Obesity is an international problem, with alarming statistics. New Zealand currently is the fourth most obese country in the Organization for Economic Co-operation and Development, with approximately two thirds of adults and one third of children either overweight or obese (Swinburn, Dominick, & Vandevijvere, 2014; University of Otago & New Zealand Ministry of Health, 2011). Obesity is of major concern because it is a preventable risk factor for the development of noncommunicable diseases (Swinburn et al., 2014). This places enormous financial burdens on the health care system as well as indirect costs to society. In New Zealand alone, the estimated total obesity-related health cost is expected to reach NZ$8 billion within the next 10 years (New Zealand Medical Association, 2014).
Given their close client contact, nurses have a key public health role in the prevention and management of obesity (Blake & Harrison, 2013; Borchardt, 2000). This is more likely to be successful when nurses have a high level of nutrition literacy and can translate this knowledge into their own lifestyle practices (Shriver & Scott-Stiles, 2000; Zhu, Norman, & While, 2011). However, studies indicate that many nurses (along with other health professionals) are either deficient in nutrition knowledge or have some knowledge of nutrition and weight management but are unclear how to translate this into effective weight management advice or even into their own lifestyle practices (Bogossian et al., 2012; Mowe et al., 2008).
This highlights nutrition content as being critical for inclusion in a nursing curriculum. However, there is no standard in New Zealand for how much nutrition information to include, nor any specific nutrition-related nursing competency for the RN scope of practice. The aim of this study was to evaluate the nutrition knowledge of undergraduate nursing students in the Bay of Plenty region of New Zealand and to compare the level of nutrition knowledge between those who received nutrition teaching and those who did not. These findings were collated to identify critical nutrition content and knowledge gaps for delivery of content in a revised undergraduate nursing curriculum.
A convenience sample of first- and second-year undergraduate bachelor of science in nursing (BSN) students from a tertiary education provider in the Bay of Plenty region of New Zealand were invited to participate in a paper-based nutrition survey between May and June 2014. Students signed an informed consent form before completing the 30-question, multiple choice questionnaire. One group received no nutrition education (n = 57), and the second group received 8 hours (minimum) of nutrition teaching (n = 140). This study was approved by the Waiariki Institute of Technology Research and Ethics Committee.
For this study, an in-house assessment survey was used to directly evaluate nutrition teaching within the BSN program. This was due to a lack of published, validated nutrition tools to assess nutrition knowledge that is taught in a nursing curricula (Carbone, 2013). Demographic information in the survey included campus of enrollment, gender, age, ethnicity, living situation, annual household income, and previous nutrition study.
Participants indicated whether they used nutrition labels when purchasing food for themselves or their family. A clarification question asked reasons as to why participants sometimes, rarely, or never used labels. Responses from three subsequent questions about the sweet biscuit food label (grams of fat, largest quantity ingredient, and food groups contributing kilojoules) were pooled for each participant into one variable, termed as Label score. Four questions related to details on the packaging claims (grams of fat, and health claims around 97% fat-free and no added sugar) were combined together for each participant into one variable termed Packaging score.
Questions then assessed knowledge about major food nutrient groups, calories versus kilojoules, body mass index (BMI), basal metabolic rate (BMR), and glycemic index. These questions formed the Other Questions score.
Unless noted otherwise, knowledge questions had four possible answers (a through d, only one correct answer); a fifth option was given as (e) not sure, which was considered an incorrect answer. The Overall Nutrition Knowledge score was obtained from 20 questions that had one possible correct answer.
Data were coded into variables. One-way analysis of variance with Scheffe post-hoc tests and two-way analysis of variance with planned simple contrasts were used to assess interactions among variables with Overall Nutrition Knowledge, Label, Packaging, and Other Questions scores. Statistical significance was set at p ⩽ 0.05. Data were analyzed using Data Desk 6.0.1. Descriptive statistics are reported as mean ± SD. Pearson’s correlation measured associations between Overall Nutrition Knowledge with each of the Label and Packaging scores. Chi-square analysis measured associations between previous nutrition study and the likelihood of scoring correctly on specific questions.
