The relationship between Nutrition Literacy and Nutrition Information seeking attitudes and Healthy Eating Patterns in the Palestinian Society

Introduction: Nutrition literacy is important because it creates motivation and knowledge among public to have accountability towards their nutrition behaviors. Three types of nutrition literacy including functional literacy (FNL), Interactive literacy (INL) and critical literacy were not studied before in Palestinian society. Aims: The aims of the study were to 1) describe three forms of nutrition literacy: FNL, INL and CrL in the Palestinian society 2) To study the relationship between different forms of nutrition literacy and food behavior and nutrition seeking information habit. Methods: A sample of 149 Palestinian participants were recruited to participate in the study. Using an online survey which was distributed through educational and social internet platforms was used to collect data on sociodemographic variable. A translated questionnaire was used to collect information on nutrition literacy and Short Format of the Diet Health and Knowledge Survey (SFDHKS) was used to collect information on diet behavior and USDA food security questionnaire was used to collect data on food security. Data was analyzed by SPSS 21. Results: This study consisted of young adults (20.4± 4.9 y) who are mainly females (78%). Most of our study sample had Bachelors degree or currently enrolled in university to obtain this degree. The mean of FNL was 2.8±0.5, INL 3.3± 0.5, CrL 3.6± 0.5. There was signicant correlation between CrL and INL (p< 0.05). There was also signicant correlation between various forms of nutrition literacy and some aspects of diet behavior and food label use. Conclusion: Palestinian society is willing to learn about and understand nutrition information and this related to diet behavior


Introduction
Palestine is a Mediterranean country with a national cuisine that is rich in olive oil, green leafy vegetables, grapes and other fruits and dairy products high consumption (1). Like other middle income countries, health transition is currently present with higher adoption of westernized lifestyle including a diet that is focused on fast food and heavy consumption of food at restaurants which is full of salt, sugar, re ned carbohydrate and fried meat and potatoes (2), (3). Alongside with this change rates of Obesity and chronic diseases are high in Palestinian territories. Recent data shows that 65.3% of Palestinians are either overweight or obese (4). Currently Cardiovascular diseases, stroke, cancer and Diabetes mellitus type 2 are among the most leading causes of death in Palestine (5). It is well known that mortality from chronic diseases is highly attributable to poor dietary habits and physical inactivity(6)..
Nutrition awareness and ability to understand and apply health and nutrition standards is very important element in the efforts to prevent diet related chronic diseases in any population. Health literacy itself can be de ned as capacity to obtain, process, understand and use health information and practices (7).
Moreover, nutrition and food literacy are two concepts that are relevant for human health as they bridge the gap between continuously changing food environment and consumers(8). Food literacy was rst used in cooking books in 1992 (9). Nutbeam's tripartite model has recently identi ed three forms of nutrition literacy including functional nutrition literacy (FNL), interactive nutrition literacy (INL) and critical nutritional literacy (CrL) (10,11). FNL refers to basic skills and abilities of consumers to obtain nutrition information, understand them and apply them. INL refers to the ability of consumer to participate in communication of nutrition information, share them and discuss them. Finally, CrL refers to ability of consumers to appraise, criticize nutrition information, its credibility and understand the relationship between food and environment (12). Studies in USA indicate strong relationship between poor nutrition literacy and poor nutrition knowledge and practice, development of chronic diseases, increased hospitalization and cost (13). A clinical trial that improved nutrition literacy lead also to improvement of nutrition knowledge and behavior. Hence the goals of this study is 1) to study patterns of FNL, INL and CrL in Palestinian society. 2) To study the relationship between nutrition literacy and food behavior and label use. 3) To study barriers towards seeking nutrition information.

Methods
A cross-sectional design was used to evaluate nutrition literacy, food security and its association with dietary habits. Palestinians older than 18 y were recruited through an electronic data collection tool which was distributed through different social methods that included facebook and professional, social and student facebook groups, in addition to the university website. The population consisted of all Palestinians living in the West Bank, Gaza, and in Israel. A convenient sampling method was adopted to reach the determined, we were able to include sample size of n = 149 adults in this study.
The data collection tool was adopted based on a Literature review. Information on age, weight, height,diet, use of food label, items of food label used, gender, education, income were obtained. Nutrition literacy including 3 subtypes were calculated using a translated questionnaire (14). Each questions' answers were given likert scale number and ranged from strongly disagree (1) to strongly agree (1). A translated to Arabic version was used in our study.
Arabic translated version of dietary habits was used and consisted of nineteen questions from the Short Format of the Diet Health and Knowledge Survey (SFDHKS) (15) that measure use of food labels, consumption of low-fat/low-calorie foods, consumption of ber, and avoidance of extra fat were used to assess nutrition behaviors.

Ethical Consideration
The research was conducted in accordance with Declaration of Helsinki and approval from the IRB at An Najah National University was obtained before conducting the study. Agreement of participants was ensured through acceptance of the invitation and answering the questionnaire.     The study demographic variables were summarized using proportions or means. Ordinal data was given numbers like Likert scale from 1 to 5 according to order and were summarized using means and standard deviation. Normality was checked and histograms provided. Pearson correlations were used to assess association between FNL, INL and CrL and food label use, diet behavior and nutrition information resources meaures. Signi cant values are less than p< 0.05. Data was analyzed using IBM SPSS 21.

