Influences of Nutritional Food Label Understanding in African-American Women with Obesity.

Chapter 1: Introduction to the Study

Introduction

Nutrition food labels have a long history. In 1906, the U.S. House of

Representatives passed the Pure Food and Drug Act, which was central to progressive

reforms in the early 20th century. President Theodore Roosevelt signed this act into law

in 1906(Pure Food and Drug Act, 1906). This law resulted from unsanitary practices in

facilities that produced food, drugs, and medicine. In 1930, the organizational name was

changed to U.S. Food and Drug Administration (U.S. Food and Drug Administration

[FDA], 2014). The FDA has become the authority on consumer education, protection,

policies, and persecution guidelines (FDA, 2014).

Nutritional food label understanding (NFLU) is one way to encourage consumer

behavior associated with nutritional health. In addition, nutrition policies should provide

information to the public that is meaningful (Roberto & Khandpur, 2014). Although

consumers support nutrition policies and have the right to such information, evidence of

the perceived effect of nutrition labeling on food choice has been inconsistent (Liu,

Wisdom, Roberto, Liu, & Ubel, 2014; Roberto & Khandpur, 2014). Several researchers

suggested nutrition education contributes to making healthy food choices and purchasing

decisions; however, it is necessary to address the underlying problem of obesity (Chen,

Jahns, Gittelsohn, & Wang, 2012a; Fitzgibbon et al., 2012; Velardo, 2015). Also,

embracing the use of nutritional food label (NFL) could influence the obesity epidemic if

consumers understand their food purchase and consumption decisions. Encouraging

behaviors associated with food habits to change implies that a user-friendly grocery

shopping experience includes clear nutrition information (Guthrie, Mancino, & Lin,

2015; Helfer & Shultz, 2014). Not only is NFLU necessary while grocery shopping, but it

is important in the restaurant and fast-food industry.

According to Schindler, Kiszko, Abrams, Islam, and Elbel (2013), habitual

behaviors, external influences, and price and time constraints are critical determinants of

food choices. Hornick et al. (2012), Schindler et al. (2013), and Spronk, Kullen, Burdon,

and O’Connor (2014) found common barriers such as confusion and lack of

understanding. The gap in the literature I addressed in this study is the lack of attention to

NFLU as a single short-term (6 months) intervention for obese African American women

(AAW) of the baby-boom era. The term baby boomer refers to individuals born in the

United States between mid-1946 and mid-1964 (Colby & Ortman, 2014). The gap

focused on nutrition literacy and nutrition behavior, which are both constructs to

understand the possible benefits of NFLU.

In this study, I used a qualitative interpreted phenomenology analysis (IPA)

design. The prerequisite for conducting this study was because of the high rate of obesity

in AAW, known to result in adverse diet-related diseases (e.g., some forms of cancer,

cardiovascular disease, and diabetes; DiNoia, Furst, Park, & Bredbenner-Byrd, 2013). A

better understanding of nutritional health behaviors, which may increase nutritional label

literacy, might help slow the obesity rate among AAW (DiNoia et al., 2013; Velardo,

2015). In addition, this understanding could provide tools for AAW to practice prudent

nutritional behaviors that stimulate healthy food purchases and eating practices (Boggs,

Ban, Palmer, & Rosenburg, 2015). Researchers agree that nutrition behaviors developed

(e.g., monitoring portion control, calorie counting) might stimulate healthy food

purchases and eating practices (Salmon & Fennis, 2014). Bridging knowledge and

behavior to form positive nutrition concepts may be beneficial in the reversal of

unhealthy behaviors (Boggs et al., 2015; Velardo, 2015). According to Boggs et al., the

relationship between nutrition quality and mortality in AAW may depend on nutritional

health education. Boggs et al. based their findings on the Dietary Approaches to Stop

Hypertension (DASH) and Prudent and Western dietary patterns. Boggs et al. showed

that practical nutrition information, such as reducing red meat and increasing the intake

of whole grain, which are DASH recommendations, was associated with reduced

mortality rates in AAW (Boggs et al., 2015). The Western dietary pattern, (e.g., high

intake of red and processed meat) was associated with increased mortality rates among

AAW (Boggs et al., 2015, p. 524).

The participants for this study were twelve obese AAW born during the baby

boom era (1946-1964) who resided in Fort Bend County, Texas at the time of data

collection. I used convenience sampling to select the study participants. In this study, I

examined and explored if modest changes to nutritional knowledge and nutritional habits

introduced and practiced by AAW could produce positive health benefits. For instance,

reading food labels with understanding, selecting foods that support healthier dietary

intake (e.g., more whole grain foods, fiber, less calories, fat content, and portion size),

and preplanning healthy meals may serve as an advantage to the construct of NFLU.

These advantages of nutrition education might influence individuals, the community, and

society by reducing the potential complications of the chronic diseases in AAW. The

adoption of NFLU from a cognitive and behavioral perspective that may introduce

healthier life choices associated with nutritional knowledge were the focus of the study.

