Health Literacy and Obesogenic Behaviors (HL-Squared)

Health Literacy as a Vehicle to Reduce Obesogenic Behaviors Among Adolescents: A Pilot Intervention

The prevalence of adolescent behaviors that can lead to obesity are alarming, and reduced life expectancy is the future of America's youth if behavioral changes are not implemented to improve health and reduce the obesity burden. Researchers have argued that health literacy is a precursor to health knowledge and is necessary for translating knowledge about healthy choices into behavior, with low health literacy being associated with reduced preventive health behaviors in adults. Given the lack of health literacy-specific interventions addressing adolescents' obesogenic behaviors, the purpose of this study is to examine the preliminary effectiveness of adding a health literacy module to an obesity prevention intervention that addresses adolescents' obesogenic behaviors.

Study Overview

• Status: Completed
• Conditions: Exercise; Obesity, Adolescent; Health Behavior; Diet, Healthy; Health Knowledge, Attitudes, Practice; Health Literacy
• Intervention / Treatment: Behavioral: Obesity Prevention; Behavioral: Health Literacy

Detailed Description

The rates of pediatric obesity (~19%) and diabetes (0.24%) in the US are alarming and behaviors implicated in obesity and type 2 diabetes are highly prevalent. Approximately 69% and 73% of adolescents consume less than two fruits and vegetables daily respectively, while 53% engage in insufficient physical activity. These behaviors magnify adolescents' immediate and long-term risks for obesity and obesity-related chronic illnesses, as well as complicate the treatment of obesity-related chronic illnesses. Children and adolescents who are obese are four times more likely to be diagnosed with type 2 diabetes than normal weight children, with serious short and long-term consequences impacting quality of life. Reduced life expectancy is the future of America's youth if behavioral changes are not implemented to improve health and reduce the obesity burden. Reversing current national trends in obesity and type 2 diabetes require novel and sustainable prevention strategies to address children and adolescents' obesogenic behaviors.

Adolescence is marked by increased autonomy in decision-making, yet data suggest that adolescents are not equipped with all the skills to make effective health-related behavioral decisions. While health knowledge works in conjunction with motivation and behavioral skills to predict behavior, most existing adolescent interventions target these variables in isolation with modest success. Researchers have argued that health literacy (HL) - the ability to access, understand, and use health information to make informed health decisions - is a precursor to health knowledge and is necessary for translating health knowledge into behavior. Low HL among adults is associated with poor ability to interpret health messages, and results in reduced preventive health behaviors. Further, parent and adolescent HL is negatively related to adolescents' obesity status. Thus, while research on adding HL to existing behavior interventions to improve adolescents' obesity prevention behaviors is lacking, it is expected that the inclusion of HL into existing interventions will increase intervention effectiveness and positive behavior outcomes.

The long-term goal of this line of research is to reduce the incidence of obesity in adolescents and by extension reduce the risk for obesity-related chronic illnesses using interventions that address individual and contextual factors related to long-term health decision-making and behavior change. The goal of the proposed study is to examine the effect of adding a HL component to an obesity prevention intervention that addresses adolescents' obesogenic behavior-related health knowledge, motivation, and behavioral skills. The central hypothesis is adolescents receiving HL training as part of an obesity prevention intervention will have higher rates of prevention behaviors than those in the obesity prevention only condition. Study goals will be achieved through the following specific aims:

Aim 1: Modify successful components of existing obesity prevention interventions into an interactive digital platform with and without HL for acceptability and usability in adolescents.

Approach: Use successful components of existing interventions, our completed preliminary research, and our research teams' expertise to develop an interactive digital intervention including HL, and obesogenic behavior-related health knowledge, motivation, and behavioral skills. Assess and modify the intervention for usability and acceptability among 14-16-year-olds through an iterative process.

Aim 2: Determine if the addition of HL training to an interactive digital obesity prevention intervention will improve adolescents' obesity prevention behaviors over the obesity intervention alone.

