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Abstract

BACKGROUND:

A healthy and quality lifestyle is built upon the fundamental pillars of healthy nutrition, quality sleep, physical activity, and stress management.

OBJECTIVE:

This study was conducted to examine the attitudes towards healthy eating and nutrition literacy knowledge levels of university students who have received health education.

METHODS:

The study sample consisted of 295 students who were studying in the field of health sciences. The study includes questions from three separate sections. The first section contains a socio-demographic characteristics form, the second section contains the Healthy Nutrition Attitude Scale (ASHN), and the third section contains the Nutrition Literacy Scala (NLS).

RESULTS:

The mean ASHN score of our study was 71.38±11.7, while the mean NLS score was 19.80±4.2. When our scale scores were categorized, the ASHN score was found to be high, while the NLS score was borderline. A positive significant relationship was found between the scale score averages of ASHN and NLS. As students’ scores on healthy eating attitudes increase, it has been observed that their nutrition literacy scores also increase.

CONCLUSIONS:

We can say that health education is important in developing healthy eating habits among university students.

Keywords

Healthy nutrition nutrition literacy university students

1 Introduction

Nutrition, which is one of the most basic needs of human beings, is a conscious behavior that needs to be done to maintain, improve health and increase the quality of life by consuming sufficient amounts of nutrients that the body requires at appropriate times [1]. A healthy and quality lifestyle is built upon the fundamental pillars of healthy nutrition, quality sleep, physical activity, and stress management. An individual’s attitude is manifested through their cognitive, emotional, and behavioral actions towards a fact, case, or situation [2].

Attitude towards healthy eating encompasses an individual’s feelings, thoughts, and behaviors related to balanced and adequate nutrition. Attitude towards healthy eating can be formed positively or negatively. Considering the relationship between attitudes and behaviors, it is likely that developing a positive attitude towards healthy eating will lead individuals towards healthy eating behavior [3].

Nutrition knowledge is one of the factors that affects the nutrition status and habits of individuals and societies. Taking care of one’s own health and developing health awareness can be effective in maintaining and improving health. Therefore, nutrition education and promoting awareness of healthy eating are crucial in preventing imbalanced nutrition [4]. Although lifestyle behaviors and health outcomes are linked to low health literacy, no study has focused on the role of health literacy in nutrition behaviors or diet outcomes. However, there are numerous studies supporting the importance of health literacy in the treatment and management of nutrition-related diseases such as diabetes, hypertension, cardiovascular diseases, and cancer [5, 6]. Nutrition literacy is defined as the capacity of an individual to access, understand, interpret, and apply basic nutrition knowledge and services that can improve their health [7].

Adoption of healthy eating behavior and habits, determination of the community’s level of nutrition literacy, and raising this level are necessary for minimizing nutrition-related problems that affect life and preventing nutrition-related diseases [8]. This study was conducted to examine the attitudes towards healthy eating and nutrition literacy knowledge levels of university students who have received health education.

2 Materials and methods

2.1 Research design

The data was collected via an online survey form created on Google Forms between March and June 2022. The population of the study was composed of students studying in faculty of health sciences. However, due to reasons such as students not wanting to participate in the survey and the presence of unreachable students, the research was completed with 295 students who are enrolled in the faculty of health sciences

2.2 Ethical approval

Ethics approval (Decision No: E.39800) was received from Artvin Coruh University Non-Interventional Clinical Research Ethics Committee dated 17.02.2022.

2.3 Collection of data

The study includes questions from three separate sections. The first section contains a socio-demographic characteristics form, the second section contains the Healthy Nutrition Attitude Scale (ASHN), and the third section contains the Nutrition Literacy Scale (NLS).