A total of 197 students completed the survey (75% of all possible students); three quarters of these students were either New Zealand European (Pakeha) or New Zealand Māori (Māori) (Figure).
Mean nutrition knowledge scores by ethnicity. Total score = Overall Nutrition Knowledge (20 questions) made up from the Label (3 questions), Packaging (4 questions), and Other Questions (13 questions), compared by ethnicity. *Other includes Pacific Islanders (n = 4), Indian (n = 5), and not defined (n = 3). **A significant difference was noted between the Pakeha and Māori groups for Overall Nutrition Knowledge, Label, and Packaging scores (p ⩽ 0.008).
Overall Nutrition Knowledge Score
The mean Overall Nutrition Knowledge score (with all participant data combined) was 11.0 ± 3.1 (55%) out of a possible 20 points, and a significant effect of ethnicity was observed for this score (F[4, 192] = 4.68, p = 0.001) (Figure). Overall, those who received nutrition teaching had a higher Overall Nutrition Knowledge score (60.5 ± 14.9 versus 52.5 ± 14.8; F[1, 187] = 7.2, p < 0.001), and improvements in nutrition knowledge were consistent across all ethnic groups (F[4, 187] = 0.53, p = 0.71). No significant effect of age on Overall Nutrition Knowledge score was noted (p > 0.05).
Label, Packaging, and Other Questions
One third of participants (34%) reported they sometimes used labels; an additional 26.4%, 17.8%, and 8.1% reported they used labels often, rarely, or not at all, respectively. The most frequent reasons (multiple answers were allowed) for not using nutrition labels were because participants did not have time (n = 60) or because they bought food they liked and were not interested in the nutrition information (n = 60). In addition, 40 participants reported they did not use nutrition labels because they did not know how to read or interpret these labels, and eight participants reported labels were not present on foods they bought. No effects of ethnicity, age, or previous nutrition study were observed with these data.
The majority of participants scored well on the sweet biscuit label question, with a mean Label score of 2.0 ± 0.9. A significant effect of ethnicity was observed for mean Label score (F[4, 192] = 4.37, p = 0.002) (Figure).
The majority of participants were able to correctly identify how many grams of fat there were in one serving of biscuits (87.2%) and which food group contributed most to the total number of kilojoules (70.7%). However, only 37.4% of participants were able to identify that flour was present in the largest quantity despite the fact that the label clearly listed it first in the ingredients list.
The majority of participants scored well with the questions on Packaging score (M = 3.3 ± 0.9). No effect of previous nutrition study was observed on Packaging score; however, Packaging score was highly correlated with the Overall Nutrition Knowledge score (r = 0.64; p < 0.001).
Most participants accurately defined the term BMI (81.1%), but less than one third of respondents (31.5%) correctly identified the overweight range of a western BMI chart. One fifth of participants (19.4%) thought a healthy BMI was 30 to 35 kg/m2, and an additional 36.2% answered they were not sure. No effects of ethnicity or age were observed; however, previous study of nutrition resulted in a higher proportion of individuals being able to choose the correct answer (49% versus 24%; χ 2 = 10.76, N = 197, p = 0.001).
Less than a quarter of participants (16.8%) were able to choose the correct definition for BMR. One third of participants (32%) thought BMR was “the rate at which calories/kilojoules are broken down after eating,” whereas an additional 35.2% reported they were not sure. A similar proportion of those with and without prior study of nutrition scored incorrectly (81% versus 84%, respectively), suggesting that this information had not been adequately delivered during teaching sessions.
Almost half of the participants (47.4%) were able to correctly identify glycemic index, although 38.2% reported they were not sure. No effect of ethnicity was observed, although previous study of nutrition improved the likelihood of scoring correctly (68.9% versus 38.1%, χ2 = 15.61, N = 197, p < 0.001).