Problem Statement

Obesity is one of the greatest problems faced by AAM in the 21st century (Antin

& Hunt, 2013; Cranford, 2014; Hatala, 2014; Lagerros & Bossner, 2013). Complicating

matters further, AAW have the highest obesity rate of any other group in the United

States (Agyemang & Powell-Wiley, 2013; Cranford, 2014). According to the World

Health Organization (WHO, 2015), obesity occurs when the body mass index (BMI) is 30

kg/m2 or greater, overweight is 30 < BMI < 25, and morbid obesity is BMI > 40 (CDC,

2014a; Flegal, Carroll, Kit, & Ogden, 2012; King, Mateson, Chirina, Shankar, &

Broman-Fults, 2013; National Center for Health Statistics, 2013; U.S. Department of

Health and Human Services, 2010). Statistics on obesity in the United States are plentiful

(Chen, Roy, & Crawford, 2013b; Flegal et al., 2012; Hatala, 2014; Healthy People 2020,

2014; National Center for Health Statistics, 2013). The state of obesity among AAW is a

public health dilemma with many health risks (Flegal, et al., 2012). It is estimated that

between 70% -78% of AAW are overweight or obese (Cranford, 2014; Fitzgibbon et al.

2012). According to King et al. ( 2013), obesity is more prevalent among AAW baby-

boomers then any other group. When comparing AAW in 2010 to AAW from a previous

generation, King et al. (2013) found that the obesity rate in AAW climbed statistically

significantly to 38.7% from 29.4% in 2007.

The phenomenon of obesity has stimulated many research studies in an aggressive

effort to determine possible resolutions in African American communities (Anekwe &

Rahkovsky, 2013; Hatala, 2014). Historically, racial and ethnic populations continue to

be disproportionately underrepresented in clinical trials for behavioral weight loss

solution (Agyemang & Powell-Wiley, 2013). The concerns about obesity in AAW have

heightened in the 21st century because risk factors, should they develop into medical

conditions, are likely to place an undue financial strain on families (Walker & Gordon,

2014).

The obesity epidemic in African American communities, especially among AAW,

has grown significantly in recent years (Center for Disease Control and Prevention

[CDC], 2014a; Cranford, 2014; Flegal et al., 2012; Walker & Gordon, 2014). Obese

individuals have tried countless interventions (e.g., bariatric surgery, pharmacotherapy,

lifestyle change programs) with limited long-term effects (Fitzgibbon et al., 2012; Hieke

& Taylor, 2012; Walker & Gordon, 2014). Moreover, combination interventions geared

toward curtailing obesity among AAW have produced limited results (Walker & Gordon,

2014). Research on NFLU to AAW as a strategy could influence the state of obesity in

this population. Zachary, Palmer, Beckham, and Surkan (2013) identified both

environmental and individual barriers that affected how foods are purchased; however, a

lack of understanding remains regarding behavioral influences needed to inform

interventions.

At the time of data collection, limited literature existed on NFLU as an initial

single short-term (6 months) strategy for combating obesity in AAW. The lack of

attention given to AAW about NFLU required a concentrated study that aided to

understand better its possible influence on weight-loss approaches (Fitzgibbon et al.,

2012). To understand the lived-experiences of obese AAW, a qualitative, interpretative

phenomenological analysis (IPA) was conducted to discover if NFLU was a promising

intervention for AAW to purchase and practice healthy eating behaviors.

Purpose of Study

In this qualitative IPA study, my aim was to better understand better the

perception of obese AAW of the baby-boomer era (1946-1964) regarding their lived-

experiences of NFLU as a single intervention. The justification for this study was based

on the gap in the existing literature that did not consider single-short-term, public health

approach toward combating obesity as a viable method. A large body of literature

identified with a combination of approaches to treating obesity (Hatala, 2014; Mastin,

Campo, & Askelson, 2012). The approaches found in the literature included (a) the

combination of diet and physical activity, (b) fasting and weight loss medications, (c)

physical activity and avoidance of fast foods, (d) meal replacements and skipping meals,

(e) structured weight-loss programs and avoiding sweets, and, in extreme cases, and (f)

diet counseling and surgery to treat obesity (James, 2013; Mastin et al., 2012; Walker &

Gordon, 2014). In opposition, these approaches have shown limited long-term success

(Agyemang & Powell-Wiley, 2013; James, 2013). Therefore, in this IPA study I sought

to understand whether NFLU as a primary intervention for obesity was a plausible

proposal for influencing food habits and behaviors known contributory to obesity.

Significance of the Study

In 2013, several states had seen a dramatic increase in the rate of obesity (Chen et

al., 2013b; Hatala, 2014). The significance of this study centered around the reported

obesity rates in AAW in the United States. According to varied research, AAW are 70%

more likely to be obese compared to other groups such as Hispanics and European

Americans in the United States (CDC, 2014a; Cranford, 2014; National Center for Health

Statistics, 2013). Although a leveling off of obesity in AAW has been reported nationally

(CDC, 2014b; Chen et al., 2013b; Healthy People 2020, 2014; National Center for Health

Statistics, 2013), obesity rates among AAW in the South are significantly higher than

other regions. In all, nine out of the 10 states with the highest obesity rates are in the

South (Robert Wood Johnson Foundation, 2013). Texas is on the list (State of Obesity,

2014). In 2014, Texas had the 15th highest adult obesity rate in the nation (State of

Obesity, 2014). The 2014 adult obesity rate in Texas was 30.9%, up from 25.3% in 2004

and 10.7% in 1990 (State of Obesity, 2014). The prevalence of obesity in AAW in Texas

has increased over the past few decades (CDC, 2014a; National Center for Health

Statistics, 2013; Robert Wood Johnson Foundation, 2013; State of Obesity, 2014; Trust

for America’s Health, 2014). In 2014, 36% of baby boomers in Texas were overweight or

morbidly obese (State of Obesity, 2014). Many AAW are significantly impacted by these

statistics, which may suggest that prudent nutritional practices based on cognition and

behavioral skills have the ability to lessen chronic diseases in this populace and improve

nutritional health.

