Health literacy, self-efficacy, food label use, and diet in young adults.

Young adulthood is an important transition period during which long-term health behavior patterns are established.1 Failure to form positive health behavior habits during this period makes young adults vulnerable to poor health outcomes and many chronic disorders later in life.1, 2 For instance, physical inactivity and unhealthy eating result in obesity which in turn increases the risk for developing Type 2 diabetes (T2D).2, 3 Young adults who develop T2D early are more likely to have a longer-term risk for poor glycemic control and they are at greater risk for developing diabetes complications than those with late-onset T2D.4 Over the last 4 decades, the prevalence of obese young adults has increased from 8% in 1971-1974 to 32.6% in 2009-2010.5 One of the important contributors to this trend is young adults’ eating habits.6, 7 Young adults are major consumers of fast food, soft drinks and “Fourth meal (the meal between dinner and breakfast)”.1 They consume less fruit, vegetables, milk, and more salty snacks than as children. Also, they eat almost the same foods everyday, which may lead to excesses or deficiencies of certain nutrients.1 Thus, their reported dietary quality is often very poor.1, 6, 7 Effective public health initiatives and/or behavioral interventions to promote healthy eating are necessary to prevent obesity and early onset T2D. 8, 9 In the US, dietary guidelines and food labels are available to help people select healthier food.8, 10, 11 In particular, food labels based on the dietary guidelines are mandatory on all pre-packaged foods.9, 12 However, this policy is only effective when people read food labels on pre-packaged food, accurately understand and effectively utilize these labels to select healthier choices. Research shows that attitude, previous nutrition education, socio-demographic factors (eg, age, sex) are significant predictors of food label use behavior.13, 14 For instance, college men chose food without reading nutrition facts on the label as they regarded this action as feminine.13 Not having received previous education on how to use food labels was also a predictor of less frequent usage of food labels.14, 15 A study conducted with American adolescents found that about three-quarters of adolescents read food labels “always” or “sometimes”, but doing so did not affect their food choices.9, 16 However, studies with European Union (EU) adults showed different findings. About a quarter of people (27.0%) read food labels and it increased their selection of healthier food.8 Although different populations (adults vs. adolescents) may account for the differences in these findings, labeling methods may also contribute to the differences. While the U.S. has nutrition facts, the E.U. uses the Choices logo (eg, smart choice) and traffic light labeling.8, 9 Thus, Americans require sufficient numeracy and literacy skills to appropriately understand and utilize nutrition fact label information. Europeans, on the other hand, only need to understand the meanings of colors (traffic light color system) or logos (Choices logos) to select healthier food choices. Different type and level of health literacy may be a significant factor in food label use behavior and its impact on dietary quality. Health literacy refers to an individuals’ capability to obtain and understand health information to make appropriate health-related decisions.17, 18 Not surprisingly, low health literacy is related to poor clinical outcomes. Sufficient health literacy is the key to improving treatment regimen adherence.17 As briefly addressed above, the US nutrition labels contain serving size, calories per serving, nutrient information, and percent of daily value based on 2000 Kcal diet on each packaged food item and a foot note on recommended daily value and ingredients in a block text.10 Therefore, Americans who are required to follow dietary regimens need to know their individual dietary recommendation based on their sex, age, physical activity level, first. Then, they must have appropriate literacy and numeracy skills to understand and recalculate the food label information presented. In addition, appropriate portion size estimation skills are necessary to follow and achieve dietary goals. Thus, it is important to identify the relationship between health literacy with food labels and food label use behaviors to design a nutrition education program to facilitate healthy eating in American young adults. Although health literacy plays an important role in making informed decisions and behavioral changes, health behaviors are also influenced by psychosocial attributes, such as self-efficacy.1 Self-efficacy differs from wishful thinking in that it refers to individuals’ beliefs in their capabilities to perform a specific behavior in diverse situations.19, 20 People with higher self-efficacy are more likely to make necessary efforts to attain a desirable outcome despite barriers, and in less than ideal circumstances.21, 22 For instance, people with high self-efficacy were more likely to actively engage in healthy diets for weight loss than people with low self-efficacy.23 Therefore, successful past experiences coupled with knowledge and skills are major contributors to increased self-efficacy.22 Studies have emphasized the significance of dietary quality in preventing obesity and T2D, which are growing public health concerns for American young adults.11, 24, 25 Therefore, specific strategies to improve dietary quality for this age group should be developed. However, this population has been understudied.1, 26 Traditionally, young adults are considered a healthy population who need little attention from researchers and clinicians.1, 27 To reduce this scientific gap, this study examined relationships between health literacy and eating behavior self-efficacy, food label use behavior, and dietary quality in American overweight obese young adults using path analyses. The hypotheses were: 1) sufficient health literacy will increase eating behavior self-efficacy and food label use behavior as well as improve dietary quality; 2) higher eating behavior self-efficacy will increase food label use behavior and improve dietary quality; and 3) frequent food label use behaviors will improve dietary quality. The obtained information will help researchers and clinicians to develop an effective behavioral intervention for American young adults who need immediate help to improve their dietary quality in order to reduce their weights and health risk in the future.