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Nutrition education can be a game-changer for our youth

Elizabeth Falkner

August 22, 2022.

I’m fortunate to spend most of my time around good food. It’s both my job and my passion.

Growing up in Los Angeles, cooking at home with my mom had a big influence on me and started my lifelong love affair with food. My fondest memories include the school lunches my mom packed for us — a peanut butter sandwich on hearty sourdough bread — no jelly and no mushy white bread for the future chef and baker. There was always a piece of fruit, like an apple or an orange or sometimes celery or carrots. And of course, a homemade cookie, which sparked my interest in making better desserts.

Mom was the head dietitian for the Las Virgenes Unified School District where I attended school. She talked about how tight the state budgets were back in the 1990s into the early 2000s and worked hard at keeping sugar-loaded sodas out of schools and pushed to have salad bars.

It wasn’t until later in my culinary career that I began a deeper exploration into the correlation between nutrition and the impact it can have on overall health.

Today, there is a stronger general understanding of how the foods we put in our bodies impact our physical health. We know healthy eating is a key contributor to energy levels and social-emotional development. There is science behind being hangry . Still, studies have shown that over 40% of daily calories consumed by children ages 2-18 are empty, or lacking in any nutrition. Poor nutrition has a significant impact on a child’s ability to focus and can lower cognitive function, which is so important when it comes to learning in school, widening many of the equity gaps that exist particularly in our most underserved communities.

Further, every year, an alarming number of children are diagnosed with Type 2 diabetes, obesity and other chronic health-related issues, most of which become lifelong battles. According to the CDC, more than 40% of fourth and seventh graders in our state are considered either overweight or obese. Research has conclusively shown that youth living in underresourced communities have 2.31 times greater odds of being affected by obesity than children living in higher-income homes and are likely to face greater health care challenges than their more affluent peers.

One way to address this gap in nutrition equity is through improved nutrition education in our schools.

I have been a chef activist my entire career, raising money and awareness for many causes, and some of the most important ones to me are the organizations that create change for the future of food. For decades, California has worked to improve eating habits by offering healthier foods on school menus. Yet this is not the stand-alone solution that will drive change in lifelong behavior. Providing access to healthier food options coupled  with integrating nutrition education in our school curriculum starting from an early age can equip our youth with knowledge to make better food choices, setting them up to live healthier lives.

We have a generation-changing opportunity to prioritize inclusive nutrition education in our schools to bridge the nutrition equity gap in California because every child should have the resources to eat healthily and learn how food impacts overall wellness. There are cost-effective ways to implement nutrition education in our schools by partnering with nonprofits that already have a good record of working in this area. Since 2008, Common Threads has taught over 130,000 Angelenos and provided more than 1.4 million hours of nutrition education for children, their parents, teachers, and families. Before the pandemic, the organization’s programming was present in over 200 schools throughout the Los Angeles region, helping young people learn about nutrition, how to make healthy meals and the importance of developing lifelong healthy eating habits. At many schools, these efforts complemented existing school activities like Glenfeliz Boulevard Elementary School’s farm-to-table gardening program , so students in the heart of LA can develop a hands-on relationship with food from the source.

Sadly, many of these kinds of programs were halted during the pandemic with school closures. As we near the new school year, it’s imperative that we prioritize the importance of nutrition education in our schools and the value of this kind of programming.

It will be an amazing day when all children who grow up in California, a state that leads in healthy food movements, in tech, and is always ahead in policy, can invest in solutions that help close the nutrition equity gap and build inclusive education in our schools that empowers youth and families to make nutritious food choices.

Elizabeth Falkner is a chef, restaurateur and advocate for nutrition equity in Los Angeles.

The opinions in this commentary are those of the author. If you would like to submit a commentary, please review our  guidelines  and  contact us .

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Nutrition Education Resources & Materials

Resources on the importance of good nutrition.

The Nutrition Facts Label

The Nutrition Facts label reflects current scientific information, including the link between diet and chronic diseases such as obesity and heart disease. The label makes it easier for you and your audience to make more informed food choices.

Learn about What’s on the Nutrition Facts Label , including details on: Calories, Serving Sizes, Added Sugars, and Percent Daily Value.

Industry members, read more about the changes to the Nutrition Facts label requirements .

More on the Nutrition Facts Label

How to Understand and Use the Nutrition Facts Label Learn how to use this information more effectively and easily.  

Interactive Nutrition Facts Label An interactive way to learn about the Nutrition Facts label and discover the wealth of information it contains.

For Educators

Health Educator’s Nutrition Toolkit Teach your audience how to use the Nutrition Facts label and to make informed choices.  

"Behind the Label” with FDA Information for Educators View this video for health educators that explains the changes to the Nutrition Facts label.

For Youth & Youth Educators

Read the Label Use these hands-on materials to challenge kids and families to look for and use the Nutrition Facts label.  

Science and Our Food Supply | Curriculum for Middle/High School Teachers Introduce students to the fundamentals of informed food choices with this nutrition-based curriculum.  

Whyville Snack Shack Games Kids can play two fun games that test their knowledge about using the Nutrition Facts label to make healthy snack choices.

For Older Adults

A How-To Guide for Older Adults Good nutrition can help older adults feel their best and stay strong. It can also help lower the risk of developing some health conditions that are common among older adults.

For Physicians & Healthcare Professionals

Physicians' Continuing Medical Education Program Resources for talking to patients about using the Nutrition Facts label to make healthy food choices.

Pediatricians' Continuing Medical Education Program Resources for talking to parents and patients about using the Nutrition Facts label to make healthy food choices.

More on Labeling

Gluten-Free Labeling Learn how gluten-free labeling can help your audience manage health and dietary intake — especially those with celiac disease.

Calories on the Menu | Menu Labeling Information Find out how calorie labeling on menus can help your community make informed and healthful decisions about meals and snacks.

Sodium | Look at the Label Learn the basics on sodium’s health effects, how-to’s for using the Nutrition Facts label to reduce sodium intake, and more.

Using the Nutrition Facts Label to Choose Milk and Plant-Based Beverages Use the Nutrition Facts Label to compare the nutrient content of different products to help you make the best choices for you and your family when choosing milk and plant-based beverages.

CFSAN Education Resource Library

FDA's Center for Food Safety and Applied Nutrition (CFSAN) has a wealth of nutrition education materials.

Consumers, educators, teachers, dietitians, and health professionals are invited to explore CFSAN’s Education Resource Library – a catalog of downloadable and printable materials and videos on nutrition (including labeling and dietary supplements), food safety, and cosmetics.

Education Newsletter

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Healthy Food Choices in Schools

3 Ways Nutrition Influences Student Learning Potential and School Performance

Advocates of child health have experimented with students’ diets in the United States for more than twenty years.  Initial studies focused on benefits of improving the health of students are apparent.  Likewise, improved nutrition has the potential to positively influence students’ academic performance and behavior. 

Though researchers are still working to definitively prove the link, existing data suggests that with better nutrition students are better able to learn, students have fewer absences, and students’ behavior improves, causing fewer disruptions in the classroom. [1]

Improve Nutrition to Increase Brain Function

Several studies show that nutritional status can directly affect mental capacity among school-aged children. For example, iron deficiency, even in early stages, can decrease dopamine transmission, thus negatively impacting cognition. [2] Deficiencies in other vitamins and minerals, specifically thiamine, vitamin E, vitamin B, iodine, and zinc, are shown to inhibit cognitive abilities and mental concentration. [3]   Additionally, amino acid and carbohydrate supplementation can improve perception, intuition, and reasoning. [4] There are also a number of studies showing that improvements in nutrient intake can influence the cognitive ability and intelligence levels of school-aged children. [5]

Provide a Balanced Diet for Better Behaviors and Learning Environments

Good Nutrition helps students show up at school prepared to learn. Because improvements in nutrition make students healthier, students are likely to have fewer absences and attend class more frequently.  Studies show that malnutrition leads to behavior problems [6] , and that sugar has a negative impact on child behavior. [7]   However, these effects can be counteracted when children consume a balanced diet that includes protein, fat, complex carbohydrates, and fiber. Thus students will have more time in class, and students will have fewer interruptions in learning over the course of the school year.  Additionally, students’ behavior may improve and cause fewer disruptions in the classroom, creating a better learning environment for each student in the class.

Promote Diet Quality for Positive School Outcomes

Sociologists and economists have looked more closely at the impact of a student’s diet and nutrition on academic and behavioral outcomes.  Researchers generally find that a higher quality diet is associated with better performance on exams, [8] and that programs focused on increasing students’ health also show modest improvements in students’ academic test scores. [9]   Other studies find that improving the quality of students’ diets leads to students being on task more often, increases math test scores, possibly increases reading test scores, and increases attendance. [10]   Additionally, eliminating the sale of soft drinks in vending machines in schools and replacing them with other drinks had a positive effect on behavioral outcomes such as tardiness and disciplinary referrals. [11]

Every student has the potential to do well in school. Failing to provide good nutrition puts them at risk for missing out on meeting that potential.  However, taking action today  to provide healthier choices in schools can help to set students up for a successful future full of possibilities.

Contributor

David Just Phd- Cornell Center for Behavioral Economics in Child Nutrition Programs

[1] Sorhaindo, A., & Feinstein, L. (2006). What is the relationship between child nutrition and school outcomes. Wider Benefits of Learning Research Report No.18. Centre for Research on the Wider Benefits of Learning

[2] Pollitt E. (1993). Iron deficiency and cognitive function. Annual Review of Nutrition, 13, 521–537.

[3] Chenoweth, W. (2007). Vitamin B complex deficiency and excess. In R. Kliegman, H. Jenson, R. Behrman, & B. Stanton (Eds.), Nelson Textbook of Pediatrics, 18 th edition . Philadelphia: Saunders.

Greenbaum, L. (2007a). Vitamin E deficiency. In R. Kliegman, H. Jenson, R. Behrman, & B. Stanton (Eds.), Nelson Textbook of Pediatrics, 18 th Edition . Philadelphia: Saunders.

Greenbaum, L. (2007b). Micronutrient mineral deficiencies. In R. Kliegman, H. Jenson, R. Behrman, & B. Stanton (Eds.), Nelson Textbook of Pediatrics, 18 th Edition . Philadelphia: Saunders.

Bryan, J., Osendarp, S., Hughes, D., Calvaresi, E., Baghurst, K. & van Klinken, J. (2004). Nutrients for cognitive development in school-aged children. Nutrition Reviews, 62 (8), 295–306.

Delange, F. (2000) The role of iodine in brain development. Proceedings of the Nutrition Society, 59 , 75–79. Sandstead, H. (2000). Causes of iron and zinc deficiencies and their effects on brain. Journal of Nutrition, 130 , 347–349.

[4] Lieberman, H. (2003). Nutrition, brain function, and cognitive performance. Appetite, 40, 245–254.

Frisvold, D. (2012). Nutrition and cognitive achievement: An evaluation of the school breakfast program. Working Paper, Emory University.

[5] Benton, D. & Roberts, G. (1988). Effect of vitamin and mineral supplementation on intelligence in a sample of schoolchildren. The Lancet, 1, 140–143.

Schoenthaler, S., Amos, S., Doraz, W., Kelly, M., & Wakefield, J. (1991). Controlled trial of vitamin – mineral supplementation on intelligence and brain function. Personality and Individual Differences, 12, 343–350.

Benton, D. & Buts, J. (1990). Vitamins/mineral supplementation and intelligence. The Lancet, 335, 1158–1160.

Nelson, M. (1992) Vitamin and mineral supplementation and academic performance in schoolchildren. Proceedings of the Nutrition Society, 51, 303–313.

Eysenck, H., & Schoenthaler, S. (1997). Raising IQ level by vitamin and mineral supplementation. In R. Sternberg and E. Grigorenko (Eds.), Intelligence, heredity and environment (pp. 363 – 392). Cambridge: Cambridge University Press.

[6] Kleinman, R., Murphy, J., Little, M., Pagano, M., Wehler, C., Regal, K., & Jellinek, M. (1998) Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics, 101(1), e3.

[7] Jones, T., Borg, W., Boulware, S., McCarthy, G., Sherwin, R., Tamborlane, W. (1995). Enhanced adrenomedullary response and increased susceptibility to neuroglygopenia: Mechanisms underlying the adverse effect of sugar ingestion in children. Journal of Pediatrics, 126, 171–177.

[8] Florence, M., Asbridge, M., & Veugelers, P. (2008). Diet quality and academic performance. Journal of School Health, 78, 209–215.

[9] Meyers, A., Sampson, A., Wietzman, M., Rogers, B., & Kayne, H. (1989). School breakfast program and school performance. American Journal of Diseases of Children, 143, 1234–1239.

Kleinman, R., Murphy, J., Little, M., Pagano, M., Wehler, C., Regal, K., & Jellinek, M. (1998) Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics, 101(1), e3.

[10] Powell, C., Walker, S., Chang, S., & Grantham-McGregor, S. (1998). Nutrition and education: A randomized trial of the effects of breakfast in rural primary school children. American Journal of Clinical Nutrition, 68, 873–879.

Cueto, S. (2001). Breakfast and dietary balance: The enKid study. Public Health Nutrition, 4, 1429–1431.

Storey, H., Pearce, J., Ashfield-Watt, P., Wood, L., Baines, E., & Nelson, M. (2011). A randomized controlled trial of the effect of school food and dining room modifications on classroom behaviour in secondary school children. European Journal of Clinical Nutrition, 65, 32–38.

Hollar, D., Messiah, S., Lopez-Mitnik, G., Hollar, T., Almon, M., & Agatston, A. (2010). Effect of a two-year obesity prevention intervention on percentile changes in body mass index and academic performance in low income elementary school children. American Journal of Public Health, 100(4), 646–653.

[11] Price, J. (2012). De-fizzing schools: The effect on student behavior of having vending machines in schools. Agricultural and Resource Economics Review, 41(1), 92–99.

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30 Million Kids in American Schools Deserve Better Nutrition

In the news / 23 February 2023

A closer look at the USDA’s latest proposal on added sugars in school meals

As a Stanford Impact Labs postdoctoral fellow working closely with Dr. Anisha Patel at the Stanford School of Medicine, I focus my research on understanding how policies that facilitate a healthy food environment improve health and prevent the onset of noncommunicable diseases, with the potential to reduce health disparities. 

When the U.S. Department of Agriculture (USDA) announced its current proposal to limit added sugars in school meals, I sat down with Stanford Impact Labs’ Kate Green Tripp to discuss the implications.

In early February 2023, the USDA announced new nutrition standards for school meals. What is important to understand about this?

School meals currently serve about 30 million children between the ages of 5 and 18 in the U.S. The majority of these kids are low-income or at increased risk of food and nutrition insecurity. School meals were first introduced in 1946 with the aim of improving food security, which simply means access to food. 

In 2010, the Healthy, Hunger-Free Kids Act strengthened nutrition standards for school meals to improve not only food security but also nutrition security — in other words, access to healthy and nutritious food. These standards limit the amount of salt, fat, and calories in school meals and standardize other requirements, such as ensuring that meals include whole grains, fruit, and vegetables. Yet no standard currently limits added sugar in school meals. The need for such a check has become urgent because research shows that school meals exceed the daily limit recommendation of added sugars per day. 

The Dietary Guidelines for Americans (DGA) recommend consuming less than 10% of total daily calories from added sugar, and the American Heart Association recommends limiting added sugar to less than 25 grams (~6 teaspoons) per day. On Feb. 3, 2023, the USDA announced a new  proposed rule on nutrition standards for school meals, which established a reduction of sodium and the first-ever limit on added sugars in school meals, in alignment with the DGA. If these new nutrition standards are implemented, school meals will be required to limit added sugar to less than 10% of total calories per day.

What does the average school meal look like now, specifically when it comes to sugar content?

Anecdotally, we know school meals have a lot of sugar, though few studies have evaluated the added sugar content. One study that assessed the amount of added sugars in school meals in 2014-2015 found that 92% of schools exceeded the limit recommendation (less than 10% of calories) in school breakfasts. The same study found that 67% of schools exceeded the limit recommendation in school lunches.

At the end of 2020,  Dr. Anisha Patel , associate professor at Stanford — in partnership with Cultiva La Salud, the Dolores Huerta Foundation, and the UC Nutrition Policy Institute — performed a  photovoice study to evaluate the perception of school meals among parents in elementary schools in the San Joaquin Valley. 

At that time, schools were operating virtually because of the COVID-19 pandemic, but parents were allowed to pick up meals for their kids. For this study, parents were asked to take photos of the foods they received, and then in focus groups, they discussed their perception of the meals. One topic parents discussed was the healthfulness of the meals. In particular, parents perceived that school meals were “ full of sugar . ¨ Working alongside two student interns in Dr. Patel’s lab — Jonathan Tyes, a medical student at the University of Louisville, and Brandon Cortes, a high school student — I used the photographs that parents provided to quantitatively evaluate the amount of added sugar in school meals.  

We  found that parents’ instincts were right: School meals are high in added sugar, and on average, school meals contain eight teaspoons (33 grams) of added sugars per day, which is two more teaspoons than the American Heart Association recommends as a daily limit. Like the previous study, we identified that the top sources of added sugar were items that are commonly consumed at breakfast, such as flavored milk, yogurt, pastries, bread, and dry fruit. We discovered some cases in which a single breakfast of a blueberry muffin, dry fruit, and low-fat milk provided up to 10 teaspoons of added sugar — almost twice the daily limit, all in one dose as a child’s start to the day.

What do we know about the health effects of sugar on school-age kids?

Added sugar is associated with many adverse health outcomes. For example, in the short term, sugar increases the risk of  tooth cavities . Added sugar is the leading cause of tooth decay in children, and high added sugar consumption in children is associated with excess  weight gain, which increases the risk of being overweight or obese. Added sugar is also associated with  cardiovascular risk factors in children, such as lipid alterations, non-alcoholic fatty liver disease, and high blood pressure. In overweight or obese children, a high intake of added sugar is also associated with insulin resistance.