In this qualitative IPA study, I explored a single short-term (6-month) intervention

that AAW can use to assist them in making healthier meal decisions and to understand

healthful dietary principles gained from NFLU(Chen et al., 2012a). Gaining knowledge

on how to use nutritional food labels for addressing obesity is a presumptive approach to

altering behavior (Chen et al., 2012a). Finding effective strategies for reducing obesity is

critical for AAW (Anekwe & Rahkovsky, 2013; Chen et al., 2012a; Flegal et al., 2012).

Hence, conducting an in-depth investigation of the lived-experiences of NFLU by obese

AAW as a strategy for promoting healthy dietary choices was the significance of this

study and could enable researchers to understand better the impact of the overall pure

human experience (Tuohy, Cooney, Dowling, Murphy, & Sixsmith, 2013). Most research

conducted in the 21st century addressed nutritional food labeling education in

combination with other programs, which resulted in short-term success (James, 2013;

Lagerros & Rossner, 2013). The assertion of this study was the importance of a lifestyle

change when nutritional literacy of AAW was addressed (understanding nutritional food

label information). It could alter behaviors known to cause obesity (James, 2013).

To date, most researchers addressed NFLU in combination with other activities

and programs that claim short-term success (James, 2013; Lagerros & Rossner, 2013).

The obesity epidemic in AAW requires nutritional interventions that will produce long-

term success, possibly achieved through understanding the perception and nutritional

literacy of this population (Naghshizadian et al., 2014). According to Webb et al. (2014),

intervening with dietary changes is needed because little is known about the healthy

eating behaviors of AAW. Establishing conscious behavior essential to nutritional health

offers benefits from an individual and societal perspective (Miller & Branscum, 2012;

Webb et al., 2014). Arming AAW with NFLU as a tool for choosing foods based on

labeling content could reverse unhealthy nutrient intake and decrease diet related diseases

(Wahlich, Gardner, & McGowan, 2013).

The focus of this study was that those who received NFLU might practice

nutritional accountability that leads to long-term success. Untreated obesity places

society at risk; therefore, society needs a preventative solution before health-related

problems develop. The impact this might have on an obesogenic society could be far

reaching. Expansion of nutritional knowledge on ways to combat obesity for a greater

good is critical in a society facing astonishing obesity statistics. This perspective centers

on positive social change.

Potential Social Change Implications of Study

While obesity is a global problem, researchers have identified the United States is

an obesogenic society (Antin & Hunt, 2013; Pruchno, Genderson-Wilson, & Gupta,

2014). Addressing the dilemma from a nutritional literacy and nutritional behavioral

perspective requires a three-tier assessment from an individual, community, and societal

sphere. The reality is that the current obesity statistic, even with the estimated ranges of

various researchers (60% to 80%), AAW deserve persistent research attention.

In 2014, more than two-thirds of adults in the United States were overweight or

obese (Ogden et al., 2014). AAW had the highest obesity rate of any other group in the

United States at 70% (Cranford, 2014). Antin and Hunt (2013) stated four out of five

AAW were considered obese in the United States. Agyemang and Powell-Wiley (2013)

claimed approximately 60% of AAW were considered obese based on the BMI index. In

2010, obesity was more common among AAW baby-boomers at 38.7%, a huge leap from

29.4% from a previous generation of AAW in 2007 (King et al., 2013).

Individual

From the individual perspective, personal nutritional health is essential to the

well-being of the mind, body, and spirit. Nutritional literacy and nutritional behaviors

may take some time to incorporate into a lifestyle change; nonetheless, increasing self-

efficacy and self-regulation on an individual level could be the start of the recognition

process of changing behaviors associated with nutritional habits at point-of-purchase and

eventually consumed. In summary, researchers have attributed chronic diseases to obesity

and poor nutrition habits. Hence, any influence that NFLU can contribute to the health

outcome of the individual may be beneficial to the community where they reside.

Community

Nutritional health is not determined by where someone lives, how much money

he or she makes, or the availability of grocery stores in his or her community. Nutritional

health lies within the communities’ understanding of how to operate in their environment

and to not let it define their nutritional health. Nutritional health begins when resources

are available in the community and accessible to the citizens. For instance, grocery stores

and fewer convenience store and fast food chains could shape a community’s nutritional

health. Nutritional food labels in grocery stores must be easily understood and legible.

Communities that embrace and incorporate NFLU may contribute to the cumulative

effects of a healthier community that addresses obesity and healthy eating behaviors.

Nutritional support in the community is important because it can establish an awareness

of how nutrition impacts obesity and its related diseases in AAW. Knowledge becomes

behavior in action. Nutritional health will require stakeholders to come together to ensure

grocery stores are available in the community, and nutritional food labels are accurate.

Communities equipped with well-stocked grocery stores engage stakeholders, encourage

educational resources, and consider nutritional health worthy, society benefits.

Society. Society is strengthened when nutritional health is promoted and practiced

by its citizens. Nutrition barriers can create a public health problem, which would require

stakeholders to advocate collectively for stronger nutrition policies such as making

nutrition label information clear and explanatory on food items. The value of NFLU will

probably need to consider the complexity of AAW physical environment, norms, values,

and economic status to lobby for laws that protect society from consumer harms related

to nutritional health (Raine, 2014). Poor patterns of eating affect nutritional health and

subsequently affect society (Hieke & Taylor, 2012; Sinclair, Cooper, & Mansfield, 2014).