The Nutrition Literacy Scale (NLS) for Adults, developed by Cesur et al., [8] consists of a total of 35 questions. The scale has five subscales: General Nutrition Knowledge, Reading Comprehension, Food Groups, Portion Sizes, and Food Label Reading and Numeracy. For scoring, each correctly answered question is given 1 point, while incorrectly answered or unanswered questions are given 0 points. The total score ranges from 0 to 35, with scores of 0–11 indicating inadequate, scores of 12–23 indicating borderline, and scores of 24–35 indicating sufficient level of nutrition literacy.

The ASHN scale developed by Tekkursun-Demir and Cicioglu [9] consists of four subscales. The first factor consists of questions that assess knowledge about nutrition, the second factor assesses attitudes towards nutrition, the third factor assesses positive nutrition behaviors, and the fourth factor assesses negative nutrition behaviors. The scale consists of a total of 21 items, with 10 questions being positive attitude items and 11 questions being negative attitude items. The rating scale for positive attitude items is “Strongly Disagree”, “Disagree”, “Undecided”, “Agree”, and “Strongly Agree”. Positive attitude items are scored from 1 to 5, while negative attitude items are scored from 5 to 1. The lowest possible score that can be obtained from the scale is 21, and the highest score is 105. When the scale score is categorized, a score of 21 indicates a very low level, a score of 23–42 indicates a low level, a score of 43–63 indicates a moderate level, a score of 64–84 indicates a high level, and a score of 85–110 indicates an ideal level of positive attitude towards healthy eating.

2.4 Statistical analysis

Statistical analyses were performed using the ‘SPSS Statistics 26’ package program. After normality analysis with the Kolmogorov-Smirnov test, descriptive statistics including the number, percentage, minimum, maximum, mean, and standard deviation were reported. Independent samples t-test and one-way ANOVA were used in comparative analyses. Pearson correlation analysis was used to evaluate the relationship between two variables. A p-value less than 0.05 was considered statistically significant in the data evaluation.

3 Results

As seen in Table 1, 64.7% of the participants reported their economic situation as good/moderate, while 35.3% reported it as poor/very poor. Approximately 83.7% of the participants were female. 52.2% of the participants reported having received nutrition education before. When we categorize the scores of the Healthy Nutrition Attitude Scale (ASHN), none of our participants received very low or low scores. This finding may be due to the fact that our participants have studied in schools that provide health education. This finding demonstrates that participants have understood the importance of the relationship between nutrition and health in line with the education they have received. Although the percentage of individuals showing a high level of attitude towards healthy eating is 61.4% and the percentage of individuals showing an ideal level of high attitude is approximately 14%, individuals with sufficient level of nutrition literacy according to the Nutrition Literacy Scale (NLS) form, make up 19.3% of all participants.

Table 1
Frequency analysis of participants’ demographic characteristics

n %

Economic status

Good/moderate 191 64.7

Poor/very poor 104 35.3

Gender

Female 247 83.7

Male 48 16.3

Presence of chronic illness

Yes 41 13.9

No 254 86.1

Nutrition education

Yes 154 52.2

No 141 47.8

Do they exercise regularly?

Yes 36 12.2

No 259 87.8

Self-assessment of weight

Underweight 63 21.4

Ideal weight 149 50.5

Overweight 83 28.1

ASHN score

Very low 0 0

Low 0 0

Moderate 73 24.7

High 181 61.4

Optimally high 41 13.9

NLS score

Insufficient 18 6.1

Borderline 220 74.6

Sufficient 57 19.3

	n	%
Economic status
Good/moderate	191	64.7
Poor/very poor	104	35.3
Gender
Female	247	83.7
Male	48	16.3
Presence of chronic illness
Yes	41	13.9
No	254	86.1
Nutrition education
Yes	154	52.2
No	141	47.8
Do they exercise regularly?
Yes	36	12.2
No	259	87.8
Self-assessment of weight
Underweight	63	21.4
Ideal weight	149	50.5
Overweight	83	28.1
ASHN score
Very low	0	0
Low	0	0
Moderate	73	24.7
High	181	61.4
Optimally high	41	13.9
NLS score
Insufficient	18	6.1
Borderline	220	74.6
Sufficient	57	19.3

Abbrevations: BMI; body mass index, ASHN; Healthy Nutrition Attitude Scale, NLS; Nutrition Literacy Scala.

