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Pediatric Obesity Column

Childhood Obesity, Health Literacy, and the Newest Vital Sign

Haynes, Beverly B. MSN, RN, CPN; Browne, Nancy T. MS, PPCNP-BC, CBN

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Journal of Pediatric Surgical Nursing: 4/6 2016 - Volume 5 - Issue 2 - p 32-33
doi: 10.1097/JPS.0000000000000095
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The Commission on Ending Childhood Obesity— a group put in place by the World Health Organization—recently released their report stating that the number of children under 5 years old affected by obesity has risen from 31 million in 1990 to 41 million in 2014 (World Health Organization, 2016). The findings were called an “exploding nightmare” by the co-chair of the commission that could reverse many of the factors that are now in place to increase life expectancy.

One of the tactics proposed by the commission to combat the problem is to promote nutrition literacy. The 2003 National Adult Assessment of Literacy found the 14% of adults had only “the most simple and concrete literary skills.” Another 4 million people were unable to take the assessment because of language barriers (Baer, Kutner, & Sabatini, 2009). Sadly, the latest assessment in 2012 did not note any significant improvement in these statistics (Goodman, Finnegan, Mohadjer, Krenzke, & Hogan, 2013).

Literacy is the ability to use printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential (U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, n.d.). The Centers for Disease Control and Prevention (CDC) promotes the definition of health literacy (HL) from Healthy People 2010 (U.S. Department of Health and Human Services, 2000) as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (CDC, 2016). It uses this definition on which to base its educational programs of HL.

The United States National Action Plan to Improve Health Literacy (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2010) is in place to ensure that all who receive health care will understand every aspect. By making health care understandable, the hope is to improve the quality of life and longevity, accessibility, quality, and safety of health care at a lower cost.

Sharif and Blank (2010) reported that overweight children aged 6–19 years who showed higher HL also had a lower body mass index, suggesting that HL be assessed early on and education be directed appropriately. Parental attitude has also been found to be inversely associated with HL in that parents with lower HL showed a lesser likelihood of using multiple strategies to help their child lose weight (Liechty, Saltzman, Musaad, & STRONG Kids Team, 2015).

Unfortunately, it is often difficult or impossible to determine the level of literacy of a person—health or otherwise—resulting in suboptimal outcomes. How do you determine if your patient or their parents have trouble with literacy? Indicators are as follows: saying they did not bring their glasses or will read it later; holding the paper close to their face or following along with their finger; acting nervous, indifferent, frustrated, or confused when confronted with a lot of information; or having inability to answer questions about what they have read (Cornett, 2009). In addition, your patient/parent may not speak English at all, making it even more difficult to assess their level of HL.

Tests are available for use by health care professionals to test HL but may take too long to administer in a fast-paced clinical setting. It was for this reason that the Newest Vital Sign (NVS) was developed. It is quick (six questions, 3 minutes) and uses an ice cream label on which to base answers; it is available in English and Spanish. The NVS is sensitive to low literacy levels. Using a common, everyday nutrition label allows the screener to assess math skills and reasoning as well as reading and comprehension. The questions may be asked at the same time that vital signs are taken with the patient or parent holding the label themselves. Comparatively, the NVS correlates with the most-often used Test of Functional Health Literacy in Adults and is reliable (Cronbach’s α > .76 for English and .69 for Spanish; Weiss et al., 2005). The Department of Health and Human Services has developed a training module for the NVS (U.S. Department of Health and Human Services, Health Resources and Services Administration, n.d.). It may be accessed by copying and pasting the following address in your browser:

Once we, as health care professionals, determine that a patient or parent has low literacy—health or otherwise—then it is our duty to ensure that they can navigate the system to receive the best care. The CDC offers a wealth of help on its Web site to assist with the training and development of materials for this purpose. Access may be obtained by following this link:


Baer J., Kutner M., & Sabatini J. (2009). Basic reading skills and the literacy of America's least literate adults: Results from the 2003 National Assessment of Adult Literacy (NAAL) Supplemental Studies (NCES 2009–481). Washington, DC: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics Retrieved from
Centers for Disease Control and Prevention. (2016). Health literacy. Retrieved from
Cornett S. (2009). Assessing and addressing health literacy. The Online Journal of Issues in Nursing, 14(3), 1–17. doi:10.3912/OJIN.Vol14No03Man02
Goodman M., Finnegan R., Mohadjer L., Krenzke T., & Hogan J. (2013). Literacy, numeracy, and problem solving in technology-rich environments among U.S. adults: Results from the program for the International Assessment of Adult Competencies 2012: First Look (NCES 2014–008). Washington, DC: National Center for Education Statistics. Retrieved from
Liechty J. M., Saltzman J. A., Musaad S. M.& STRONG Kids Team (2015). Health literacy and parent attitudes about weight control for children. Appetite, 91, 200–208.
Sharif I., & Blank A. E. (2010). Relationship between child health literacy and body mass index in overweight children. Patient Education and Counseling, 79, 43–48.
U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics. (n.d.). National Assessment of Adult Literacy. Retrieved from
U.S. Department of Health and Human Services. (2000). Healthy People 2010: Introduction. In Selden C. R., Zorn M., Ratzan S. C., & Parker R. M. (Eds.), National Library of Medicine Current Bibliographies in Medicine: Health Literacy (NLM Pub. No. CBM 2000–1). Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.
    U.S. Department of Health and Human Services, Health Resources and Services Administration. (n.d.). Effective Communication tools for healthcare professionals: Addressing health literacy, cultural competency, and limited English proficiency. Retrieved from
    U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health literacy. Washington, DC: Author.
    Weiss B. D., Mays M. Z., Martz W., Castro K. M., DeWalt D. A., Pignone M. P., … Hale F. A. (2005). Quick assessment of literacy in primary care: The Newest Vital Sign. Annals of Family Medicine, 3, 514–522.
    World Health Organization. (2016). Final report of the commission on ending childhood obesity. Retrieved from
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