Results
This study consisted of adults mostly in their twenties (20.4±4.9) y who have Bsc or are currently enrolled in programs that lead to Bsc degree. Most of our study participants are female. The income of this ranged mainly from 3000-6000 shikel.
Different pointed related to FNL, InL and CrL and the rest of factors related to seeking nutrition information are expressed in likert scale. (Table 1) In sum, the highest likert scale value was for CrL and the lowest were for FNL.
Functional literacy FNL consisted of seven points. The lowest likert scale was for participants was for the understanding of what balanced diet is composed, awareness of WHO recommendation for healthy diet and ability of the study participants to apply principles of healthy diet on their everyday diet style. In terms of dietitian and nutrition information and language, the participants had better likert scale. (Table 2) Interactive Literacy The INL is composed of 8 points. Participants had higher scores of INL factors relative to FNL. INL was composed seeking nutrition information resources, sharing information with friends and family. The participants seemed to express low con dence of internet as source of information. (Table 2) Critical Literacy The study participants showed positive attitudes for towards engagement in nutrition change towards healthier diet at social, work-place, family and friends level. They expressed high demand of having meals served at work, university and school places. They also expressed motivation towards in uence on other to make healthier dietary choices. (Table 2) Barriers to seek nutrition information Study participants disagreed on di culty of nutrition information as barriers to seek nutrition information diet and healthy dietary guidelines. However, study paricipants agreed that presence of Arabic resources for information and credibility could be obstacles towards using nutrition information use. (Table 3)

Relationships between Different Types of Literacy, Food Label and Diet Behavior
In this study FNL did not correlate with CrL and INL. However, FNL correlated with use of food label, whereas both CrL and INL correlated with looking at ingredients and points related to low fat, low calorie, serving size and health bene t were signi cantly related to INL. Similar to that in terms of diet behavior, seeking low calorie, low fat products and cooking correlated signi cantly with INL, whereas adding cheese and mayonise was less common in participants with CrL accountability.There was signi cant correlation between FNL and nutrition information seeking information (

Discussion
In this study we describe three different forms of nutrition literacy in a group of Palestinians mainly youth who study or work in health related profession. Also we showed that nutrition label use, nutrition seeking information and diet behavior are related signi cantly related to nutrition literacy.
People who showed higher FNL were less likely to have poor dietary behavior. Also, participants who had higher level of FNL seemed to trust resources of nutrition information such as doctors, nurses, books and internet. Previous literature supports positive association between diet behavior and nutrition literacy (16, 17). So one can conclude that improved nutrition literacy could prevent chronic diseases (18).
In terms of FNL, although our study group showed lack of knowledge in terms of WHO guidelines for healthy diet and application of dietary guidelines to everyday living. They expressed high understanding of nutrition knowledge and languages which correlated signi cantly with low calorie and low fat diet.
This could be overestimated and misleading as guidelines to healthy diet have other aspects such as intake of fruits and vegetables and lower intake of soft drinks among others, which is in accordance with what was found previously (17,19). For example the score for con dence on the de nition of healthy diet was high, whereas the knowledge of WHO guidelines on healthy nutrition was low, which indicate that the participants may have overestimated their skills with regards to nutrition knowledge.
With regards to INL, participants were con dent in sharing nutrition information and in uencing peers and family, also health prefessionals, whereas interent as source of information was not well received. In a study among women using facebook as source of information on eating disorders was related to disorganized eating and negative body image (20).
Our study group are critical of work, university and work place attitudes towards providing healthy meals.
In addition, study group showed tendency to in uence and be in uenced by others. They are con dent more of that they think is credible source of information. Young students use websites such as facebook, twitter and Youtube to obtain information about diet when confronted health issues such as DM2 (21).
Nutrition knowledge was associated with decrease intake of fat rich food sources and calories. A diet rich in cholesterol, saturated fat and trans-fat is associated with increase in serum low density lipoprotein (22). To reduce the risk of cardiovascular disease the amount of saturated fat and trans fat in diet should be reduced (23,24). In literature, food selection is related to nutrition knowledge(25, 26) as some nutrition basic knowledge is related to diet change (27). In study among 231 students, those who have more than 35% of their total calories from fat had lower nutrition knowledge scores and females had more nutrition knowledge than males.
Nutrition literacy was higher in females compared to males. This in agreement with what was done before in 201 adults older than 18 y from Australia, nutrition knowledge with regards to nutrition recommendations, food nutrients, food choices, diet related diseases were higher in females relative to males, although total knowledge and nutrition recommendations were signi cantly higher(28). Other studies report demographic variation in nutrition knowledge, lower SES, unemployed, less educated have lower knowledge scores (29). Particularly, nutrition knowledge is important for women as it help to protect their offspring from malnutrition or future over-nutrition (30).
Mediterranean diet is a diet that lowers chronic disease and it is predominant in countries like Palestine.
In a study among 127 students, greater nutrition education was associated with higher adherence to Mediterranean diet (31). Hence, nutrition education to improve nutrition literacy among Palestinian people could have impact on the prevalence of chronic diseases in the society.
This study is not without limitation including using convenient sample and its cross sectional design. Our sample represented mainly young students who had or currently enrolled in basic clinical nutrition class, so this sample is not represented of general Palestinian society who may be lagging behind in terms of nutrition knowledge which indicate the need for programs to improve nutrition literacy among Palestinian society.
In this study we reported descriptive data on different types of nutrition literacy that indicated that Palestinian society has interest in knowing better about nutrition from credible, but nd it di cult to apply healthy nutrition on everyday life. Both CrL and INL signi cantly correlated with each other. Nutrition literacy correlated signi cantly with label use, diet behavior and credible sources of nutrition information.
Efforts are needed to raise the nutrition knowledge in the Palestinian society.

Consent form
The goals of the study were discussed in social media platforms and participants were asked to ll online survey if they want to participate in the study and lling the form was considered consent to participate in the study.

Data Availability
The datasets generated and/or analyzed during the current study are not publicly available due [being kept con dential for future work] but are available from the corresponding author on reasonable request.