No nutrition literacy instruments have been tested in breast cancer survivors, yet nutrition is a critical lifestyle factor for optimizing weight and improving quality of life in breast cancer survival. Our objectives were to adapt our Nutrition Literacy Assessment Instrument for breast cancer populations and to pilot test its validity and reliability. We modified the instrument based on review by content experts in cancer and nutrition and cognitive interviews with 18 cancer survivors. The modified instrument (Nutrition Literacy Assessment Instrument for Breast Cancer, NLit-BCa) was pilot-tested with 17 high-risk women and 55 breast cancer survivors. We conducted the NLit-BCa on two separate occasions 4 weeks apart and assessed reliability by confirmatory factor analysis. Construct validity was evaluated by comparing results of the NLit-BCa to a Healthy Eating Index score derived from two separate 24-h dietary recalls. Content validity of the NLit-BCa was acceptable (0.93). Entire reliability for three instrument domains was substantial (>0.80), while remaining domains demonstrated fair or moderate reliability. Significant relationships were found between five of the six domains of nutrition literacy and diet quality (P < 0.05). The NLit-BCa is content valid and demonstrates promising reliability and construct validity related to diet quality, through a larger sample size, and removal of non-discriminating items is needed to confirm these findings. Thus, the NLit-BCa demonstrates potential for comprehensively measuring nutrition literacy in breast cancer populations.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Fryar CD CM, Ogden CL (2014) Prevalence of overweight, obesity, and extreme obesity among adults: United States, 1960-1962 through 2011-2012. http://www.cdc.gov/nchs/data/hestat/obesity_adult_11_12/obesity_adult_11_12.pdf. Accessed 17 Feb 2015
Pruitt JD, Bensimhon D, Kraus WE (2006) Nutrition as a contributor and treatment option for overweight and obesity. Am Heart J 151(3):628
WCRF (2009) Policy and action for cancer prevention. Food, nutrition, and physical activity: a global perspective. American Institute for Cancer Research, Washington DC
Silk KJ, Sherry J, Winn B, Keesecker N, Horodynski MA, Sayir A (2008) Increasing nutrition literacy: testing the effectiveness of print, web site, and game modalities. J Nutr Educ Behav 40(1):3–10
Gibbs H, Chapman-Novakofski K (2012) Exploring nutrition literacy: attention to assessment and the skills clients need. Health 4(3):120–124
Gibbs H, Chapman-Novakofski K (2013) Establishing content validity for the nutrition literacy assessment instrument. Prev Chronic Dis 10:E109. doi:10.5888/pcd10.120267
Kushi LH, Byers T, Doyle C et al (2006) American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin 56(5):254–281
Kroenke CH, Chen WY, Rosner B, Holmes MD (2005) Weight, weight gain, and survival after breast cancer diagnosis. J Clin Oncol 23(7):1370–1378
Blanchard CM, Courneya KS, Stein K (2008) Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society's SCS-II. J Clin Oncol 26(13):2198–2204
Thomson CA (2012) Diet and breast cancer understanding risks and benefits. Nutr Clin Pract 27(5):636–650
Maley M, Warren BS, Devine CM (2013) A second chance: meanings of body weight, diet, and physical activity to women who have experienced cancer. J Nutr Educ Behav
Heidemann C, Schulze MB, Franco OH, van Dam RM, Mantzoros CS, Hu FB (2008) Dietary patterns and risk of mortality from cardiovascular disease, cancer, and all causes in a prospective cohort of women. Circulation 118(3):230–237
Polit DF, Beck CT (2006) The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 29(5):489–497
Befort CA, Klemp JR, Fabian C et al (2014) Protocol and recruitment results from a randomized controlled trial comparing group phone-based versus newsletter interventions for weight loss maintenance among rural breast cancer survivors. Contemp Clin Trials 37(2):261–271
Moshfegh AJ, Rhodes DG, Baer DJ et al (2008) The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes. Am J Clin Nutr 88(2):324–332
Miller PE, Mitchell DC, Harala PL, Pettit JM, Smiciklas-Wright H, Hartman TJ (2011) Development and evaluation of a method for calculating the Healthy Eating Index-2005 using the Nutrition Data System for Research. Public Health Nutr 14(02):306–313
Wirth R, Edwards MC (2007) Item factor analysis: current approaches and future directions. Psychol Methods 12(1):58
Lt H, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model Multidiscip J 6(1):1–55
Shrout PE (1998) Measurement reliability and agreement in psychiatry. Stat Methods Med Res 7(3):301–317
Bennett IM, Chen J, Soroui JS, White S (2009) The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med 7(3):204–211
Wolf MS, Knight SJ, Lyons EA et al (2006) Literacy, race, and PSA level among low-income men newly diagnosed with prostate cancer. Urology 68(1):89–93
Parker RM, Baker DW, Williams MV, Nurss JR (1995) The test of functional health literacy in adults. J Gen Intern Med 10(10):537–541
(2002) The Diabetes Prevention Program (DPP) description of lifestyle intervention. Diabetes Care 25(12):2165–2171
Guenther PM, Kirkpatrick SI, Reedy J et al (2014) The healthy eating index-2010 is a valid and reliable measure of diet quality according to the 2010 Dietary Guidelines for Americans. J Nutr 113.183079
Morris NS, Field TS, Wagner JL et al (2013) The association between health literacy and cancer-related attitudes, behaviors, and knowledge. J Health Commun 18(1):223–241
The research team would like to thank Dr. Sheshadri Madhusudhana, Nikki Malomo, and Denise Sharp in the Department of Oncology/Hematology at Truman Medical Center in Kansas City, MO, for their support with recruitment. Sarah Owens, RD and Brigid Pikus were also instrumental with data entry.
The study was supported by grant no. IRG-09-062-04, awarded to the University of Kansas Medical Center by the American Cancer Society and by grant no. UL1TR000001 from Frontiers: The Heartland Institute for Clinical and Translational Research awarded to the University of Kansas Medical Center by the NIH National Center for Advancing Translational Science.
No financial disclosures were reported by the authors of this paper.
Ethics Approval and Consent to Participate
The study was approved on August 7, 2013, by the Human Subjects Committee of the Institutional Review Board, protocol #13838 (Exempt b).
Electronic supplementary material
Below is the link to the electronic supplementary material.
(DOCX 16 kb)
Rights and permissions
About this article
Cite this article
Gibbs, H.D., Ellerbeck, E.F., Befort, C. et al. Measuring Nutrition Literacy in Breast Cancer Patients: Development of a Novel Instrument. J Canc Educ 31, 493–499 (2016). https://doi.org/10.1007/s13187-015-0851-y
- Health literacy
- Health education
- Nutrition therapy education