The greater good is possible if leaders in society understand the role education could play

in policy change initiatives and nutrition regulatory agencies.

The implications for social change with my findings are that AAW will use

behaviors that demonstrate healthier food choices by embracing NFLU at the point of

purchase and during meal planning. Practicing nutritional health might create life-long

health benefits to individuals, family, community, and society. Programs geared toward

NFLU offer a broader link to reduce chronic disease and medical cost. Targeted

interventions for specific populations potentially can improve society. Further research

on NFLU directed toward obese populations should be encouraged in African-American

communities.

Background

For the past few decades, a great deal of attention has been directed toward

combating obesity and chronic diseases in the United States (Agyemang & Powell-Wiley,

2013; Antin & Hunt, 2013; Murimi, Chrisman, McAllister, & McDonald, 2015;

Naghshizadian et al., 2014; Odulana et al., 2014; Sutherland, 2013; Walker & Gordon,

2014). A person is considered obese if the BMI is 30 kg/m2 and beyond (CDC, 2014a;

U.S. Department of Health and Human Services, 2010; National Center for Health

Statistics, 2013). The BMI concept is the anthropometric noninvasive measurement tool

that measures obesity and a guide to monitor weight reduction.

Current theoretical and empirical researchers (e.g., Matsin et al., 2012) have

focused on weight reduction as a multi-faceted approach, which includes diet and both

physical activity (structured and activities of daily living). Walker and Gordon (2014)

identified diet and physical activity as ways to resolve obesity; however, assessing

cognition may be vital for the most salient strategies that can be adapted to healthier

behaviors and outcomes. James, Pobee, Oxidine, Brown, and Joshi (2012) explained that

both exercise and a diet buddy at work may be suitable methods for addressing obesity;

however, the perceived benefit is lost when work is over. Bariatric surgery and

pharmacotherapy are conventional methods suggested for morbidly obese individuals,

which offer unrealistic expectations of success (Lagerros & Rossner, 2013). The

outcomes of these strategies are limited and have not done much to impact the overall

rate of obesity in AAW; in fact; reports show that the population continues to be

disproportionately vulnerable (DiNoia et al., 2013; Millender, 2014; Zachary et al.,

2013). Obesity has grown to epidemic proportions in AAW, so much so that avenues to

reverse its trajectory must be well thought-out and acted upon (Agyemang & Powell-

Wiley; 2013). The collective verdict is AAW have the highest rates of obesity compared

to other racial or ethnic groups. Agyemang and Powell-Wiley (2013) cited approximately

60% of AAW were obese compared to Non-Hispanic, White women. Sutherland (2013)

found similar statistics and made a recommendation to examine AAW’s behavioral long-

term changes related to healthy lifestyles. Furthermore, researchers have well

documented the host of obesity-related issues, which include elevated cholesterol, and

increased risk of heart disease, hypertension, gall bladder disease, sleep apnea, and some

cancers, all leading to an increase in mortality (DiNoia et al., 2013; Mastin et al., 2012;

Sutherland, 2013; Walker & Gordon, 2014).

According to Roberto and Khandpur (2014), assessing the impact of nutrition

with food labels, consumers have trouble understanding the content on food packages.

Another concern is front labels panel versus back labels panel, and which design meets

the need of consumers. Based on the premise that habits form behaviors, AAW may not

embrace front or back labels if reading the information is too complex (Raine, 2014;

Sutherland, 2013; Zimmerman, 2013). In addition, according to the Dietary Guidelines

for Americans (DGA), there are challenges around consumers’ knowledge and dietary

behavior changes (Rowe et al., 2011; Sutherland, 2013).

The role of the DGA is to provide science-based nutrition recommendations for

the public to build healthy diets and prevent diet-related chronic diseases (Rowe et al.,

2011). Diet-related diseases from poor dietary practice are economically and socially

debilitating (Chen et al.; 2013a; Rowe et al., 2011). The underlying prescription for

conceivable behavioral change is the promulgating of knowledge that consumers can

understand and apply to their lifestyle practices that center around consumer purchase

decisions. Webb et al. (2014) acknowledged that an unhealthy diet is a leading

contributor to chronic diseases in AAW living in the United States. Stages of change is

another construct that may shed light on how eating habits are developed along with

sociodemographic factors and a health history that may uncover nutrition health

behaviors.

Preventing or reversing chronic diseases may be embodied in the perceptions or

influences of life experiences of this population and other blended factors such as a

willingness to change, lack of family support, cultural attachments, beliefs, attitudes, and

economics that NFLU could have on creating a healthy lifestyle for AAW (Antin &

Hunt, 2013). The motivation to change, according to Miller-Soederberg et al. (2015), is

based on how individuals judge their dietary decisions. Further, the researchers argued

that understanding the food label content demands an adequate description of the reported

information.

Nutrition literacy and nutrition behaviors are the aspects this study explored and

the role NFLU could provide in healthy dietary performance. Because of the supported

evidence, that confirms how obesity affects populations’ dietary performance; there lies a

perplexing reality that while knowledge may be available, the content of that knowledge

may be lacking comprehension (Hornick et al., 2012; Miller-Soederberg & Cassady,

2015). Further, Hieke and Taylor (2012) wrote in their comprehensive overview of the

nutrition labeling literature that no agreement exists on the effectiveness of nutritional

labeling. Hieke and Taylor acknowledged many that researchers found the message on

food label panels were manipulative with broad claims of nutrition benefits.