Table 2 presents the minimum, maximum, mean, standard deviation, skewness, and kurtosis values for the ASHN and NLS scores. As shown in Table 2, the mean ASHN score of our study was 71.38±11.7, while the mean NLS score was 19.80±4.2. When our scale scores were categorized, the ASHN score was found to be high, while the NLS score was borderline. As a result, we observed that although the majority of our participants who received health education in schools were aware of the importance of nutrition for health, they were inadequate in terms of nutrition literacy.

Table 2

Evaluation of ASHN and NLS scale scores

	n	min.	max.	$\bar{x}$	SD	1	2	Skewness	Kurtosis
1. ASHN	295	40	103	71.38	11.7	1	.377*	–.036	–.236
2. NLS	295	6	27	19.80	4.2	1		–.008	–.222

Abbrevations: ASHN; Healthy Nutrition Attitude Scale, NLS; Nutrition Literacy Scala, SD; Standart deviations, *p < 0.001.

As seen in Table 2, a positive correlation was found to be statistically significant (p < 0.001) between the scores obtained from ASHN and NLS scales. As the attitude towards healthy eating increases, so does the level of nutrition literacy. It can be concluded that individuals who are aware of the importance of healthy eating also have a higher level of nutrition knowledge.

As seen in Table 3, individuals with good/moderate economic status had higher ASHN scores (p < 0.05) and NLS scores (p < 0.01) compared to those with poor/very poor economic status. This finding indicates that individuals with a higher economic status place more importance on healthy nutrition and have a higher level of nutrition literacy.

Table 3

The comparison of ASHN and NLS levels in different groups

	$\bar{x}$ /SD	$\bar{x}$ /SD	p
Levels of ASHN and NLS in different economic status groups
	Good/Moderate	Poor/Very poor
ASHN	72.55±11.4	69.22±12.1	.019*
NLS	20.27±4.1	18.93±4.4	.009**
ASHN and NLS levels in females and males
	Female	Male
ASHN	71.73±12.04	69.58±9.91	.190
NLS	20.16±4.07	17.96±4.58	.001**
The relationship between the presence/absence of chronic disease and levels of ASHN
and NLS
	Yes	No
ASHN	74.24±10.3	70.92±11.9	.065
NLS	21.07±4.4	19.59±4.2	.037*
The levels of ASHN and NLS in the group that received nutrition education and the group that did not receive it
	Yes	No
ASHN	75.10±11.6	67.31±10.5	.000***
NLS	21.31±3.5	18.15±4.4	.000***
The levels of ASHN and NLS in the group that regularly exercises and the group that
does not exercise
	Yes	No
ASHN	74.78±12.4	70.91±11.6	.063
NLS	20.78±4.2	19.67±4.2	.139

Abbrevations: ASHN; Score of Healthy Eating Attitude Scale, NLS; Nutrition Literacy Scala, $\bar{x}$ ; mean, SD; standard deviation, p; significance level, *p < 0.05, **p < 0.01, ***p < 0.001.

In our study, there was no statistically significant difference in ASHN scores between female participants (71.73±12.04) and male participants (69.58±9.91). However, the nutrition literacy level of female participants (20.16±4.07) was significantly higher (p < 0.01) than that of male participants (17.96±4.58). In our study, participants with chronic diseases had higher ASHN and NLS scores than those without any diseases, and the difference in NLS scores was statistically significant (p < 0.05). Chronic diseases are conditions that require individuals to maintain daily activities such as nutrition, sleep, exercise, and excretion in a certain order. The results of our study indicate that individuals with chronic diseases understand the importance of nutrition and have a higher level of knowledge about nutrition.