A closer look at nutrition in American kids reveals alarming numbers:

• Children in the U.S. consume an average of  17 teaspoons (70.8 grams) of added sugar per day. 
• About 8 in 10 school-age children in the U.S. consume more than 10% of calories from added sugar.
• More than one-third of children in the U.S. meet the definition of overweight or obese .
• 1 in 5 adolescents have  pre-diabetes .
• 1 in 5 children ages 6-11 and more than half of adolescents have experienced  dental caries.

What will it take for the proposed standards to be implemented?

It is important to note that the USDA's proposed rule is simply that: a proposal. The USDA will receive  public comments for 60 days before developing the final rule. If the proposed rule doesn’t change, the policy will not be fully implemented until the 2027-2028 school year to allow schools to adjust to the necessary change s. In the meantime, in the 2025-2026 school year, the amount of added sugar will be limited on items that are the primary sources of added sugars in school meals, such as grain-based desserts (no more than 2 oz equivalents/week), breakfast cereals (no more than 6 grams/oz), yogurt (no more than 12 grams/6 oz), and flavored milk (no more than 10 grams/8 oz).  

I would like to see this policy be implemented sooner rather than later with stricter standards, but I am hopeful and recognize this as a huge step in the right direction. However, I anticipate the proposal will see a lot of pushback from the food industry, which is known for using a variety of tactics to prevent and delay health policies that could affect their economic interests. That makes this a particularly critical moment for children's health advocates to submit comments   supporting these standards and to remain vigilant until the standards are fully implemented.

In other exciting news, California is also considering passing a  bill that would limit added sugar in school meals based on the American Heart Association recommendation of less than 25 grams/day. If this bill passes, California will be the first state to have stricter added-sugar criteria, and this measure will likely be implemented sooner than the USDA standard.

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Childhood Nutrition Facts

Healthy eating in childhood and adolescence is important for proper growth and development and to prevent various health conditions. 1,2 The Dietary Guidelines for Americans, 2020–2025 recommend that people aged 2 years or older follow a healthy eating pattern that includes the following 2 :

• A variety of fruits and vegetables.
• Whole grains.
• Fat-free and low-fat dairy products.
• A variety of protein foods.

These guidelines also recommend that individuals limit calories from solid fats (major sources of saturated and trans fatty acids) and added sugars, and reduce sodium intake. 2 Unfortunately, most children and adolescents do not follow the recommendations set forth in the Dietary Guidelines for Americans . 2–4

Healthy eating can help individuals achieve and maintain a healthy body weight, consume important nutrients, and reduce the risk of developing health conditions such as 1,2

• High blood pressure.
• Heart disease.
• Type 2 diabetes.
• Osteoporosis.
• Iron deficiency.
• Dental caries (cavities).

The US Department of Agriculture provides healthy eating plans through MyPlate.gov .

• Schools are in a unique position to provide students with opportunities to learn about and practice healthy eating behaviors. 15
• Eating a healthy breakfast is associated with improved cognitive function (especially memory), reduced absenteeism, and improved mood. 16–18
• Adequate hydration may also improve cognitive function in children and adolescents, which is important for learning. 19–23  
• Between 2001 and 2010, consumption of sugar-sweetened beverages among children and adolescents decreased, but still accounts for 10% of total caloric intake. 10
• Between 2003 and 2010, total fruit intake and whole fruit intake among children and adolescents increased. However, most youth still do not meet fruit and vegetable recommendations. 11,12
• Empty calories from added sugars and solid fats contribute to 40% of daily calories for children and adolescents age 2–18 years—affecting the overall quality of their diets. Approximately half of these empty calories come from six sources: soda, fruit drinks, dairy desserts, grain desserts, pizza, and whole milk. 4   Most youth do not consume the recommended amount of total water. 13
• CDC School Nutrition Environment
• Dietary Guidelines for Americans, 2020–2025
• National Cancer Institute’s Risk Factor Monitoring and Methods: Food Sources Data on US dietary intake of the top food sources
• School Health Guidelines to Promote Healthy Eating and Physical Activity
• Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary Health and Human Services and the Secretary of Agriculture . Washington, DC: US Department of Health and Human Services; 2015.
• US Department of Health and Human Services and US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans . 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/ .
• Krebs-Smith SM, Guenther PM, Subar AF, et al. Americans do not meet federal dietary recommendations. Journal of Nutrition. 2010;140:1832–1838.
• Reedy J, Krebs-Smith SM. Dietary Sources of Energy, Solid fats, and added sugars among children and adolescents in the united States. Journal of the American Dietetic Association. 2010;110:1477–1484.
• Institute of Medicine. Preventing Childhood Obesity: Health in the Balance . Washington, DC: The National Academies Press ; 2004.
• Kushi LH, Byers T, Doyle C, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. A Cancer Journal for Clinicians 2006;56:254–281.
• Kaiser LL, Townsend MS. Food insecurity among US children: Implications for nutrition and health. Topics in Clinical Nutrition. 2005;20:313–320.
• Alaimo K, Olson CM, Frongillo EA. Food insufficiency and American school-aged children’s cognitive, academic and psychosocial developments. Pediatrics  ,2001;108:44–53.
• Kleinman RE, Murphy JM, Little M, et al. Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics, 1998;101:1–6.
• Mesirow MA, Welsh JA. Changing beverage consumption patterns have resulted in fewer liquid calories in the diets of US children: National health and nutrition examination survey 2001–2010. Journal of the Academy of Nutrition and Dietetics . 2015;115(4):559–66.
• Kim SA, Moore LV, Galuska D, et al. Vital Signs: Fruit and vegetable intake among children—United States, 2003–2010. MMWR . 2014; 63(No. RR-31):671–6.
• Drewnowski A, Rehm CD. Socioeconomic gradient in consumption of whole fruit and 100% fruit juice among US children and adults. Nutr J. 2015;14:3.
• Drewnowski A, Rehm CD, Constant F. Water and beverage consumption among children age 4–13 years in the United States: Analyses of 2005–2010 NHANES data. Nutr J. 2013;12(1):85.
• US Department of Agriculture. MyPlate.gov .
• Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR . 2011;60(RR05):1–76.
• Taras HL. Nutrition and student performance at school. Journal of School Health. 2005;75:199–213.
• Rampersaud GC, Pereira MA, Girard BL, et al. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. Journal of the American Dietetic Association. 2005;105:743–760.
• Hoyland A, Dye L, Lawton CL. A systematic review of the effect of breakfast on the cognitive performance of children and adolescents. Nutrition Research Reviews. 2009;22:220–243.
• Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and health. Nutrition Reviews. 2010;68(8):439–458.
• Kempton MJ, Ettinger U, Foster R, et al. Dehydration affects brain structure and function in healthy adolescents. Human Brain Mapping. 2011;32:71–79.
• Edmonds CJ, Jeffes B. Does having a drink help you think? 6 to 7-year-old children show improvements in cognitive performance from baseline to test after having a drink of water. Appetite. 2009;53:469–472.
• Edmonds CJ, Burford D. Should children drink more water? The effects of drinking water on cognition in children. Appetite. 2009;52:776–779.
• Benton D, Burgess N. The effect of the consumption of water on the memory and attention of children. Appetite. 2009;53:143–146.

Healthy Youth

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Nutrition and Food Literacy: Framing the Challenges to Health Communication

Paula silva.

1 Laboratory of Histology and Embryology, Department of Microscopy, School of Medicine and Biomedical Sciences (ICBAS), University of Porto (U.Porto), Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal

2 iNOVA Media Lab, ICNOVA-NOVA Institute of Communication, NOVA School of Social Sciences and Humanities, Universidade NOVA de Lisboa, 1069-061 Lisbon, Portugal

Rita Araújo

3 Departamento de Artes e Humanidades, Escola Superior de Comunicação, Administração e Turismo, Instituto Politécnico de Bragança, Campus do Cruzeiro—Avenida 25 de Abril, Cruzeiro, Lote 2, Apartado 128, 5370-202 Mirandela, Portugal; [email protected]

Felisbela Lopes

4 Centro de Estudos de Comunicação e Sociedade, Instituto de Ciências Sociais, Universidade do Minho, Campus de Gualtar, 4710-057 Braga, Portugal; tp.ohnimu.sci@alebsilef

Sumantra Ray

5 NNEdPro Global Institute for Food, Nutrition & Health, Cambridge CB4 0WS, UK; [email protected]

6 School of Biomedical Sciences, Ulster University at Coleraine, Coleraine BT52 1SA, UK

7 Fitzwilliam College, University of Cambridge, Cambridge CB3 0DG, UK

Associated Data

Not applicable.

Nutrition and food literacy are two important concepts that are often used interchangeably, but they are not synonymous. Nutrition refers to the study of how food affects the body, while food literacy refers to the knowledge, skills, and attitudes necessary to make informed decisions about food and its impact on health. Despite the growing awareness of the importance of food literacy, food illiteracy remains a global issue, affecting people of all ages, backgrounds, and socioeconomic status. Food illiteracy has serious health implications as it contributes to health inequities, particularly among vulnerable populations. In addition, food literacy is a complex and multidisciplinary field, and there are numerous challenges to health communication that must be addressed to effectively promote food literacy and improve health outcomes. Addressing food illiteracy and the challenges to health communication is essential to promote health equity and improve health outcomes for all populations.