Sinclair et al. (2014) noted a marked difference exists in the way various

consumers interpret nutrition information; however, it actually did not change dietary

habits because of the complexity of steps required to yield behavioral change. Bandura’s

(2001) research on the theory of human behavior indicated that learning occurs through

imitation of behavior once cognition has been acknowledged. Bandura’s theory embraces

a cognitive approach to the learning process. How AAW construct the knowledge of their

nutritional health may lie within the theory which Bandura (2001) called social cognitive

therapy (SCT).

Bandura’s work has been regarded as influential from the standpoint of learning

takes place through imitation of behaviors (Bandura, 2001). The theory of SCT affirms

behavior can change if individuals are cognitively competent with the ability to modify a

path by making healthier food choices and improved self-efficacy (Bandura, 1998; 2001;

Mastin et al., 2012; Walker & Gordon, 2014). Self-efficacy offers belief in achievement

when the environment is introduced to change because the environment is a factor in the

way people behave (Bandura, 1998). Understanding NFL information can influence the

state of obesity and be a plausible reality if AAW embrace the concept.

The genesis of nutritional behaviors of AAW may well be the consequence of

food choice at the point of purchase. An important element is understanding that there is

a cognitive connection to the perception that influences unhealthy food choices. It is also

essential to know how AAW thinks and talks about healthy eating (Bisogni, Jastran,

Seligson, & Thompson, 2012). Healthy eating cannot emerge without an awareness of

what constitutes the act. Nutritional literacy has to be challenged to move forward in

changing behavior of AAW (Carbone & Zeollner, 2012). According to research, AAW

are the primary grocery shoppers and food preparers in the home. Educating AAW with

nutritional food labels may be the missing link from keeping this population from

selecting and preparing nutritious meals.

Chen et al. (2013b) and James (2013) found it important to consider the insight of

nutritional food label knowledge as contributory to healthful dietary practices.

Populations who are at risk for obesity require efforts directed toward targeted

interventions and programs for changing food behaviors and habits; therefore, in this

study, I focused on nutritional behaviors geared toward healthy eating practices and

limited comprehensive discussion of obesity. Further, as the researcher, my plan was to

discover if a single short-term strategy, such as NFLU, influenced unhealthy nutrition

purchases practiced at the point of purchase. Incorporating the use of nutritional food

labels to purchase healthy diet items could play a role in reducing potentially life-

threatening health threats, such as diseases that could subsequently become chronic and

debilitating (Hornick et al., 2012).

Theoretical Framework

The theoretical base for this qualitative IPA study was phenomenology,

developed by Husserl in 1990 as an eidetic method (Pietkiewicz & Smith, 2014). The

philosophical approach had the aim of isolating unique components of the phenomena by

recognition of the lived experiences or by how the experiences appeared in an

individual’s world (Husserl, 1970; Pietkiewicz & Smith, 2014; Tuohy et al., 2013). IPA

lets the phenomenon speak for itself through the participants’ lens and voices while the

researcher examines and decodes the rich and detailed descriptions of each experience

(Pietkiewicz & Smith, 2014). IPA is a method that addresses the human experience by

interpretation or perception of a phenomenon from an individual perspective of life and

living (Husserl, 1970; Tuohy et al., 2013). It is referred to as a study of the “lived

experience having insight into the experiences of other's phenomenon” (Tuohy et al.,

2013, p. 18). In my study, the phenomenon was exploring if NFLU benefited obese

AAW. There was equal interest in exploring if there were social and cognitive

explanations in the lived experiences that would preclude behavior aimed at healthier

choice and consumption. Phenomenology suggests that individuals have some knowledge

based on the context of the world they are living in thereby asking for a retrospective

account of behaviors learned is a way to gain meaning that can be interpreted (Husserl,

1970; Jacob, 2013).

Bandura’s (2001) SCT was considered when exploring the social and cognitive

constructs of AAW. Self-efficacy, self-reflection, self-regulation, and forethought were

perspectives that were explored for understanding the human capability possible in

determining individual destiny (Bandura, 1986). Bandura’s SCT theory was integral in

the direction of incorporating improved nutritional food choices that could lead to a

healthier lifestyle (Walker & Gordon, 2014). Bandura’s work has been well established in

the social sciences, higher education, and psychology (Bandura, 1986, 1998). Bandura

(2001) posited that behavioral change is possible when the central base of the individual

is broadened by knowledge. Knowledge motivates self-belief, self-efficacy, and self-

regulation, all of which are all attributes that create desired effects (Bandura, 1977).

Combining Husserl’s basis of phenomenology and Bandura’s SCT, the study assessed the

magnitude of the lived experiences of obesity and potential for mastery of using NFLU as

a strategy for healthier food choices at the point of purchase and meal preparation. The

philosophical approach and theoretical base were contributory in framing the research

questions in this study.

Central Research Question

I. How will NFLU impact meaning to the obese state of AAW in Fort Bend County,

Texas?

Subresearch Questions

1. How beneficial will NFLU be to obese AAW?

2. What skills would be helpful for obese AAW to achieve for NFLU to be a

plausible intervention for combating obesity?

3. What are some possible reasons NFL may or may not be practiced by

AAW who are obese?

4. How would obese AAW interpret NFL relationship to the nutritional

behaviors they practice?

Nature of the Study

The nature of this qualitative IPA research focused on NFLU as an approach for

dealing with obesity and nutritional knowledge literacy in AAW. Mindful of finding out

ways AAW made sense of NFLU, I related the study of Husserl’s philosophy as a way to

describe the influences of life and living in the purest form of those who experienced the

phenomenon (Jacob, 2013; Roberts, 2013; Tuohy et al., 2013). In this IPA study, my aim

was to discover how obese AAW participants made sense of their personal and social

surroundings as they related to nutritional behaviors and assessed self-systems for

increasing their cognitive capacity toward healthy eating.