Hypothesis: Adolescents in the obesity prevention plus HL intervention will have higher rates of obesity prevention behaviors at posttest and follow-up compared to the obesity prevention only group.

Approach: Conduct a two-arm randomized controlled trial (RCT) intervention (obesity prevention only, obesity prevention/HL) and estimate the intervention's effects on obesogenic behaviors. Adolescents (n = 36; 14-16-year-olds) will be randomly assigned to each condition (18/condition). Conduct pretest, posttest, and 1- month assessments of HL, obesogenic behaviors, and obesogenic behavior-related motivation, behavioral skills, and knowledge.

Outcomes: Intervention completion will result in effect size estimates of improvements in obesity prevention behaviors, health knowledge, motivation, and behavioral skills for both groups with greater improvements for the HL group at posttest and follow-up. The obesity prevention/HL intervention group will also have higher HL at posttest and follow-up. Retention, recruitment, completion and treatment fidelity rates will be established.

Innovation & Impact: This study incorporates HL, an understudied but potentially critical factor in adolescents' health behaviors. The intervention will be developed and implemented in a digital format which will increase reach and impact. This is the first study examining the effect of including HL in adolescents' obesity prevention interventions. This study sets the groundwork for a full scale, RCT to assess the benefit of HL training added to an obesity prevention intervention to address adolescents' obesogenic behaviors.

• Study Type: Interventional
• Enrollment (Actual): 36
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • New York
    • New York, New York, United States, 10027
      • CUNY Graduate School of Public Health and Health Policy

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 13 years to 17 years (Child)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Adolescents 13-16 years old at time of enrollment (may turn age 17 during the study
• Must have parental consent
• All weight classifications

Exclusion Criteria:

• Adolescents younger than 13 years or older than 16 years at time of enrollment
• No parental consent
• Medical conditions preventing engagement in physical activity
• Medical conditions resulting in extremely restricted diets (e.g., ketogenic diet)
• Already participating in an intervention related to healthy eating, physical activity and/or obesity prevention or treatment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Vaping and Obesity Prevention Only; Obesity prevention and vaping; Vaping:Factual information about vaping devices and vapingBeliefs and attitudes about nicotine productsRefusing and avoiding vapingRecognizing addiction and getting help; Health information:• Factual information about healthy eating and activity (PA); Motivation:Personal: Create positive attitudes toward engagement in healthy eating and PASocial: Enlisting social support to increase healthy eating and PASocial: Identification of community resources that promote and support healthy eating and PA; Behavioral SkillsTips for engaging in prevention behaviors and avoiding risk behaviors in the context of existing barriersSkills for social situations around behaviorsSkills for making behavior part of routineBuild autonomy, self-efficacy and model good health decision-making for health behaviors	Behavioral: Obesity Prevention; This intervention includes content specific to obesity behaviors-related health information, motivation, and behavioral skills.
Experimental: Health Literacy and Obesity Prevention; Obesity prevention and health literacy (HL).; Health LiteracyFunctional HL: skills for reading/understanding nutrition labels and medication instructions.Interactive HL: verbal skills for interacting with others on health issues.Critical HL: connections between advocacy and healthMedia HL: skills for accessing and identifying reliable source of media.; Health information:• Factual information about healthy eating and activity (PA); Motivation:Create positive attitudes toward engagement in healthy eating and PAEnlisting social support to increase healthy eating and PAIdentification of community resources that promote and support healthy eating and PA; Behavioral SkillsTips for engaging in prevention behaviors and avoiding risk behaviorsSkills for social situations around behaviorsSkills for making behavior part of routineBuild autonomy, self-efficacy and good health decision-making for health behaviors	Behavioral: Obesity Prevention; This intervention includes content specific to obesity behaviors-related health information, motivation, and behavioral skills.; Behavioral: Health Literacy; This intervention includes content specific to improving health literacy.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Improvement in Participants' Healthy Eating Behaviors as Assessed by the Dietary Screener Questionnaire and the National Youth Physical Activity and Nutrition Study	Percent of participants improved healthy eating (e.g., fruits and vegetables) behaviors	5 months
Reductions in Participants' Unhealthy Eating Behaviors as Assessed by the Dietary Screener Questionnaire and the National Youth Physical Activity and Nutrition Study	Percent of participants reduce unhealthy eating (sugary and salty foods, junk foods) behaviors	5 months
Improvements in Participants' Physical Activity as Assessed by the Youth Activity Profile	Percent of participants increase number of days with 60 minutes of more of physical activity	5 months
Improvements in Participants' Physical Activity as Assessed by the Godin and Shephard Leisure-Time Physical Activity Questionnaire	Percent of participants in weekly leisure activity score	5 months
Reductions in Participants' Sedentary Activity as Assessed by the Youth Activity Profile	Percent of participants with increase in number of days with less than 2 hours of sedentary behaviors	5 months
Reduction in Participants' Sugar-sweetened Beverage Consumption as Measured by the Dietary Screener Questionnaire and the National Youth Physical Activity and Nutrition Study	Percent of participants with reduced sugar-sweetened beverage intake	5 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Participants' Functional Health Literacy Will be Assessed Using the Assessments of Adolescent Health Literacy Scales	Percentage of participants with maintenance (at max score) or improvement in objective measure of reading and numeracy skills for health	5 months
Participants' Interactive Health Literacy Assessed Using the Assessments of Adolescent Health Literacy Scales	Percentage of participants with maintenance at max score or improvement in objective assessment of interactive health literacy	5 months
Participants' Critical Health Literacy Will be Assessed Using the Assesments of Adolescent Health Literacy Scales	Percentage of participants with maintenance or improvement in objective measure of social skills and critical thinking for health	5 months
Participants' Media Health Literacy Will be Measured Using the Adolescent Media Health Literacy Scale and eHeals	Percentage of participants with maintenance or improvement in objective measure of media literacy for health	5 months
Participants' Overall Health Literacy Will be Assessed Using the Assessments of Adolescent Health Literacy Scales	Percentage of participants with maintenance or improvement in objective measure of three core components of health literacy (functional, interactive, critical)	5 months

Collaborators and Investigators

• Sponsor: City University of New York, School of Public Health
• Collaborators: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
• Investigators: Principal Investigator: Sasha A Fleary, PhD, City University of New York

Publications and helpful links

General Publications

• Fleary SA. A Web-Based Intervention to Improve Health Literacy and Obesogenic Behaviors Among Adolescents: Protocol of a Randomized Pilot Feasibility Study for a Parallel Randomized Controlled Trial. JMIR Res Protoc. 2022 Aug 16;11(8):e40191. doi: 10.2196/40191.

Study record dates

Study Major Dates

• Study Start (Actual): November 16, 2022
• Primary Completion (Actual): December 30, 2024
• Study Completion (Actual): December 30, 2024

Study Registration Dates

• First Submitted: January 16, 2020
• First Submitted That Met QC Criteria: January 30, 2020
• First Posted (Actual): February 5, 2020

Study Record Updates

• Last Update Posted (Actual): May 1, 2026
• Last Update Submitted That Met QC Criteria: April 9, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: physical activity; obesity; adolescent; health literacy; diet; information-motivation-behavioral skills model
• Additional Relevant MeSH Terms: Nutrition Disorders; Overnutrition; Body Weight; Overweight; Pathological Conditions, Signs and Symptoms; Nutritional and Metabolic Diseases; Signs and Symptoms; Obesity; Pediatric Obesity; Motor Activity; Health Behavior; Behavior; Health Services; Health Care Facilities Workforce and Services; Preventive Health Services; Health Education; Consumer Health Information; Health Literacy
• Other Study ID Numbers: HLSQUARED01; R21DK117345 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No