1. Introduction

The world is becoming increasingly complex. It is hard to keep up with everything that is going on in the news, let alone all the information needed to know just to navigate your day-to-day life. Every day, people worldwide feel confused about what to eat for health. People look for science-based information but struggle with the vast amount of information and do not know what to believe. People feel that scientists do not agree with each other and are constantly changing their minds. With so much information about what people should eat and how much exercise they should do each day, it can be difficult for even the most educated people to sort through it all, and this confusion can lead them to make unhealthy choices when they are not aware of what they are doing [ 1 , 2 ]. In the first part of the paper, we attempted to clarify the differences between nutrition and food literacy, which are often wrongly used as synonyms. We explored food illiteracy as a major global issue that leads to poor health outcomes and even death [ 3 ]. Food illiteracy also promotes health inequities, especially if it is combined with other factors such as poverty and a lack of access to fresh foods or proper nutrition education programs [ 4 ]. Food literacy is an important aspect of health literacy because it helps individuals make informed decisions about what they eat and how it affects their health [ 2 ]. In a world where processed and fast foods are often more convenient and accessible than nutritious options [ 5 ], having food literacy can make a big difference in a person’s overall health and well-being. It can also help to prevent chronic health conditions such as obesity, heart disease, and type 2 diabetes, which are often related to poor diet and nutrition [ 6 ]. In the last part of the paper, we explain how food literacy must be framed in the context of health literacy, the importance of both knowledge and skills in food and nutrition, and the broader understanding of health and wellness that is necessary for individuals to make informed choices and decisions about their health.

We conducted a literature review to provide an overview of the challenges to health communication concerning nutrition and food literacy. The results are presented as a topical review. We would like to emphasize that this manuscript constitutes a literature review that offers a comprehensive summary of the research findings gathered from diverse sources. Its purpose is to present a holistic overview of existing research on a specific topic without strictly adhering to rigorous systematic review methodologies, such as a formal systematic search strategy or strict inclusion and exclusion criteria. Scopus and Web of Science were used to conduct the search. Multiple search terms were used, including “nutrition literacy”, “food literacy”, “nutritional literacy”, “health literacy”, “health communication”, and “science communication”. Only reports written in English were considered, regardless of whether they were published. A strategy known as “pearl-fishing” or “chaining” chaining’ was employed to identify relevant research articles. This involved a thorough examination of references in other articles, as well as recent articles that cited older, pertinent articles. The selection was limited to papers published in English in peer-reviewed journals and book chapters. Initially, the abstracts were reviewed to gauge their relevance, resulting in the identification of 215 papers. Each of these studies was meticulously studied and analyzed. This process led to the discovery of additional pertinent references, resulting in the inclusion of 161 additional relevant papers in this comprehensive review.

3. Health, Nutrition, and Food Literacy

According to Scopus and Web of Science, nutrition literacy appeared first in the title of a scientific document in 1995 in a study carried out by Sullivan and Gottschall-Pass that was carried out to assess the food label nutrition knowledge of healthy Canadians, i.e., to evaluate their nutrition literacy [ 7 ]. Nutrition literacy continued to be used without a specific definition; it was used under the umbrella of the more general term health literacy. The definition of nutrition literacy evolved from the tripartite model of health literacy developed by Don Nutbeam, who defined it as a set of cognitive and social abilities that affect an individual’s motivation and capacity to access, understand, and manage information that allows the promotion and maintenance of a healthy status. According to this definition, health literacy is more than being able to read package inserts or being successful in appointments and exam schedules, rather it is being able to make informed decisions [ 8 ].

Don Nutbeam [ 8 ] identified three health literacy levels: functional, communicative/interactive, and critical. A functional or basic level of health literacy implies knowing how to read and write, understanding simple health messages, and being able to act according to the health information provided. The functional level highlights the importance of knowing health risks, health services, and a set of healthcare recommendations. This includes understanding the labelling of prescription drugs and the ability to read instructions for taking prescription medication. This information is usually distributed to the public through leaflets as the objective is to obtain global benefits [ 8 ]. The communicative/interactive level involves a more advanced cognitive level and developed skills that allow individuals to seek and use health information to respond to changing needs. At this level, the focus is on improving individual capacities such as lifestyle changes and the effective use of health services. It also involves the ability to discuss information with health professionals to make informed decisions [ 8 ]. For example, it includes understanding a treatment option and how that treatment compares with other options. The most advanced level is critical literacy, which implies an even more advanced cognitive level that allows the individual to critically analyze health information and use the results of their analysis to be alert and thus acquire control over their life events [ 8 ]. However, the definition of these three levels of health literacy has some limitations. They only apply to literate communities and assume that a high level of education corresponds to a high level of health literacy and that this is a prerequisite or guarantee that the person will respond in the desired way, which may not correspond to reality [ 9 ].

Nutrition and food literacy are two linked concepts related to the ability to understand and apply knowledge about food. Understanding the differences between these concepts is crucial. Definitions in the literature are presented in Table 1 . Briefly, nutrition literacy (sometimes mentioned as nutritional literacy) has to do with understanding the role of various nutrients in healthy eating, as well as how to read nutrition labels and make healthy food choices. Food literacy focuses more on the social aspects of food: how it is produced, where it comes from, who grows it, and how these things affect our health.

Nutrition and food literacy definitions found in the literature.

Nutrition literacy is the level to which people can acquire, process, and comprehend the fundamental nutritional data and services that they need to make correct dietary decisions [ 10 ]. This implies having the knowledge of nutritional principles and the ability to understand, analyze, and use nutritional information; that is, to know the nutrients and their health effects [ 11 ]. It involves an individual’s capacity to acquire, understand, and use nutritional information from several sources [ 12 ]. This includes knowing how foods are digested, their relationship with health, and how to use this information to make healthy choices.

Having nutrition literacy may not be sufficient to achieve the desired well-being and health. It is necessary to have food literacy; that is, to have knowledge, skills, and behaviors that are interrelated and that are necessary to decide, handle, choose, cook, and eat food [ 13 , 14 , 15 ]. Food literacy is an individual’s ability to make decisions that lead to better individual health status and lead to a sustainable food system considering all social, environmental, cultural, economic, and political factors [ 16 ]. Krause et al. (2016) defined nutrition literacy as a subfield of food, with both being specific dimensions of health literacy [ 17 ]. According to the authors, nutrition and food literacy are different but complementary concepts. The main difference lies in the skills needed to be literate in nutrition, food, or health. Thus, nutrition literacy consists of the ability to understand basic nutritional information, which is a requirement for a broader array of skills defined for food literacy. The authors suggest the use of food literacy instead of nutrition literacy as it is broader and includes the skills necessary for healthy and responsible eating behavior [ 17 ].

Vidgen (2016) identified eight domains of food literacy: (1) access; (2) management and planning; (3) selection; (4) knowledge of food origin; (5) preparation; (6) eating; (7) nutrition; and (8) language [ 18 ]. Truman et al. (2017) expanded the components of the definition of food literacy by considering six core themes: (1) capabilities and behaviors; (2) healthy food and choices; (3) culture; (4) knowledge; (5) emotions; and (6) food systems [ 15 ].

Food literacy measurement involves evaluating the following skills: reading, understanding, and analyzing information; gathering and sharing nutrition and food knowledge; shopping and preparing food; and evaluating the factors that impact their individual food choices and their influence on society [ 17 ].

Vettori et al. (2019) highlight the importance of evaluating the skills needed to access and adhere to a healthy diet when measuring nutrition and food literacy [ 19 ]. A nutrition and food-literate community includes people who eat to ensure their health and well-being while ensuring a sustainable food system. Nutrition and food literacy reflect the individual’s inspiration to adopt suitable behaviors and healthy food choices for oneself, others, and the environment [ 19 ].

Health, food, and nutrition literacy are critical factors that impact every level of prevention in health and disease ( Figure 1 ). Primary prevention refers to actions taken to prevent the disease onset. Health literacy is essential in promoting healthy lifestyles and behaviors that can prevent chronic diseases. Eating a healthy diet rich in fruits, vegetables, whole grains, and lean proteins can reduce the risk of developing conditions like heart disease, diabetes, and certain types of cancer. Education about the importance of a balanced diet and how to read nutrition labels can also help people make healthier food choices [ 20 , 21 ]. Secondary prevention refers to actions taken to detect and treat a disease early before it causes significant harm. Food and nutrition literacy is critical in secondary prevention because it enables individuals to make informed decisions about their diet and lifestyle to manage chronic conditions such as high blood pressure, high cholesterol, and diabetes. For example, individuals with food and nutrition literacy may be able to modify their diet to reduce their risk of developing complications from these conditions [ 20 ]. Finally, tertiary prevention focuses on managing the complications and symptoms of chronic diseases. Health literacy is essential in tertiary prevention because it enables individuals to understand their condition and adhere to their treatment plan. Education about how to read food labels, plan meals, and cook healthy foods can help these individuals better manage their condition and prevent complications [ 20 ].