This qualitative study employed an IPA perspective setting aside prejudgments

(Moustakas, 1994). To bracket out the researcher’s biases versus addressing them was

acknowledged (Moustakas, 1994; Tuohy et al., 2013). Because of the lack of empirical

support for the nutritional behavior of AAW, in this study, I sought to understand how

obese AAW experienced their existence using their words in an interpretive

phenomenological framework of analysis (Roberts, 2013). The dynamic qualitative

process allowed a subjective exploration of an experience from a participants’

perspective of phenomenology hermeneutics, which meant interpretation (Roberts, 2013).

Gathering in-depth subjective data from AAW on NFLU happened during the face-to

face interview exchanges. The responses of AAW were analyzed for what governed their

nutritional behaviors followed by an analysis of data to infer possible causes of obesity. It

was hoped these articulated constructs would uncover meaning to the phenomenon of

NFLU as a strategy to reverse the trajectory of obesity in AAW and provide a better

understanding of nutritional behaviors in this population.

The themes and patterns that evolved from this study were analyzed with the use

of NVivo 10 computer software. From entering data into NVivo 10 software, themes and

patterns were extracted based on the open-ended, semi-formal interview questions.

Answering the research question was based on inclusion criteria. For example, potential

participants were eligible for this study if they were (a) AAW born in the United States,

(b) agreed without coercion to participate in the qualitative study, (c) were between 51-64

years old, (d) lived in Fort Bend County within the zip code of 77477 at the time of data

collection, (e) obese past one year with a BMI of 30 kg/m2 or greater, and (f) primary

grocery shopper of the home.

Definition of Terms

African American women (AAW): The term AAW in this study described women

born to African American parents and considered themselves African Americans or

Black, which are both acceptable terms because the term describes a region of origin

(American Psychological Association [APA], 2010).

Baby-boomer era: A period in the United States that was marked by a substantial

rise in birth rates post-World War II between the years of 1946 to 1964 (Colby &

Ortman, 2014).

Health (Behavioral) literacy: Health literacy has been defined as the cognitive

and social skills that determine the motivation and ability of individuals to gain access to,

understand and use information in ways which promote and maintain good

health(Sorensen et al., 2012).

Body mass index (BMI): A calculation of a person's weight in kilograms divided

by the square of height in meters (CDC, 2014b). individuals who have a BMI < 30 but >

40 are obese.

Dietary Guidelines for Americans (DGA): DGA provides science-based nutrition

recommendations for the public to build healthy diets and prevent diet-related chronic

diseases (Rowe et al., 2011).

Epidemic: An abnormally high number of occurrences of a disease within the

population (CDC, 2014b).

Interpretative phenomenological analysis (IPA): IPA is concerned with the

detailed examination of personal lived experience, the meaning of experience to

participants and how participants make sense of that experience(Tuohy et al., 2013).

Nutritional food label understanding (NFLU): NFLU geared toward the

identification of nutrients and nutrient values of food items found in front and back food

label panels that can be used to assist consumers in the selection of healthy food items

(FDA, 2012).

Nutritional literacy: the point at which an individual has the cognition to accept,

understand, and recognize basic nutrition information required to make appropriate

healthful food choice decisions while grocery shopping and meal preparation (Carbone

&, Zoellner, 2012).

Obesity: An excess of body fat as expressed by BMI >30 but > 40(Minority

Women Health, 2012).

Phenomenology: a qualitative research approach concerned with understanding

certain group behaviors from that group's point of view (Moustakas, 1994).

Self-efficacy: refers to an individuals’ confidence in their ability to change

behaviors.Self-efficacy affects the amount of energy that a person will extend to

individual will persist despite adversity (Bandura, 1977).

Self-regulation: refers to the self-directive process through which learners

transform their abilities into task related skills that will assist in managing new behaviors

learned from an educational experience. Self-regulation is a continual monitoring so not

to repeat behaviors that have been replaced by new ways. (Bandura, 2001).

Social cognitive theory (SCT): A theory based on the assumption that people learn

by observing others and eventually learn new behaviors. It is especially useful when

applied to interventions aimed at personal development, behavior pathology, and health

promotion (Bandura, 1977; 2001).

Assumptions

A universal assumption exists that eating healthy is easy and does not require

cognitive ability. This assumption is questionable. The required actions to select healthy

foods could be determined by what taste good and how much it cost. Yet, what to

purchase at the grocery store involves consistent cognitive or nutritional understanding.

The epidemic of obesity in AAW is assumed to be the result of inconsistent calorie

monitoring, portion control, and decreased fat intake in an individual’s diet. These

assumptions suggest the study population understands the importance of behaviors geared

toward practices that promote healthy lifestyles. This is a reasonable assumption;

however, the evidence is lacking in support of this claim. The evidence may emerge in

patterns and theme development to help explain the phenomenon under study associating

nutrition practices with obesity in AAW. What a person believes and how people behave

are often contradictions in their reality. In other words, the lack of empirical evidence to

support or disprove a claim then must fall to the development of the research process to

unravel the unknowns. Without a clear direction to the nature of qualitative research, the

assumption is data received from the participants will not be generalizable.

The greatest assumption as the researcher is that the participants were truthful and

accurately answered the questions during the interview based on their lived experiences.