More than half of all participants (54.1%) identified that saturated fat is most likely to contribute to high blood cholesterol levels. One quarter selected trans-fat as being the biggest contributor, and 7.7% thought it was due to unsaturated fat. Almost half of the participants correctly identified olive oil as being an example of unsaturated fat. There was no effect from nutrition study, age, or ethnicity observed with these data.
The findings from this study have important implications for nutrition education in undergraduate nursing curricula in New Zealand. Although students who were taught the nutrition curriculum scored higher on overall nutrition knowledge than those who had not received nutrition teaching, significant gaps were found in the nutrition knowledge of many undergraduate nursing students. However, it must be noted that the current study used an in-house assessment survey rather than a validated nutrition tool due to the lack of a suitable published tool that was applicable to a nursing curricula (Carbone, 2013). The current tool therefore should be validated (particularly in those of different ethnicities) and tested in a larger number of participants (ideally from different undergraduate nursing programs) before more definitive conclusions can be drawn.
Despite this, the lack of nutrition literacy found in the current study is consistent with published research on nutrition literacy of nursing students (Mowe et al., 2008; Van den Berg, Okeyo, Dannhauser, & Nel, 2012). In a meta-analysis of 15 studies that assessed nursing knowledge of nutrition (Bakre, Akodu, & Akodu, 2012), it was shown that RNs generally had insufficient nutrition knowledge. Clearly, more research is needed on the nutrition knowledge required by graduate nurses entering the workforce to facilitate effective delivery of nutrition information in their roles as primary health care workers.
The findings of this study also are consistent with published research on nutrition knowledge of consumers in New Zealand. A number of studies indicate that many New Zealanders have reduced nutrition literacy, particularly an inability to use and interpret food nutrition labels (Gorton, Mhurchu, Bramley, & Dixon, 2010; Signal et al., 2008). Many individuals in these studies reported that they did not have time to read nutrition labels and that the labels were too hard to understand; these responses agree with those in the current study. New Zealand currently is trying to simplify its nutrition labelling, and in 2014, the health-star rating system in which foods are all scored based on a health algorithm was implemented (Ministry for Primary Industries, 2013). Similar rating systems have been shown to increase the likelihood of healthy food choices in other countries (Hawley et al., 2013; Katz, Njike, Rhee, Reingold, & Ayoob, 2010), but its efficacy in New Zealand has yet to be determined.
The current data suggest further research is needed to inform curriculum changes in the teaching of nutrition in undergraduate nursing programs in New Zealand. Undergraduate nursing programs need to prepare graduate nurses to work closely with their patients (using culturally appropriate strategies when necessary) to provide effective nutrition education and support regarding food and lifestyle choices. In the curricula that has been evaluated in this article, the current nutrition teaching does not adequately meet the needs of the students, neither personally or professionally in their future roles as nurses. Ideally, nutrition/lifestyle and healthy eating education should be addressed (and reinforced) throughout the degree program and continued into clinical practice areas. Finally, it would be relevant to track these nursing students through their degree completion and into the workplace to determine how their levels of nutrition knowledge change over time and how nutrition knowledge translates into their clinical as well as their own lifestyle practices.
- Bakre, A.T., Akodu, A.K. & Akodu, B.A. (2012). Examining the nutritional knowledge of nurses: A theoretical perspective. Journal of Public Health and Epidemiology, 4(4), 105–109.
- Blake, H. & Harrison, C. (2013). Health behaviours and attitudes towards being role models. British Journal of Nursing, 22, 86–94. doi:10.12968/bjon.2013.22.2.86 [CrossRef]
- Bogossian, F.E., Hepworth, J., Leong, G.M., Flaws, D.F., Gibbons, K.S., Benefer, C.A. & Turner, C.T. (2012). A cross-sectional analysis of patterns of obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United Kingdom. International Journal of Nursing Studies, 49, 727–738. doi:10.1016/j.ijnurstu.2012.01.003 [CrossRef]
- Borchardt, G.L. (2000). Said another way: Role models for health promotion: The challenge for nurses. Nursing Forum, 35(3), 29–32. doi:10.1111/j.1744-6198.2000.tb01002.x [CrossRef]
- Carbone, E.T. (2013). Measuring nutrition literacy: Problems and potential solutions. Journal of Nutritional Disorders & Therapy, 3(1), 1–2.