Health, nutrition, and food literacy play a critical role in the prevention and management of diseases across all stages of prevention. The authors acknowledge NNEdPro for the figure conceptualization.

A comprehensive understanding of nutrition literacy is imperative in today’s complex world. It should not be isolated from the two other critical components of health and food literacy. This integration is of paramount importance in providing individuals with a comprehensive understanding of how their dietary choices affect their overall health and broader societal and economic well-being. Health literacy emphasizes the importance of informed decision making in health matters. Food literacy extends health literacy scope to include the social, cultural, economic, and environmental dimensions of food. This broader understanding of nutrition literacy extends beyond simply acquiring knowledge and interpreting food labels. It serves as a reminder that nutrition literacy encompasses a wider social, cultural, and political context, operating at personal, interpersonal, and societal levels. The inclusion of these elements in nutrition literacy helps individuals make healthier food choices and appreciates the wider implications of their dietary decisions. Therefore, a comprehensive conception of nutrition literacy ought to incorporate crucial components of both health and food literacy to provide individuals with a comprehensive understanding of the significance of nutrition in their lives. It is not simply a matter of knowing what to consume; it also involves understanding the rationale behind its significance and integration into the broader context of health and sustainability. This comprehensive approach has the potential to lead to healthy individuals and a sustainable global community [ 12 ].

4. The Emergence of Food Illiteracy as a Global Issue

The increase in non-communicable diseases related to unhealthy lifestyle habits, including diet, is usually related to food illiteracy increase [ 22 , 23 ]. The latter could be explained by the lack of knowledge about navigating the complex food system and ensuring regular food intake according to nutritional recommendations [ 19 ]. Food systems have become highly complex in the 21st century with the “nutrition transition”, characterized by the increase in variety, availability, and accessibility of processed and ultra-processed and low nutrient and energy-dense food [ 24 , 25 , 26 ]. This type of food is typically mass-produced and has a long shelf life. In addition, it is a very popular food type because it is heavily marketed and easily available in supermarkets, restaurants, and vending machines, or because it can be ordered on the Internet and consumed at home. Today, people have less time to prepare meals from scratch than ever before, which can lead them to consume unhealthy foods that are easy to prepare. The consumption of pre-prepared food and the increase in takeout meals reduces the time spent in the kitchen. Consequently, a decline in cooking and food preparation skills has been observed. As older people stop cooking, they miss the opportunity to teach younger people [ 24 , 26 , 27 ].

The emergence of food illiteracy as a global issue due to the modern lifestyle and diet of many people around the world is a serious problem [ 24 ]. Several factors contribute to food illiteracy, including a lack of access to education about healthy eating, lack of access to affordable healthy food, lack of time to cook healthy meals, lack of knowledge about how to prepare healthy meals, and high levels of stress, which can lead to unhealthy eating habits [ 28 ]. These determinants of health play a significant role in shaping food and health literacy [ 17 ]. They are crucial for governments when determining equity and resource allocations. Therefore, directing more funding towards increasing literacy, especially among disadvantaged groups, can be a key strategy in addressing the broader issue of food illiteracy and its associated health challenges.

Food illiteracy is a growing problem in many countries worldwide as people are exposed to misinformation about the food they consume and its effects on their health [ 29 ]. When people have a low level of food literacy, they may be unaware of how much salt or sugar is in their food or how many calories are in a serving. They may not know which ingredients are good or bad for them. They might not realize what types of foods they should eat more often or less often, based on their age or health status [ 30 , 31 , 32 ]. There are two types of food illiteracy: the first is when people do not know what certain foods are or how to prepare them, and the second is when people have a poor understanding of the nutritional value of different foods and do not know how to properly balance meals [ 28 ]. This lack of knowledge about what we eat has led to unprecedented rates of obesity and diabetes, which often lead to other health problems such as cardiovascular disease and kidney disease. Although many people know that diet plays a role in weight gain and obesity, they may not realize that diet also has an impact on diabetes [ 33 ]. Research has suggested that certain dietary habits can help reverse diabetes by enhancing insulin sensitivity and reducing blood sugar levels [ 34 ]. If the prevalence of obesity continues to increase, almost half of the world’s adult population will become overweight or obese by 2030 [ 35 ]. The government and health authorities have highlighted the health and social complications related to inappropriate dietary patterns [ 36 ].

Children’s food literacy rates are low. Many schools or day-cares do not provide students with healthy meals during school hours; instead, they rely on parents to pack lunches from home or provide snacks from vending machines that only offer sugary snacks such as chips or candy bars instead of healthier options such as fruits or yoghurt bars [ 37 ]. Early life stages represent an important period since lifelong habits are developed and life circumstances influence health outcomes in adulthood. The important social, emotional, and cognitive changes that occur during youth mean that there is a greater tendency to engage in risky behaviors during this life phase. Irresponsible eating habits can have negative health effects with individual, familial, and social consequences [ 38 ]. Therefore, improving healthy eating habits and lifestyles in the early stages of life is of major concern worldwide. Eating is a socially constructed practice that is important for understanding and pursuing health [ 39 ]. However, food and eating practices occupy a relatively minor place in the scholarship. Communication with the public is the initial stage of the behavior-change process and is a crucial piece of effective public policy [ 40 ]. To combat this problem, governments should invest more money in educating children about healthy eating habits at school so that they can make good choices throughout their lives [ 41 ].

Food illiteracy has also been shown to be a major contributor to food waste. Approximately one-third of all food produced worldwide is wasted, and this number continues to increase annually [ 42 ]. This is a problem because of wasted resources and can have serious health, social, economic, and environmental effects [ 43 ]. Food waste begins at home, where consumers often buy more than they need or want and then waste what is left over when they do so [ 44 ]. The health effects of food waste are numerous. For example, the loss of nutrients from discarded fruits and vegetables means that people who eat this food have a lower nutritional intake than those who do not [ 45 ]. Additionally, when food is discarded instead of eaten, it causes greenhouse gas emissions by rotting in landfills [ 46 , 47 ]. Food waste also has economic and environmental effects. If more fruits and vegetables are eaten rather than thrown away after reaching their expiration dates, more money would be saved by consumers who would not need to buy new produce. Moreover, people consume more processed foods than ever before, causing them to throw away more packaging [ 48 ]. However, there are other factors at play here too: climate change is causing droughts around the world, which means that crops are failing due to a lack of rain and heat stress on plants during ripening periods. The result is less food available for everyone, from farmers down to consumers, which means higher prices on produce at grocery stores which causes consumers to buy less healthy foods overall because they are too expensive for their budgets [ 49 ].

Measuring food literacy is of the utmost importance. According to a recent scoping review, there are now 12 tools available to assess adult food literacy. The authors found that even though most of them cover all four aspects of food literacy, theoretical frameworks are rarely applied. They also concluded that existing tools have only been tested in a few situations, and they mainly rely on biased self-reporting techniques [ 50 ]. The self-perceived food literacy scale (SPFL) and the short food literacy questionnaire (SFLQ) are the ones that have been validated in more countries [ 51 , 52 , 53 , 54 , 55 , 56 ]. Both primarily concentrate on individuals’ skills and competencies needed for making appropriate food choices [ 57 ]. The SPFL scale was created by Poelman et al. (2018) to measure adults’ food literacy concerning healthy diets, knowledge, skills, and behaviors necessary for the appropriate planning, management, selection, preparation, and consumption of food [ 53 ]. Despite limited application, generally, SPFL revealed that better food literacy was linked to better impulse control, less impulsive behavior, and healthier food consumption [ 53 ] and that adults with a low and medium level of education have a low food literacy level [ 58 ]. The relationship between Body Mass Index (BMI) and SPFL was also analyzed, and depending on the context, BMI may predict [ 52 , 59 ] or have no effect on the SPFL final score [ 58 ].

The SFLQ [ 57 ] scale has been used in food and nutrition intervention research to assess respondents’ functional, interactive, and critical food literacy abilities. Consumers in Italy who had received specialized education in human nutrition scored higher on the SFLQ and SPFL than those without this knowledge. Furthermore, the SFLQ scores were notably higher among women [ 59 ].

5. Food Literacy Health Inequities

In recent years, there has been an increased interest in exploring the relationship between food literacy and health outcomes. As already mentioned, people who lack basic knowledge about food tend to be more likely to develop illnesses like obesity, heart disease, diabetes, and cancer [ 6 ]. Therefore, it is important to understand the factors that contribute to the issues surrounding food literacy and health inequities to help policymakers and educators combat them altogether. Sometimes, inequity and inequality are wrongly used as synonyms, although the former entails determining whether the inequality is morally incorrect, while the latter is just a dimensional description used anytime numbers are uneven [ 60 ]. “Health inequities are differences in health status or the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age” [ 61 ]. These social factors may include, but are not limited to, democratic decision-making procedures, accessibility of financial resources, environmental disadvantages, and opportunity structures.

