The Effects of Nutrition Literacy Assessment on Patient-Centered Nutrition Interventions Provided by Dietitians
Marchello, Nicholas Jason
University of Kansas
Dietetics & Nutrition
Copyright held by the author.
MetadataShow full item record
Introduction: Nutrition literacy is a distinct subset of health literacy, a leading contributor to negative health outcomes. Nutrition literacy involves aspects of functional literacy (nutrition knowledge) and integrative literacy (how to use that knowledge to make everyday decisions around diet). While several tools exist to objectively measure nutrition literacy, there is no evidence that nutrition literacy assessment occurs in everyday outpatient clinical practice amongst registered dietitians (RD), and what barriers may exist to implementing such assessments into everyday practice. There is also no evidence whether using such assessments could aid RDs in providing patient-centered nutrition interventions that improve nutrition literacy deficits and diet patterns. The purpose of this study was to examine how RDs currently assess patients for nutrition literacy, what barriers exist in outpatient clinics to implementing such assessments into practice, and whether such assessments can help create tailored, patient-centered nutrition interventions that help patients improve nutrition literacy deficits and improve diet behaviors. Methods: Three phases of this pilot study were conducted to answer the research questions of this dissertation. First, 28 outpatient clinical RDs and 7 outpatient clinic managers were interviewed, using semi-structured interviews, to examine current assessment methods for health and nutrition literacy, as well as barriers and possible solutions to implementing a short nutrition literacy survey into outpatient clinical use. Second, 6 outpatient clinics and their dietitians were recruited to participate in a randomized controlled trial involving nutrition literacy assessment and patient-centered nutrition interventions. Clinics were randomized in a 2:1 intervention-control fashion. All participating RDs were trained extensively in health literacy, patient-centered communication techniques, and teach-back methods. Each clinic recruited 17-19 patients, all of whom were scheduled for a nutrition session with a participating RD. Due to difficulties maintaining active participation among RDs, we altered our randomization to a 3:2 intervention/control design, with one intervention clinic oversampling to compensate for a lack of a fourth intervention clinic. Prior to their session, all participants completed the Nutrition Literacy Assessment Instrument (NLit), a 42-question assessment of nutrition literacy divided into 6 subscales. All participants also completed the Rapid Eating Assessment of Patients (REAP) and the Behavioral Risk Factor Surveillance System (BRFSS) 2011 Fruit and Vegetable Module, two short screeners of dietary intake. Intervention-arm RDs received global and subscale data from the NLit, and focused interventions towards nutrition literacy deficits; control-arm RDs did not receive these data, and provided standard interventions. All RDs recorded nutrition interventions with participants, which were then analyzed by study personnel for teach-back usage utilizing the Teach-back Loop Score, a new method of assessing the success of teach-back techniques. One-month post-intervention, all participants again completed the NLit and the two diet screeners, as well as a patient satisfaction survey based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, developed by the Agency for Healthcare Research and Quality. Handouts typically used by RDs in normal counseling sessions were analyzed for readability using three methods: the Flesch Reading Ease Score, the Flesch-Kincaid Reading Level, and the CDC Clear Communications Index. Lastly, the four RDs who participated in the intervention arm of the randomized controlled trial were interviewed, using semi-structured interviews, on how using nutrition literacy assessments affected nutrition interventions, and what could be improved around these assessments to improve feasibility of implementation into everyday clinical use. Results: No RDs (n=28) stated using any objective assessments of health or nutrition literacy in everyday practice; instead, RDs stated they use subjective methods to assess for health and nutrition literacy. Multiple barriers to implementation, such as length of the assessment, completion rates of paperwork by patients, and support from clinic administration, were discussed. There were no differences between-arms (n=34 for control, n=60 for intervention) at baseline (p=0.30), post-intervention (p=0.34), or change (p=0.82) of NLit global scores; however, the intervention arm displayed significant improvements in global NLit score (p=0.03) and Household Food Measurement (p=0.05). There were no differences between-arms at baseline, post-intervention, or change for all NLit subscale scores, except for Consumer Skills, where control participants had a significant improvement in score (p=0.05) when compared to intervention participants. By study end, both control and intervention arms improved in global NLit category (p=0.02 and p=0.01, respectively). No significant differences between-arms or within-arms for subscale NLit categories were found. There was no relationship between randomization arm and change in NLit global score (p=0.89). Intervention RDs completed more successful Teach-back loops than control RDs (p=0.05). Intervention RDs outperformed control RDs in using simpler language (95.0% vs 87.9% of respondents) and performing teach-back (85.9% vs 76.7%); however, there were no significant differences between-arms in any category. There were no significant correlations between patient satisfaction and randomization arm (p=0.99), global NLit score at baseline (p=0.07) or change in global NLit score post-intervention (p=0.34). Overall, there was no significant difference between control and intervention arms in Flesch Reading Ease (66.53 vs. 66.20, p=0.7) and Flesch-Kincaid Reading Level (7.03 vs. 6.28, p=0.4) for handouts. However, the control arm scored significantly lower on the Clear Communications Index than the intervention arm (62.50 vs. 78.25, p=0.04). For REAP results post-intervention, intervention-arm participants reported significant differences from control-arm participants in the frequency of dining out (p=0.01) and eating full-fat dressings and mayonnaise (p=0.05),with trending significant differences in frequency of eating fried foods (p=0.07) and sweets 2 times/day (p=0.09). Within-arm analysis showed intervention-arm participants improved in 16 of 25 diet-related categories. For BRFSS data, intervention-arm participants reported higher consumption of whole fruit (p=0.02) and beans (p=0.01) than control participants post-intervention. Both arms improved in green vegetable consumption (p=0.05 for intervention, p=0.08 for control) by study end. All four intervention-arm RDs felt the NLit was appropriate for assessing nutrition literacy in their patient populations, and aided in focusing nutrition interventions towards literacy weaknesses. Several barriers to permanent implementation were discussed as well. Conclusions: While objective assessments to examine patient nutrition literacy are not commonly used by RDs, such assessments are feasible, and can help RDs better tailor nutrition interventions towards nutrition literacy deficits. These personalized, patient-centered interventions help foster positive diet behavior improvements. Future studies around nutrition literacy assessments in clinical practice should include assessing objective markers for diet-related chronic disease, such as cholesterol levels or fasting blood glucose.
- Dissertations 
Items in KU ScholarWorks are protected by copyright, with all rights reserved, unless otherwise indicated.
We want to hear from you! Please share your stories about how Open Access to this item benefits YOU.