Adult Weight Management

AWM: Nutrition Education (2006)


Kessler H, Wunderlich SM.  Relationship between use of food labels and nutrition knowledge of people with diabetes.  Diabetes Educ 1999; 25(4): 549-559.

PubMed ID: 10614259
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
To identify how people with diabetes use food labels to manage their intake of specific nutrients, if dietary-related health problems influence use of food labels, which information is used on the Nutrition Facts label, and the relationship between food label use and nutrition knowledge.
Inclusion Criteria:
Type 1 or Type 2 diabetes.  Women with gestational diabetes were not identified in the study.
Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:


Sample population obtained from individuals attending the American Diabetes Association patient education programs presented throughout New Jersey.  A nonprobability accidental sample method was implemented to obtain the participants for the study.


Cross-sectional study.

Blinding used (if applicable)

Not applicable.

Intervention (if applicable)

4-page questionnaire.

Statistical Analysis

Descriptive statistics used to assess demographic and clinical characteristics of the participants.  Nonparametric test used to examine the association between dependent and independent variables from the sample population.  Chi-square was used to test significance of nominal and ordinal data.

Data Collection Summary:

Timing of Measurements

4 page questionnaire was completed by participants prior to starting patient education program.

Dependent Variables

  • Questionnaire was based on USDA DHKS.  Questions related to dietary context in which people use food labels, relevant health status and health-related behaviors.  Questionnaire specifically focused on new Nutritional Facts information and its use by people with diabetes.  To assure content validity, field experts reviewed the questionnaire and a pilot program was instituted to test question phrasing.

Independent Variables

  • Demographic knowledge information and relevant data

Control Variables


Description of Actual Data Sample:

Initial N: 190 participants, 78 males, 112 females

Attrition (final N):  See above

Age:  Total sample:  2% were <30, 6% were aged 31-40, 16% were aged 41-51, 34% were aged 52-62, 26% were aged 63-73, and 16% were aged 74+   

Ethnicity:  Total sample:  68% Caucasian, 23% African American, 7% Latino, 1% Asian, 1% Other 

Other relevant demographics:

Anthropometrics:  Differences between label users and non-users were not statistically significant for gender, age group, race, education, household type, or duration of diabetes

Location:  6 different locations in New Jersey 


Summary of Results:


Label Users (%) Non-Users (%)
Sugar 88


Total Fat 75 25
Sodium 72 28
Calories 71 29
Cholesterol 63 37
Total Carbohydrates 59 41
Serving Size 58 42



Percent Daily Values



Other Findings

The majority of individuals used food labels "often" (61%), followed by "sometimes" (30%), "rarely" (4%), and "never" (5%); therefore 91% were considered users and 9% non-users.

People with diabetes read food label information 22% more often than general consumers, checking sugar content ranked highest.

Only 59% of label users referred to the total carbohydrate listings.

The level of nutrition knowledge for the majority of participants was "fair" or less (54%), with the remaining scoring "good" and above (46%).

The use of nutrition labeling has a limited effect on nutrition knowledge gain.

Author Conclusion:
The data from this study suggests that people with diabetes read food label information more often than the general consumer population.  Demographic characteristics such as age, gender, race, education, and household type did not influence the extent of usage in this study.  In accordance with the Health Belief Model, having diabetes is sufficient reason to take the time to use food labels.  This study population exhibited an awareness of the relationship between diet and nutrition and health maintenance.  Although use of nutrition labeling was high, deficiencies in nutrition knowledge were evident for both label users and nonusers.  Individuals who received most of their information from healthcare provider had a "good" or better nutrition knowledge score.  An education program is needed that teaches how to apply information from the Nutrition Facts label to make healthy food choices.
Funding Source:
University/Hospital: Montclair State University
Reviewer Comments:
Questionnaire tested for validity but not reliability.  Sample not representative of population.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? ???
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? ???
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? ???
  7.5. Was the measurement of effect at an appropriate level of precision? ???
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? ???
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? ???
  8.3. Were statistics reported with levels of significance and/or confidence intervals? No
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes