods used to measure nutrition literacy. However, the researchers responsible for article selection tried to carefully select the articles based on the inclusion and exclusion criteria and the purpose of the research. In addition, the included studies were limited to those published in English. Therefore, research theses and articles in other languages were not reviewed. Most of the reviewed articles had focused on nutrition knowledge and attitude. Therefore, further studies aimed at assessing nutrition literacy are necessary. Medical students’ academic years provide an excellent opportunity for learning and increasing nutrition literacy. To better understand food literacy in the studied community and determine the effective factors, longitudinal studies can be conducted to determine food behaviors among health workers. Conclusion Medical students have a low to moderate level of nutrition literacy. Moreover, many of these students have insufficient nutrition knowledge. Acknowledgements: We are very grateful to everyone who contributed to this project. Ethical Permission: Not applicable. Conflict of Interests: No conflict of interest was reported in this study. Authors’ Contribution: Ramezankhani A (First Author), Introduction Writer/Methodologist/Discussion Writer (50%); Vahidi Sh (Second Author), Introduction Writer/Methodologist/Discussion Writer (50%) Funding: No organization funded this research. | ||
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