The second assumption is that the study participants were honest about when they were

born. In the baby-boomer era, AAW have the highest obesity rates of any ethnic

population. The age between 51 to 64 years old; in addition, they have not agreed to

participate in the study based on the gift that will be award after the interview sessions.

The third assumption is that AAW are aware of the outcomes that result from the

nutritional decisions they make. There is also the assumption that extra body weight

(obesity) can be a health issue, and participants know they must shoulder their nutritional

behaviors to lose weight. The fourth assumption is that just because nutritional education

is offered in the form of instruction, understanding food label content does not suggest

the practice will be incorporated while grocery shopping or meal preparation. Finally, I

felt the face-to face interview method was a valid way to collect data from the study

participants. Verifying these assumptions can only come from the voice of the

participants.

Scope and Limitations

The study participants were limited to obese AAW born during the baby-boom

era, aged 51 to 64 years of age, who resided in Fort Bend County, Texas within the zip

code of 77477 at the time of data collection. NFLU content came from the suggested

guidelines used by the U.S. Department of Agriculture (USAD), and the DGA(FDA,

2014). Restrictions of the study may have created limitations based on several factors.

One factor could have been that the study findings may not be applicable to other settings

or populations without modifiers. Another limitation was the study sample (obese AAW)

might not represent the population as a whole. The study took place in an urban setting,

which limited rural AAW with similar criteria. Biases of the researcher could have

limited the study purpose because human beings cannot be always objective or neutral,

possibly because of the passion the research topic. One final limitation was while

qualitative methods address the perceptions and experiences of participants, the

collection and analysis of the copious amount of data were time intensive and

transcription of data expensive. Finally, I explained social change implications and

recommendations for future research.

Summary and Transition

In Chapter 1, I introduced the study. The purpose was to explore and examine the

lived-experiences that influenced nutritional behavior and the perceptions of obese AAW.

The central focus was on NFLU as it related to healthy food selection at the point of

purchase. I hoped that NFLU as a single intervention would help to reverse the trajectory

of obesity and increase nutrition literacy while grocery shopping and meal preparation in

AAW. Much of the current literature addressed combination strategies for dealing with

the obesity epidemic, but these are time-consuming, costly, and short-lived (James et al.,

2012; Lagerros & Rossner, 2013; Mastin et al., 2012; Walker & Gordon, 2014). This

information is necessary to inform the audience of the complexity of the research

problem. NFLU has the potential to promote healthy nutritional behaviors in AAW in

Fort Bend County, Texas. The failure to understand and practice prudent dietary

behaviors that might reverse the trajectory of obesity suggest valuable information is

absent or deficient concerning the necessary components of nutritional health.

Knowledge gaps in nutritional health could place AAW in jeopardy of debilitating

chronic diseases that have links to obesity, which is considered an important health crisis

in AAW in the United States (Flegal et al., 2012; Minority Women Health, 2012; Ogden

et al., 2014; Trust for America’s Health, 2014).

Nutritional literacy and nutritional behavior as they relate to food-label content at

the point of purchase incorporated into food purchases are significant gaps in the

literature in AAW within the baby boom era. There is evidence within the literature that

found improving nutritional intake could abate many of the debilitation health conditions

(Anekwe & Rahkovsky, 2013; Sharma, Sheehy, & Kolonel, 2014). In addition, nutrition

literacy and nutritional behavior are identified as societal problems that pose risks to

individual, family, community, and societal health (Anekwe & Rahkovsky, 2013; James,

2013; Lagerros & Rossner, 2013). The economic burden, health disparities, and long-

term hazard of poor nutrition health among AAW, because of obesity, will affect current

and future populations, which makes this study significant.

Chapter 2 is the literature review, a compilation of current research published in

peered reviewed journals that will address the study questions. In Chapter 2, I evaluate

mixed-methods, quantitative, and qualitative studies; however, my study only used a

qualitative IPA methodology to support the study that addressed NFLU as a single short-

term strategy to the obesity crisis in AAW. I focused on themes and patterns emerged and

contributed to the understanding of nutrition literacy, and nutrition behavior experiences

in obese AAW at the point of purchase and during meal preparation.

Chapter 3 the methodology section of the dissertation. The chapter describes a

qualitative IPA study along with the sample population and predetermined criteria to

participate in the study. In addition, the process to invite participants to the study were

discussed as well as the Computer-Assisted Qualitative Data Analysis Software

(CAQDAS) for data management and analysis.

Chapter 2: Literature Review

Background

Obesity is one of the greatest problems that AAW in the United States faces in the

21st century. Complicating matters further, AAW have the highest obesity rate of any

other group in the United States (Agyemang & Powell-Wiley, 2013; Cranford, 2014).

Obesity is defined as a Body Mass Index (BMI) score of 30 kg/m2 or greater (Flegal et

al., 2012; King et al., 2013; WHO, 2015). Statistics on obesity in the United States are

plentiful (Chen et al., 2013b; Flegal et al., 2012; Hatala, 2014; Healthy People 2020,

2014; National Center for Health Statistics, 2013). The alarming state of obesity in AAW

is a public health dilemma with many costly health risks (Flegal, et al., 2012). Anekwe

and Rahkovsky (2013) cited five health conditions for which poor nutrition can result in

poor health (e.g., heart disease, some cancers, stroke, diabetes, and osteoporotic hip

fractures).

