Health LiteracyAssociation between health literacy and child and adolescent obesity
Introduction
Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” [1]. The concept of health literacy encompasses a variety of factors, including but not limited to individual cognitive capacities, communication skill, decision-making capacity, cultural/social/policy influences, and the context in which interactions with a health system occur [2], [3], [4]. However, most attempts to measure health literacy have been limited to capturing “functional health literacy” including specific skills such as reading comprehension and numeracy or the capability to perform mathematical computations required to manage one's health [5].
Numerous studies have demonstrated the association between better functional health literacy (FHL) and better health outcomes in adults [6], [7], [8], [9], [10], [11]. Fewer studies are available in pediatrics, but those that do exist demonstrate an association between low FHL amongst parents and more medication dosing errors [12], worse asthma care [13], and worse glycemic control in children with type 1 diabetes [14].
While the decisions of parents affect child health outcomes, children can also be in a position to influence their own health, particularly within the context of chronic diseases such as asthma and diabetes. Children as young as 4 years have been reported to be involved in their own self-care [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. In one study, 4- to 6-year-old children understood that they required low sugar diets, and that insulin was needed to convert sugar into energy [17]; in another, children aged 9–12 years read carbohydrate details on food labels and regulated insulin doses to match their energy needs [18]. Within the context of child obesity, children regularly have the opportunity to make independent decisions about their food consumption; we know that school-aged children eat almost half their meals in school [27] and are targeted by advertising via vending machines and snack bars [28].
In a previously published study amongst overweight children, we reported a relationship between a child's own FHL and his or her body mass index [BMI). Using the Short Test of Functional Health Literacy in Adults (STOFHLA) and regression analysis adjusting for parental literacy and BMI, we found that child FHL was independently and inversely associated with child BMI Z score [29]. To our knowledge, no other investigators have reported on the relationship between a child's own FHL and obesity; hence, we sought to test this relationship again in a more general population. Because parent vs. child's influence on health-related decision-making likely varies as children advance through the cognitive stages from childhood through adolescence, we hypothesized that parental FHL would be a driver for obesity in school-aged children, while adolescent FHL would drive obesity amongst adolescents.
Section snippets
Methods
We conducted an anonymous cross-sectional survey of a convenience sample of parent-child dyads in the outpatient waiting rooms of urban pediatric primary and subspecialty care clinics of an academic children's hospital. Clinics were either hospital-based or at one of two primary care sites (Wilmington, DE, and Philadelphia, PA). Children meeting the following inclusion criteria were enrolled: aged 7–19, accompanied by a legal guardian who is also a biological parent, and parent and child speak
Demographic characteristics
We surveyed 239 child-parent dyads. Median (IQR) child BMI percentile was 82 (55–95); 65 (27%) were obese. Median (IQR) parent BMI was 27.5 [23], [24], [25], [26], [27], [28], [29], [30], [31], [32]; 85 (35%) were obese. As expected for a sample recruited in a health care setting, the prevalence of obesity in this sample is higher than national averages and slightly higher than average for the Philadelphia, PA, and Wilmington, DE, where subjects were recruited. The median age of children was 11
Discussion
Consistent with our hypothesis, parent and child FHL had a differential effect on child obesity for school-aged children vs. adolescents. In concordance with what we know from clinical practice, we found that child obesity in school-aged children is most associated with parental factors (parent obesity and parental health literacy). For adolescents, we found that adolescent obesity was strongly associated with the adolescent's own FHL. These findings, along with several other interesting
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