- Gorton, D., Mhurchu, C.N., Bramley, D. & Dixon, R. (2010). Interpretation of two nutrition content claims: A New Zealand survey. Australian and New Zealand Journal of Public Health, 34, 57–62. doi:10.1111/j.1753-6405.2010.00474.x [CrossRef]
- Hawley, K.L., Roberto, C.A., Bragg, M.A., Liu, P.J., Schwartz, M.B. & Brownell, K.D. (2013). The science on front-of-package food labels. Public Health Nutrition, 16, 430–439. doi:10.1017/S1368980012000754 [CrossRef]
- Katz, D.L., Njike, V.Y., Rhee, L.Q., Reingold, A. & Ayoob, K.T. (2010). Performance characteristics of NuVal and the Overall Nutritional Quality Index (ONQI). The American Journal of Clinical Nutrition, 91, 1102S–1108S. doi:10.3945/ajcn.2010.28450E [CrossRef]
- Ministry for Primary Industries. (2013). Research report: The ability of New Zealand consumers to use the Health Star Rating system. Retrieved from http://www.foodsafety.govt.nz/industry/general/labelling-composition/health-star-rating/research-report-health-star-10-12-13.pdf
- Mowe, M., Bosaeus, I., Rasmussen, H.H., Kondrup, J., Unosson, M. & Rothenberg, E.The Scandinavian Nutrition Group. (2008). Insufficient nutritional knowledge among health care workers?Clinical Nutrition, 27, 196–202. doi:10.1016/j.clnu.2007.10.014 [CrossRef]
- New Zealand Medical Association. (2014). Tackling obesity. Retrieved from https://www.nzma.org.nz/publications/tackling-obesity
- Shriver, C.B. & Scott-Stiles, A. (2000). Health habits of nursing versus non-nursing students: A longitudinal study. Journal of Nursing Education, 39, 308–314.
- Signal, L., Lanumata, T., Robinson, J.-A., Tavila, A., Wilton, J. & Mhurchu, C.N. (2008). Perceptions of New Zealand nutrition labels by Māori, Pacific and low-income shoppers. Public Health Nutrition, 11, 706–713. doi:10.1017/S1368980007001395 [CrossRef]
- Swinburn, B., Dominick, C.H. & Vandevijvere, S. (2014). Benchmarking food environments: Experts’ assessments of policy gaps and priorities for the New Zealand government. Auckland, New Zealand: University of Auckland. Retrieved from https://cdn.auckland.ac.nz/assets/fmhs/soph/globalhealth/informas/docs/Full%20Food-EPI%20report1.pdf
- University of Otago & New Zealand Ministry of Health. (2011). A focus on nutrition: Key findings of the 2008/09 New Zealand adult nutrition survey. Retrieved from http://www.health.govt.nz/system/files/documents/publications/a-focus-on-nutrition-v2.pdf
- Van den Berg, V.L., Okeyo, A.P., Dannhauser, A. & Nel, M. (2012). Body weight, eating practices and nutritional knowledge amongst university nursing students, Eastern Cape, South Africa. African Journal of Primary Health Care & Family Medicine, 4(1), 1–9. doi:10.4102/phcfm.v4i1.323 [CrossRef]
- Zhu, D., Norman, I.J. & While, A.E. (2011). The relationship between health professionals’ weight status and attitudes towards weight management: A systematic review. Obesity Reviews, 12, e324–e337. doi:10.1111/j.1467-789X.2010.00841.x [CrossRef]