Health inequity is evident across all life stages, from birth to old age [ 62 ]. Hargrove (2018) found that BMI trajectory throughout the transition to adulthood is shaped by several factors, including race and ethnicity, gender, and socioeconomic level of origin [ 63 ]. A recent retrospective study found that early life adversity was associated with overall dietary quality outcomes. However, the authors suggested that other factors also drive dietary quality, including limited access to reliable information about food to make informed decisions about food choices for healthy living [ 64 ]. These studies show that the relationship between health and socioeconomic status is not simple, nor does it adhere to a single linear pattern. Rather, health disparities are influenced by multiple factors that may reflect a complex combination of the effects of social disadvantage, discrimination, power differentials, and access to resources within environments that include cultural norms, policies, and practices. Butcher et al. (2020) conducted a case study to analyze Australian food literacy education programs throughout the life cycle and their effects on reducing health disparities for those who are at risk of social and economic disadvantages. The authors found that programs promoting food literacy are essential to enhance the health of vulnerable groups [ 65 ].

Food literacy is especially important for disadvantaged populations as they are more likely to suffer from food-related health inequities due to their limited access to healthy foods and information about how healthy diets can improve their lives. It is noted that most people in developed nations have high levels of food literacy, but those in developing countries do not [ 66 ]. Even in industrialized nations, those who live in rural and regional areas are more likely to face social and economic deprivation, prejudice, and possible social or physical isolation; all these factors may eventually affect their access to health care and wholesome food [ 65 , 67 ]. Moreover, marketers of unhealthy food usually target disadvantaged populations that have fewer opportunities to correct disinformation [ 68 , 69 , 70 ].

Education programs should focus on improving levels of food literacy among populations with low levels of education—this would help reduce health inequities globally while also making sure that everyone has access to nutritious foods and knows how best to prepare them.

6. Food and Nutrition Disinformation: Challenges to Health Communication

Media and personal experiences influence individual food choices. The information consumed about a specific food impacts the individual perception of it. Food and nutrition disinformation is one of the challenges to health communication. Disinformation spread through various channels, such as social media, online forums, and even mainstream media, can lead to confusion and misinterpretation of nutritional information, resulting in harmful dietary practices and misinformed health decisions. It is crucial to conduct a critical analysis of the information and to seek out credible sources for nutrition advice [ 71 , 72 ].

The internet and social media enable information to be shared rapidly and widely, including disinformation. Therefore, it is difficult for health authorities to counter false claims and keep up with untrue information spread. There are several reasons why people may turn to the Internet and social media for food and nutrition information [ 73 ]. Some people may be looking for specific information about a type of food, such as nutritional values or health benefits [ 74 ]. Others may be looking for recipes, meal ideas, or cooking tips [ 75 ]. Additionally, some people may be motivated to use the Internet and social media for food and nutrition information due to health concerns, such as weight loss, diabetes, or food allergies [ 76 , 77 ]. Social media can also play a role in people’s food choices and food-related behaviors as they may be influenced by the food-related content they see on these platforms [ 78 ].

Some food and beverage companies, as well as individuals and organizations, spread disinformation to promote their financial interests. Disinformation about food and nutrition is spread by the food industry through advertising, marketing, and lobbying, which can contribute to confusion and misconceptions about food choices [ 79 ]. This can include promoting unhealthy products or claiming that certain ingredients are more healthy than they are [ 1 ]. There is evidence that food advertisements go against nutritional recommendations, which blocks the flow of knowledge about nutrition [ 69 , 80 ].

Many people lack the scientific literacy needed to critically evaluate nutritional information and distinguish between credible and non-credible sources [ 81 ]. Despite the individual level of literacy, there is often a lot of conflicting information about what is considered a healthy diet, making it difficult for people to determine what is truly beneficial for their health [ 82 ]. A recent study found that despite Mexican American women articulating links between diet and disease, they felt overwhelmed and perplexed by the contradicting information from both official and private sources. Moreover, those women mentioned the existence of critical information gaps, distinguishing between the information available and the information needed [ 83 ]. Multiple and conflicting sources of information are also something that parents usually face when trying to provide healthy food [ 84 ].

Despite the efforts of government agencies and the existence of healthy eating guidelines, there is an ongoing need to address these challenges. Health organizations must continue to provide credible, evidence-based information and promote scientific literacy among the public. Health professionals and nutrition experts should be vigilant in detecting and countering misinformation regarding food and nutrition. Furthermore, social media companies and other online platforms can play a pivotal role in reducing the spread of disinformation by promoting credible sources of information and limiting false claims.

6.1. Health Communication

Before defining nutrition and food communication, it is also important to clarify the meaning of health communication. Simply, it is the application of communication approaches to inform and affect decisions and actions to improve individual and global health. However, this simple definition has changed over time.

In 1996, Roger defined health communication as any human communication type related to health [ 85 ]. In the same year, Ratzan, Payne, and Bishop advanced with a more complete definition by affirming that health communication deals with the combination of a man’s physical, occupational, and intellectual dimensions, which guarantee human well-being [ 86 ]. Two years later, Gary Kreps and his colleagues (1998) described health communication as a vibrating and critical field of study dealing with the influence of human and mediated communication in health care delivery and health promotion [ 87 ]. In the same article, the authors distinguish health care delivery and health promotion as two sub-areas of health communication study. Researchers dedicated to health care delivery analyze the effects of communication in the provision of health care. Those dedicated to the study of health promotion aim to study the messages and means used in public health promotion [ 87 ]. Later, in 2006, the importance of health communication in promoting public health was reinforced by Thomas, who said that health communication is a powerful tool for transmitting messages that impact the quality of life of populations and policy formulation [ 88 ]. According to Thomas, communication can be between a physician and patient or a health or communication professional and the public and can use a wide range of print, audio-visual, and virtual media to achieve its goals [ 88 ]. In 2009, the book “ Emerging perspectives in health communication: Meaning, culture, and power ” was published, in which the authors, Heather M. Zoller and Mohan J. Dutta, define health communication as a set of communication processes and messages in which health issues are the focus [ 89 ]. Zoller and Dutta divided health communication into two sub-areas, which were different from the ones previously established by Kreps et al. [ 87 ]: one that studies communication processes and one that analyses messages [ 89 ].

According to Liu and Chen (2010), health communication is essential for health prevention and promotion, doctor–patient relationship improvement, public health awareness, and health risks communication [ 90 ]. The same authors remarked that health communication must be done through different channels to be successful in influencing people’s attitudes and in encouraging behavior change through a more healthy lifestyle. Liu and Chen argued that successful health communication strengthens an individual’s awareness of the value of their health and improves their readiness to face potential future health challenges. Additionally, Liu and Chen highlighted the importance of communication to change public health, improve public health services, and improve life quality at individual and community levels [ 90 ]. Schiavo’s (2013) definition of health communication is one of the most agreed-upon definitions within the scientific community: “health communication is a multifaceted and multidisciplinary field of research, theory, and practice. It is concerned with reaching different populations and groups to exchange health-related information, ideas, and methods in order to influence, engage, empower, and support individuals, communities, health care professionals, patients, policymakers, organizations, special groups and the public, so that they will champion, introduce, adopt, or sustain a health or social behavior, practice, or policy that will ultimately improve individual, community, and public health outcomes.” [ 91 ].

6.2. Nutrition and Food Communication

Food is a basic and essential need for human survival and healthy life. Eating behavior depends on several factors, including environmental, economic, political, and social [ 92 ]. In recent decades, all over the world, there has been an increase in diseases related to unhealthy diets. Inadequate nutrition practices are associated with an increased risk of noncommunicable diseases [ 93 ]. Obesity, for example, is one of the major risks for heart failure [ 94 ], type 2 diabetes [ 95 ], hypertension, and coronary heart disease [ 96 ]. In this context, nutrition and food communication is crucial to influence healthy eating behaviors.

The principles for effective nutrition and food communication are, in many ways, close to the theories of social marketing because it applies marketing rules and procedures to persuade a target audience to voluntarily accept, refuse, change, or stop a specific behavior [ 97 ]. Kotler and Zaltman (1971) first proposed that the principles of commercial marketing could be applied to ideas, behaviors, and relevant social programs. According to them, social marketing is the design, execution, and control of strategies that seek to increase the approval of a social idea or practice by a specific target audience. Therefore, marketing thinking can be applied to a range of social activities carried out by “non-business organizations” [ 98 ].

Andreasen’s definition of social marketing emphasizes that the purpose of social marketing is behavioral change. He defined social marketing as the application of commercial marketing tools to explore, develop, implement, and evaluate programs aimed to induce behavior change to improve individual well-being and that of society at large [ 99 ]. This definition includes four concepts: 1) voluntary behavioral change; (2) clear identification of the benefit of behavioral change by the target audience; (3) use of marketing techniques (consumer orientation, market research, segmentation, audience definition and marketing mix); and (4) individual improvement and collective well-being, not of the organizations involved in social action [ 100 ].

Social marketing implies a systematic planning process focused on behavior change, the development of clear messages, the design of interventions, their implementation, and the continuous evaluation of results [ 97 ]. Social marketing is a tool with great potential to motivate behavior change toward better health and, more specifically, is an effective mode of promoting healthy diets with individual, family, community, and social effects [ 101 , 102 , 103 , 104 ].