In this study conducted with individuals studying in the field of health sciences, participants who received nutrition education were found to have significantly higher attitudes and knowledge about nutrition compared to those who did not receive nutrition education (p < 0.001). This result indicates that nutrition education provided in educational institutions has a positive effect on individuals’ nutrition behavior.

Another finding of our study is that although not statistically significant, the attitudes towards healthy eating of individuals who exercise were higher compared to those who do not exercise. However, when it comes to nutrition literacy, there was no difference between individuals who exercise and those who do not. This finding suggests that individuals who exercise know the importance of nutrition but may not have basic nutrition knowledge or literacy. As seen in Table 4, there was no significant difference in ASHN and NLS scores among the underweight, normal weight, and overweight groups.

Table 4

Comparison of ASHN and NLS averages in groups where the individual evaluates his/her own weight

	Underweight (63)	Normal Weight (149)	Overweight (83)
	$\bar{x}$ ±SD	$\bar{x}$ ±SD	$\bar{x}$ ±SD	Significance
ASHN	70.32±12.9	71.64±11.6	71.71±11.1	F:.328
				p:.721
NLS	20.27±4.1	19.26±4.5	20.41±3.7	F:2.486
				p:.085

Abbrevations: ASHN; Score of Healthy Eating Attitude Scale, NLS; Nutrition Literacy Scala, p; significance level.

4 Discussion

In this study conducted to evaluate the healthy eating attitudes and nutrition literacy of university students studying in the field of health, it was found that the ASHN score was high and the NLS score was borderline. However, a positive significant relationship was found between the scale score averages of ASHN and NLS in the study. In other words, an increase in the scores related to healthy eating attitudes of students leads to an increase in their nutrition literacy scores. In the study conducted by Ozenoglu et al., [10] when the ASHN score was evaluated by gender, it was found that women’s ASHN score was higher than men’s score. The authors stated that the reason for this is that women are responsible for the nutrition of the whole family, especially children, in society, and therefore have a higher tendency to access and apply more accurate information on healthy eating.

In the study conducted by Manippa et al., [11] it was found that female participants scored higher on the nutrition behavior test than male participants. In another study conducted by Ree et al., [12] it was reported that women placed more importance on healthy eating than male participants. In a study conducted by Gonen & Ceyhan [3] on students studying at the Faculty of Sports Sciences, it was found that the ASHN scores showed a significant difference according to gender. In contrast to the literature, our study did not find a statistically significant difference between ASHN scores among men and women. This can be attributed to the fact that our study group consisted of students receiving health education. It is possible to think of nutrition literacy as a method or process that enables individuals to access nutrition information and make sense of the information obtained. In the study conducted by Arslan & Mertoglu, [13] it was found that the level of nutrition literacy was high. The development of nutrition literacy is an important factor in ensuring proper food selection and a healthy dietary pattern. In the study conducted by Taylor et al., [7] it was reported that individuals with low levels of nutrition literacy consumed more foods associated with a Western-style diet, while individuals with good nutrition literacy tended to choose more foods specific to the Mediterranean diet. When evaluating our study results, nutrition literacy was found to be borderline.

In studies conducted on nutrition literacy in the literature, it has been observed that the average score of nutrition literacy is significantly higher in women than in men [14, 15]. Ozupek & Arslan [16] stated in their study on university students that the proportion of women with sufficient nutrition literacy level was higher than that of male students. When we compared nutrition literacy by gender in our study, it was found that women’s nutrition literacy was significantly higher than men’s. Considering both the literature and our study results, this difference between genders can be explained by the fact that women attach more importance to factors such as their appearance, weight loss, and body image, and pay more attention to nutrition knowledge.

Nutrition literacy is influenced by sociodemographic characteristics such as gender, age, education level, socioeconomic status, and dietary habits [17 –19]. With globalization, the speed of spread of diseases and the number of individuals with chronic illnesses is rapidly increasing. To achieve the targeted level of quality of life and to protect health worldwide, it is necessary to increase the awareness of nutrition among individuals and society. Increasing this awareness is directly related to acquiring sufficient and balanced nutritional habits and increasing the level of nutrition literacy [20, 21]. In our study, individuals with good/medium economic status had higher nutrition literacy scores compared to those with poor/very poor economic status. This finding indicates that individuals with a better economic status prioritize healthy eating and have higher levels of nutrition literacy.

