Evid Based Nurs doi:10.1136/eb-2014-101881
  • Child health
  • Cross-sectional study

Low parent health literacy is associated with ‘obesogenic’ infant care behaviours

  1. Jennifer Lee Besse
  1. Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
  1. Correspondence to: Dr EunSeok Cha, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE Atlanta, GA 30322-4201, USA; echa5{at}

Commentary on: [CrossRef][Medline][Web of Science]Google Scholar

Implications for practice and research

  • Obesogenic infant care behaviours may increase childhood obesity, and predict obesity and related health risks in adulthood.

  • Poor parent health literacy predicts poor child health outcomes including childhood obesity.

  • Nurses should assess parent health literacy and provide appropriate support to prevent obesogenic infant care behaviours.

  • Future research could focus on evaluating parent educational programmes tailored to health literacy level and effectiveness on reducing obesogenic care behaviours.


Family-centred childhood obesity prevention programmes are recommended from the prenatal period onwards.1 ,2 Such programmes address obesogenic infant care behaviours including: infant feeding including formula feeding, provision of sweet drinks and early introduction of solid foods; parent behaviours such as feeding immediately in response to crying and bottle-propping and physical activity-related care behaviours such as excessive television (TV) exposure and limited prone ‘tummy time’ position.3 Health literacy is an important consideration for obesity risk. A parent–child dyad study found that parent health literacy was related to childhood obesity, while adolescent health literacy is linked to obesity in adolescence.4 Few studies, however, have examined parent health literacy and obesogenic infant care behaviours specifically. Yin and colleagues examined this relationship and the potential to inform childhood obesity prevention initiatives.


A cross-sectional analysis of baseline data, obtained as part of the Greenlight cluster randomised trial, from 844 caregiver–child dyads, was undertaken. Participants were enrolled during the infants’ 2-month well-child visits at four university affiliated paediatric continuity clinics. Parental interviews, guided by an adapted Infant Feeding Style Questionnaire, assessed obesogenic infant care behaviours (formula feeding, provision of sweet drinks, early introduction of solid foods, controlling, laissez-faire and unresponsive parent behaviours, TV exposure, and inadequate tummy time). Parental health literacy was measured using the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Data were analysed using the R data analysis software (V.2.15). Comparisons were made between the analysis of unadjusted and adjusted data for child, parent and household characteristics to examine relationships between health literacy and obesogenic infant care behaviours.


Of the 844 participating dyads, 95% (n=808) of caregivers were mothers with about 11% (n=93) identified as having low health literacy (S-TOFHLA≤22: 7.8% inadequate, 3.2% marginal). Parents with low health literacy were more likely to primarily feed their infants formula milk, coerce their child to feed, feed immediately when their baby cried and report bottle-propping and inadequate tummy time. About 3% and 11% of parents reported giving their infant sweet drinks and introducing solid foods early, respectively; there was no significant difference by level of parent health literacy. Likewise, TV watching while feeding did not significantly differ by level of parent health literacy.


Despite the significance of the study undertaken by Yin and colleagues, the findings must be carefully interpreted, as the relationships between specific care behaviours and obesity are not yet fully supported by evidence. Recommendations prohibiting TV viewing before the age of 2 and encouraging tummy time from birth, for example, are primarily concerned with child development not obesity.5 The reported proportion of low health literacy in this study was also significantly lower than other studies (11% compared with 46%).6 It is unclear if study participants had higher levels of health literacy or if findings were influenced by variations in the way S-TOFHLA was administrated. Finally, the study's specific aims and data analysis strategies were not clearly articulated. Yin and colleagues compared study variables after dichotomising health literacy (low vs adequate), instead of examining associations among variables, and reported using the Mann-Whitney U test for categorical outcomes despite it being a non-parametric test intended for continuous variables.

This study has important implications for nursing practice and research. Obesogenic infant care behaviours are common among parents. Nurses are well positioned to support parents in reducing these behaviours through health literacy-sensitive support. Nurses should be empowered to assess parent health literacy and provide appropriate support to parents to reduce obesogenic infant care behaviours. Family-centred childhood obesity prevention programmes tailored to parent health literacy level should be developed.


  • Competing interests None.


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