As with other health topics, food communication occurs at three different levels: at an individual level, studying the effects of communication on food knowledge and behaviors and the influence of interpersonal relationships between people, family members, health professionals, and their respective social networks on health outcomes. It occurs at an organizational level in the study of the effects of public communication on individual health. And finally, it occurs at a societal level, studying the effects of communication on large-scale social changes. Consequently, researchers must carry out multi-level research to identify, criticize, explain, predict, and understand the intrapersonal, interpersonal, group, organizational, cultural, media, and relevant social systems dynamics [ 105 ].

The dietary choices made by individuals have a significant impact on their health, which aligns with fundamental principles of public health. To promote public health, it is essential that individuals are equipped with knowledge and resources to comprehend and choose healthier food alternatives. Therefore, improving food communication with the public within the realm of public health initiatives is a pressing priority. This comprehensive communication strategy encompasses the dissemination of crucial messages not only by government agencies and health organizations but also by media outlets and food companies. The implementation of effective food communication, firmly rooted in the principles of public health, plays a pivotal role in enabling individuals to make informed dietary decisions. These decisions, in turn, have a significant impact on overall well-being, aligning with the fundamental objectives of public health initiatives [ 106 ].

As for other health topics, food communication must be framed in a way that is effective, trustworthy, and beneficial for public health. Therefore, the information should be accurate, science-based, and free from bias or conflicts of interest. Food communication must be audience-centered, clear, concise, easy to understand, and relevant to the needs and interests of the target audience. Moreover, the information should consider the audience’s cultural, social, and economic background. The information source should be trustworthy and credible, with a reputation for providing accurate and reliable information [ 107 ]. The information should empower people to make informed decisions about their food choices and health.

Governmental agencies can play a vital role in increasing food literacy by providing citizens with resources that help them make informed decisions about food. Governments must promote healthy eating habits through policy changes such as taxes on unhealthy foods [ 108 , 109 , 110 , 111 ] or subsidies for fresh vegetables and fruit [ 111 ]; these policies will help people make healthier choices such as reducing the consumption of salt [ 112 ] or sugar [ 113 , 114 ]. According to Nnoaham et al. (2009, p. 1330) “tax on unhealthy foods, combined with the appropriate amount of subsidy on fruits and vegetables, could lead to significant population health gains” [ 115 ]. This combination assumes particular importance in low-income populations, where governmental authorities should work with private organizations and businesses to implement programs that increase access to fresh fruits and vegetables [ 116 , 117 ]. While taxes and subsidies can be useful tools in reducing consumption and promoting health, they are not a panacea and must be implemented as part of a comprehensive approach that includes education, awareness-raising, and the availability of healthier options. When evaluating the effectiveness of taxation and subsidy programs, it is crucial to consider scientific research findings related to the factors influencing taxation outcomes. This includes understanding how taxes on unhealthy foods and beverages impact supply side changes in the nutritional value and environmental sustainability of the food supply. Additionally, it involves assessing consumer attitudes and knowledge about food, as well as macroeconomic outcomes such as governmental revenue, consumer welfare, and overall population and planetary health outcomes [ 110 ].

Providing clear and concise information about the ingredients, nutritional value, and origin of food products through labelling can help consumers make informed decisions about what they eat. Labels are a powerful tool to communicate nutrition information and improve food literacy since most people use this information consistently. Although a significant part of the population report looking for nutrition information on the label when shopping, they do not understand all of the information contained in the label [ 118 , 119 ]. Some studies report a lack of knowledge about some concepts like energy and energy terms [ 119 ], fiber [ 120 ], and serving size information [ 121 ]. Front-of-package nutrition messaging may guide consumers to healthy choices in some cases, but the understanding of label nutrition information depends on several socio-demographic factors and their interaction. For example, younger adults may be more likely to interpret label nutrition information [ 122 , 123 , 124 , 125 ], which does not necessarily mean that they use a food label to the desired level [ 120 ], and sometimes this can result in undesired consequences such as impacting young adults’ relationships with food and disordered eating [ 126 ]. Regarding gender, there are also some controversial results. Some studies revealed that females are more likely to use nutrition information on labels [ 118 , 122 , 127 ]. However, others did not find differences between male and female consumers in label nutrition information use [ 128 , 129 ]. Concerning socioeconomic factors, several studies have focused on education as a key indicator of the utilization of labelled nutrition information. People with higher levels of education tend to better understand nutrition information and how to interpret it [ 122 , 128 , 130 , 131 ]. Some studies show that low-income individuals may struggle to understand complex nutrition information [ 122 , 124 , 125 , 128 ]. These socio-demographic factors can interact and compound, making it difficult for some individuals to understand and use nutrition information effectively. It is important for nutrition education and outreach efforts to take these factors into account to ensure that everyone has the information they need to make informed food choices.

Encouraging people to grow their own food or participate in community farming programs can increase their understanding of where food comes from and how it is produced [ 132 ]. Teaching people how to cook healthy and nutritious meals can also increase their food literacy and knowledge of healthy eating habits [ 133 , 134 ]. Findings suggest that the incorporation of cooking programs and food literacy education into the curriculum can help young people develop healthy eating habits and a better understanding of food, which may positively influence children’s food-related preferences, attitudes, and behaviors [ 135 , 136 , 137 , 138 ].

Governments worldwide have expressed their concern by funding public education campaigns that promote the importance of food literacy and provide information on healthy eating habits, food preparation, and cooking. Launching these campaigns can significantly increase awareness and understanding among the public. Effective communication about nutrition improves people’s knowledge and ability to make decisions that lead to healthier diets. Regardless of the size, budget, and time available, successful message creation, implementation, and development require the involvement of researchers and multidisciplinary participation [ 100 , 139 ]. Most social marketing campaigns target young people, children, and teenagers and aim to change behaviors. In most cases, the intention is to encourage the consumption of fruit and vegetables and the adoption of healthier practices [ 140 ]. The most well-known food and nutrition campaigns, which served as the impetus for subsequent ones, began in the United States. The Henry L. Kaiser Family Foundation introduced “Low-Fat Eating for America Now” in 1987 to lower fat consumption to 30% of total calorie intake [ 141 , 142 ]. The California Department of Health Services began the “5 a Day for a Better Health” program in 1991 to promote the consumption of fruits and vegetables [ 143 ]. Also in 1991, the “Energize Your Life!” campaign was launched to promote healthy behaviors such as a balanced diet and physical exercise [ 144 ]. Also in the United States, the “Steps” campaign was implemented in 2005, aimed at African American women aged between 18 and 49, which, in addition to recommending the consumption of fruit and vegetables, sought to motivate them to practice regular physical exercise [ 145 ]. In 2007, the “5 a Day for a Better Health” campaign was replaced by the “Fruits and Veggies—More Matters” campaign, which aimed to increase adult knowledge about the recommendation and benefits of eating 7 to 13 servings of fruits and vegetables daily [ 146 ]. Between 2018 and 2019, there were several phases of the “Celebrate Your Plate health” campaign created by the University of Ohio, which had its pilot year in 2017. The campaign aimed to increase the consumption of fruits and vegetables and used a mix of communication channels, both print and digital. The study that was carried out to evaluate the effects of the campaign concluded that the campaign led to greater consumption and a greater intention to increase the consumption of fruits and vegetables but warned of the need for further studies to be carried out to determine the reason for causality [ 147 ]. Still in the United States, specifically in Multnomah County, Oregon, the campaign “It Starts Here” was launched in 2011 to inform residents about the high amount of sugar in soft drinks and sugary juices [ 148 ]. That same year, in Philadelphia, the “Get Healthy Philly” campaign was launched, aiming to reduce the consumption of sugary drinks by children to prevent obesity. As part of this campaign, leaflets were distributed and advertisements were made for radio and television. The use of the media was very favorable because, in addition to its great reach, a change of discourse was observed in different contexts directed towards the prevention of obesity [ 149 ]. In addition, the campaign increased the number of parents who changed their behavior after seeing the television advertisement and who started giving fewer sugary drinks to their children [ 150 ]. In 2016, the “Our health is in our hands” campaign was launched to raise obesity awareness and increase involvement in prevention, nutrition, and exercise programs offered by the Brooklyn Partnership to Drive Down Diabetes (BP3D) [ 151 ]. The excessive consumption of salt is also a concern of the authorities because it contributes to the onset of chronic diseases. During 2014–2015, the Philadelphia Department of Public Health conducted a campaign through radio, print news, and traffic signs to promote awareness of the link between salt consumption and cardiovascular disease and stroke [ 152 ]. Outside the United States, we highlight the campaigns carried out in Europe, such as “La Santé Vient en Mangeant” resulting from the “Manger Bouger” program launched in 2002 in France. The campaign aimed to improve the health status of the French, considering nutrition to be one of the change factors [ 153 ]. The campaign “Le Plaisir de Bien Manger et d’Être Actif!” began in 2007 in Luxembourg and consisted of a set of nutritional recommendations [ 153 ]. In Italy, the ViviSmart campaign aimed to promote a healthy diet and lifestyle among primary school children [ 154 ]. The first Portuguese campaign launched in 2017, under the slogan “Juntos contra o sal”, aimed to reduce salt intake by 3 g per day [ 155 , 156 ] and was followed by the campaigns “Juntos contra o açúcar” and “Juntos pela Alimentação saudável” [ 155 , 156 ]. In 2019, the first Portuguese campaign to promote a healthy diet was massively promoted through different means (television, radio, billboards, public transport, social media, and regional press). This campaign, entitled “Comer melhor, uma receita para a vida”, aimed to encourage the consumption of fruit, vegetables, legumes, and water [ 155 , 156 ].