Chronic diseases are illnesses that require individuals to maintain daily life activities such as nutrition, sleep, movement, and elimination in a certain order. In our study, the NLS scores of individuals with chronic diseases were found to be significantly higher than those without any diseases. Our findings suggest that individuals with chronic diseases have a better understanding of the importance of nutrition and have a higher level of knowledge about nutrition. Quality of life is an important issue for every risk group in society, including university students. Living away from their families, changes in their psychological state and social environment, their economic situation, and their access to nutritious and regular meals can all create significant problems for students. In addition to these issues, a lack of sufficient knowledge about nutrition literacy among students can also lead to a decrease in their quality of life [22, 23]. Individuals educational status or having a profession in the field of health can positively affect their level of nutrition literacy [7, 24]. In this study with individuals studying in the field of health sciences, it was found that the attitudes towards nutrition, nutrition knowledge, and nutrition literacy were significantly higher in students who received nutrition education compared to those who did not receive nutrition education. This result shows that nutrition education provided in educational institutions has a positive effect on individuals’ nutrition behavior. In the study conducted by Ozupek & Arslan [16] among nutrition and dietetics students, the highest level of nutrition literacy was observed in individuals classified as underweight according to BMI. In contrast to the literature results, our study found no significant difference in NLS scores between underweight, normal weight, and overweight groups. In a study conducted by Zoellner et al., [25] similar results were obtained, and no relationship was found between nutritional literacy scores and BMI. Zoellner et al., have suggested that the reason for obtaining such a result in their study is because people generally tend to be dishonest about their weight information. There may be different reasons for not finding a statistically significant difference between NLS and self-evaluation of people’s weight in our study. Even if an individual has a high level of nutritional literacy, they might still struggle to put that knowledge into practice. In other words, despite having good nutritional knowledge, the person may choose to consume high-calorie and processed foods instead of opting for low-calorie and nutritious options. In such cases, it is possible that there is no correlation between the NLS and the individual’s self-assessment of weight.

5 Conclusions

Not making the right food choices during university years can lead individuals to inadequate and imbalanced nutrition. Especially during the most important and productive period of their lives, it is necessary for students to have sufficient knowledge, attitude and skills in nutrition literacy to create a positive attitude towards healthy food choices and awareness of healthy eating. The study can also involve collecting data on the factors that influence the attitudes and nutritional literacy of students towards healthy nutrition. Factors such as socio-economic status, cultural beliefs, and access to healthy food can affect the attitudes and nutritional literacy of students. The findings can help policymakers in developing policies and strategies aimed at promoting healthy eating habits among young people. Providing education on health, nutrition, and nutrition literacy should be a priority for university students.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

The authors report no funding.

References

Kılıncarslan

, Bayrakdar

, Avcı

. Investigation of the healthy nutrition attitudes of students in the field of physical education and medicine. UGEAD. 2022;8(1):44–56.

Kose

, Tayfur

. BMI, Physical Activity, Sleep Quality, Eating Attitudes, Emotions: Which One is Affected by Mindful Eating? BMI, Physical Activity, Mindful Eating. Progr Nutr [Internet]. 2021;23(1):e2021002.

Gonen

, Ceyhan

. The relationship between the attitudes of students of the faculty of sports sciences towards healthy nutrition and their self-esteem. IJOESS. 2022;13(48):625–37.

, Wang

, Shi

, et al. Awareness of nutrition and health knowledge and its influencing factors among Wuhan residents. Front Public Health. 2022;10:987755.

Agralı

, Akyar

. Turkish validation and reliability of health literacy scale for diabetic patient. ACU Sağlık Bil Derg. 2018;9(3):314–21.

Oncu

, Vayısoglu

, Guven

, et al. Evaluation of Chronic Disease Management in Individuals with Hypertension and Its Relationship with Health Literacy. Anatol JFM. 2018;1:31–2.

Taylor

, Sullivan

, Ellerbeck

, et al. Nutrition literacy predicts adherence to healthy/unhealthy diet patterns in adults with a nutrition-related chronic condition. Public Health Nutr. 2019;22(12):2157–69.

Cesur

, Kocoglu

, Sumer

. Evaluation instrument of nutrition literacy on adults (EINLA) A validity and reliability study. Integr Food Nutr Metab. 2015;2(3):174–7.

Tekkursun Demir

, Cicioglu

. Attitude Scale for Healthy Nutrition (ASHN): Validity and Reliability Study. Gaziantep Uni J Sport Sci. 2019;4(2):256–74.

10.

Ozenoglu

, Cevik

, Colak

, et al. Changes in nutrition and lifestyle habits during the COVID-19 pandemic in Turkey and the effects of healthy eating attitudes. Mediterranean J Nutr Metabolism. 2021;14(3):325–41.

11.

Manippa

, Padulo

, van der Laan

, et al. Gender differences in food choice: effects of superior temporal sulcus stimulation. Front Hum Neurosci. 2017;11:597.

12.

Ree

, Riediger

, Moghadasian

. Factors affecting food selection in Canadian population. Eur J Clin Nutr. 2008;62(11):1255–62.

13.

Arslan

, Mertoglu

. The relationship between nutrition literacy levels and media literacy levels of university students. JSES. 2022;(01):271–80.

14.

Michou

, Panagiotakos

, Lionis

, et al. Health and nutrition literacy levels in Greek adults with chronic disease. Public Health Panorama. 2019;5(2-3):123–329.

15.

Cesur

, Sumer

. Nutrition literacy status of adults residing in Sivas province and its relationship with quality of life: A cross-sectional study from Turkey. IJMHS. 2018;8(1):1–9.

16.

Ozupek

, Arslan

. Evaluation of the Relationship Between Popular Diet Practice, Nutrition Literacy and Body Mass Index: A Study on Nutrition and Dietetics Students. Turk J Diab Obes. 2021;3:340–50.

17.

Uysal

, Ceylan

, Koc

. Health literacy level and influencing factors in university students. Health Soc Care Community. 2020;28(2):505–11.

18.

Rochman

, Nasrudin

, Helsy

, et al. Nutrition literacy program for ımproving public wellness. J Phys Conf Ser. 1028;1028:012031.

19.

Pakseresht

, Rezaei

, Pasha

, et al. Health promoting lifestyle among students at Guilan University of Medical Sciences. J Holist Nurs. 2017;27(1):19–26.

20.

Chandrasekara

, Jayasinghe

. Nutrition Literacy for Human Health: A Review on Current Global and Sri Lankan Scenario. Vavuniya J Sci. 2022;1(2):27–42.

21.

Viola

, Bianchi

, Croce

, et al. Are Food Labels Effective as a Means of Health Prevention? J Public Health Res. 2016;5(3):768.

22.

Erem

, Bektas

. Is nutritional literacy level in young adults associated with quality of life? Food and Health. 2023;9(2):129–38.

23.

Onurlubas

, Dogan

, Demirkıran

. Diatery Habits of College Student. JAFAG. 2015;32(3):61–9.

24.

Hoseini

, Hoseini

. Investigating nutritional literacy of male student athletes contributed in Iran university games. J Health Literacy. 2019;4(1):53–9.

25.

Zoellner

, Connell

, Bounds

, Crook

, Yadrick

. Nutrition Literacy Status and Preferred Nutrition Communication Channels Among Adults in the Lower Mississippi Delta. Prev Chronic Dis. 2009;6(4):1–11.

Investigation of the healthy nutrition attitude and nutritional literacy level of university students receiving health education