Using social media and online resources to share information about food, nutrition, and healthy eating can reach a large audience and help to increase food literacy. One of the oldest digital ways of providing nutrition information is through websites. One study showed that interaction with the “5 a Day, the Rio Grande Way” website resulted in increased fruit and vegetable consumption by adult inhabitants of rural areas [ 157 ]. Digital interventions need to be audience-specific to be effective, as shown by obesity interventions for low-income mothers in rural areas [ 158 ], for teenagers [ 159 ], or to encourage healthy eating habits among middle-aged men for the prevention of chronic diseases [ 160 ].

The use of digital resources should be encouraged in classrooms. One study analyzed a blog created by students as part of a nutrition course called Food Logging and Blogging. The results show that blogs are an asset for promoting nutrition literacy and that their use in a pedagogical context is important [ 161 ]. Online information about healthy eating habits is needed to counterbalance the large number and diversity of marketing campaigns encouraging unhealthy food consumption to which young people are exposed. According to Cairns et al.’s (2013) review, most food marketing strategies target children and are for foods high in fat, salt, or sugar, such as sugary breakfast cereals, fast food, and soft drinks [ 162 ]. Rowbotham et al. (2020) conducted a review to map the way chronic disease prevention is addressed by the media and found that nutrition-related issues were predominant and that this issue had been driven by the fact that children are highly exposed to advertisements for unhealthy food [ 163 ]. A study carried out among mothers who wrote blogs where they provided information on maternal care, including health, showed that most articles were about nutrition and that these were also the most appreciated by followers. The study alerts us to the importance of these blogs being able to be used for successfully transmitting health information [ 164 ].

Nutrition is one of the most covered health topics on social media and this is increasing. A recent study that analyzed the behavior of adolescents concerning health-related content on social media showed that food care was the topic sought by 30% of respondents [ 165 ]. A retrospective analysis of the Facebook ® pages of German insurance companies also found that healthy eating is one of the topics most discussed on that social media [ 166 ]. Marketing campaigns such as Food Hero created by Oregon State University in 2009, within the scope of the Extension Nutrition Education Program, to promote the consumption of vegetables and fruits, were more successful on social media, namely Facebook ® , Twitter ® , and Pinterest ® , than through the other channels used [ 167 ]. As with other digital interventions, creators of nutrition content for social media must consider the target audience, the most appropriate platforms, and the most appropriate strategy for each of them [ 168 ]. The message and its source are the most important factors to consider. An experimental study analyzed the reaction of 700 secondary school students to images used in an anti-obesity campaign carried out on blogs, digital news, and Facebook ® . It was found that interaction with the media depends on the credibility of the source and that the campaign affects self-perception of weight, but the authors warn that there is a risk that images with provocative messages will have an effect contrary to the desired one [ 169 ]. When social media is used with nutrition messages targeted at young people, healthcare professionals face competition from influencers. A study compared young people’s reactions to Instagram ® and Youtube ® messages linked by influencers and nutritionists and concluded that the latter must improve their approach to these media [ 170 ]. The study recommends that those professionals use social media to inform young people and that they should create attractive and impactful messages. It also recommends that professionals report their own experiences and life stories, which their followers identify as increasing authenticity and reliability and generate greater persuasiveness [ 171 ]. An analysis on Twitter ® confirmed that, also on this platform, most articles published on nutrition are written by people with no training in the health field and that many of them can produce unwanted results [ 171 ]. Another study revealed that during the recent COVID-19 pandemic, nutrition was among the topics associated with a greater number of fake news [ 172 ]. On the other hand, the pandemic seems to have alerted nutritionists to the communication potential of social media to increase health literacy and not just to publicize their services, as they had done until then [ 173 ]. In short, social media has a high potential as a means of communication and it is important that health professionals [ 171 ] and other institutional entities, such as, for example, those responsible for school nutrition programs [ 2 ], start using them regularly and effectively.

Communication is a fundamental component of enhancing healthcare quality as it enhances patient safety, ensures care coordination, supports patient-centered practices, and facilitates collaboration among healthcare teams. An effective communication strategy ensures that healthcare providers, including doctors, nurses, specialists, and support staff, are on the same page regarding a patient’s treatment plan. Whenever everyone is informed, there is improved coordination in delivering care, reducing the risk of errors and ensuring that patients receive the right interventions at the right time. Clear and open communication helps to identify potential safety issues and prevent medical errors [ 174 , 175 ]. The provision of patient-centered care requires effective communication. It involves listening to patients, understanding their concerns, and involving them in decision-making regarding their treatment. This approach enhances patient satisfaction and leads to improved health outcomes [ 176 ]. Effective communication systems within healthcare organizations allow for the collection and analysis of data related to patient care. By sharing insights and outcomes, health care providers can identify areas where quality improvement is needed and implement changes accordingly [ 177 ]. In healthcare settings, various professionals work together as teams to manage patients’ healthcare. Communication among team members fosters collaboration, ensuring that everyone understands their role and responsibility. Miscommunication can result in misunderstandings, delays in care, or misinterpretations of patient information. Open and clear communication helps to prevent these issues, ensuring that healthcare providers receive accurate and relevant information about patients [ 178 ]. Communication with the patients is essential for their education. Those who are well informed are more likely to follow their treatment plans and make healthy lifestyle choices. Effective communication channels enable health care professionals to remain informed and actively participate in continuous learning, thereby elevating the standard of care they provide. Patients who feel heard, respected, and informed about their care are more likely to be satisfied with their healthcare experience, which can have a positive impact on the overall quality [ 175 ]. Communication is often a legal and ethical requirement in healthcare. Clear communication of risks and benefits is essential to meet these obligations and maintain the highest standards of care. By prioritizing effective communication, healthcare organizations can enhance patient outcomes and provide superior care.

7. Conclusions

Nutrition and food literacy are different concepts which refer to the understanding of the role that food plays in maintaining health and well-being. This includes knowledge of the nutritional value of different foods, the impact of food choices on health, and the ability to access, prepare, and cook nutritious meals. Unfortunately, the emergence of nutrition and food illiteracy as a global issue has led to widespread health problems, including the rise of chronic diseases such as obesity, diabetes, and cardiovascular disease. The creation of food literacy and health inequities is also a concern as certain groups, such as low-income populations and marginalized communities, may face additional barriers to accessing healthy food and nutrition information. This can lead to health disparities and further exacerbate existing health inequities. To address these issues, there is a growing need for food literacy pathways to health. This includes education and training programs that provide people with the knowledge, skills, and resources they need to make informed food choices and to access, prepare, and cook nutritious meals. These programs should be culturally and linguistically appropriate and should be accessible to all populations, including those who are at risk of nutrition and food illiteracy. Food and nutrition disinformation is another major challenge to health communication as it can lead people to make unhealthy food choices and undermine efforts to promote healthy eating. This is particularly true in the digital age, where false or misleading information about food and nutrition can spread quickly and widely through social media and other online channels. It is important for health professionals, educators, and policymakers to work together to address these challenges and to promote accurate and trustworthy information about food and nutrition. In conclusion, nutrition and food literacy is a critical aspect of maintaining health and well-being, and addressing the global problem of nutrition and food illiteracy is essential for promoting public health. By providing people with the knowledge, skills, and resources they need to make informed food choices and to access, prepare, and cook nutritious meals, we can help to improve health outcomes and reduce health inequities. The future of nutrition and food literacy holds immense promise. The complexities of the modern world present exciting opportunities for research, education, and policy development. Technological innovations, such as mobile apps and online resources, can be used to provide accessible and personalized nutrition guidance. Collaboration among healthcare professionals, educators, and community leaders can help create comprehensive food literacy programs that empower individuals from all backgrounds to make informed choices regarding their diet. Furthermore, we must advocate for policies that promote equitable access to healthy food and accurate nutritional information, especially for under-served populations. By taking advantage of these opportunities and forging partnerships, we can collectively work towards a future where nutrition and food literacy become powerful tools for improving public health, reducing disparities and fostering a culture of well-informed healthy living.

Acknowledgments

NNEdPro for Figure 1 conceptualization.

Funding Statement

This research was funded by FCT—The Foundation for Science and Technology, IP under Grant UIDB/05021/2020.

Author Contributions

Conceptualization, P.S. and S.R.; writing—original draft preparation, P.S.; writing—review and editing, P.S., R.A., F.L. and S.R. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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