Approximately four out of five AAW are overweight or obese, and they are 70%

more likely to be obese than are non-Hispanic, White women (Cranford, 2014;

Fitzgibbon et al., 2012; Minority Women Health, 2012). Obesity is the highest among

AAW baby boomers (38.7% obese vs. 29.4%), and when compared to a previous

generation of 2007 to 2010, the statistics are alarming because they have continued to

escalate (King et al., 2013) despite the lifestyle interventions, therapies and combination

approaches aimed at fighting obesity.

Researchers agree the burden of obesity’s lack of control in AAW is a foremost

concern (Hieke & Taylor, 2012; James, 2012; Naghshizadian et al., 2014; Sutherland,

2013). The rate of obesity’s deterioration into a crisis of disproportionation may center on

the perception of weight from a subjective stance (Naghshizadian et al., 2014). Although

this may be true, the solution may encompass targeted, individual-level approaches on

increasing nutrition cognition and behavior modification (Fitzgibbon et al., 2012; Hieke

& Taylor, 2012; Millender, 2014; Sutherland, 2013). This research study explored a

single, short-term approach based on NFLU to gain an understanding of nutritional health

that may influence food choices in AAW.

An analysis of the literature was completed to address the gap identified on NFLU

as a single short-term targeted interventional approach with AAW considering their

lived-experiences. Nutrition literacy and nutrition behavior were explored and examined

in this research study. The framework of the study was based on the perceptions of obese

AAW and the interpretation of their lived-experience with nutritional health, point-of-

purchase, and meal preparation. Guthine et al. (2015) acknowledged the complexity of

nutrition information and the necessity for clear information for individuals to decipher

the context. Liu et al. (2014) explained that food labels could be more efficient if they

were simplistic; however, he questioned their long-term use without precommitment

nudges.

The literature review focused on NFLU as a single short-term (6-month)

intervention to addressing obesity in AAW. In addition, the literature review investigated

perceptions and influences that might predict ability and behavior that may prevent AAW

from embracing NFLU as a lifestyle for nutritional health, point of purchase, and

consumption. Empirical peer-reviewed studies covered the vast amount of the literature

reviewed and were used to frame the argument of this study. Because of the scholarly

nature of this project, no empirical literature was excluded. Research studies were written

in the English and conducted in the United States and globally were the sources in this

study.

The literature sources were gathered from various electronic databases and the

Internet. The sources included Academic Search Primer, CINAHL, EBSCO, ERIC,

Goggle Scholar, MEDLINE Plus, Ovid MEDLINE, ProQuest, PubMed, SAGE, Science

Direct, SCOPUS, and World Cat. A combination of many terms was used to search for

supportive literature on the research subject. The key terms researched used were

African-American women, Bandura, behavior change, black women, body mass index,

culture, eating behavior, dietary interventions, dietary quality, ethnic, baby-boomer, food

culture, food label(ing), grocery shopping, health behavior, health literacy, health

promotion, interpretive phenomenology, lifestyle change, lived-experience, minority

health, motivation, nutrition behavior, nutrition health, nutritional facts panel, nutrition

literacy, obesity(obese) point-of-purchase, qualitative, self-efficacy, self-regulation,

social cognitive theory, and weight loss practices.

The literature review begins with the history of the nutritional food label industry,

nutrition literacy, AAW knowledge of food labels literacy, and nutritional behavior. The

theoretical framework for this study is applied to Bandura’s social cognitive theory (SCT)

concentrating on self-regulation and self-efficacy as they apply to NFLU. The summary

will conclude chapter 2.

History of Nutritional Food Labels

The history of nutritional food label use in the United States is important.

Nutritional food labels are the genesis for understanding the content and ingredients of

the nutrients recommended and subsequently consumed by society (FDA, 2014). The

first government bill passed to protect consumers from inferior foods was the U.S. Pure

Food and Drugs Act (Pure Food and Drug Act, 1906). This bill was the consequence of

unsanitary conditions of factories that manufactured food in the United States. In 1906,

President Theodore Roosevelt signed the Pure Food and Drug Act into law. The name

later changed to the FDA, which is an agency today housed within the U. S. Department

of Health and Human Services (FDA, 2014; Webb et al., 2014). The FDA’s role is to

ensure facts on processed food labels are accurate and provide product-specific

information to the public (FDA, 2014). Nutritional label content has to be convincing;

otherwise, consumers will not use them, thus losing the benefit of their intended purpose

(Hieke & Taylor, 2012; Sinclair et al., 2014). Another layer of protection was the

Nutritional Labeling and Education Act (NLEA), which oversees the labeling process on

process food items (FDA, 2014).

Since its publication in 1994, the NLEA requirements have provided nutritional

information for consumers to make informed decisions on food items at the point of

purchase (Hieke & Taylor, 2012; FDA, 2014). Researchers have shown that the practice

of reading the facts on food labels does develop the ability to choose healthy foods

(Guthrie et al., 2015; Hieke & Taylor, 2012; Miller-Soederberg & Cassady, 2015).

However, from an individual and societal perspective, nutrition and health benefits can be

difficult to achieve if individuals have nutrition literacy and nutrition behavior

circumstances that keep them for being engaged in this process (Barnett & Praetorius,

2015; Cha et al., 2014; Velardo, 2015; Zimmerman, 2013). Critics have described a

consumer’s reluctance to use nutritional labels because it takes time to process the

information (Kiesel, McCluskey, & Billas-Boas, 2011). Educating populations on the

importance of serving size, the amount per serving, calories, and the recommended daily

value (DV) become a critical element in the fight against obesity and promoting healthful

choices (Carbone & Zoellner, 2012; Hornick et al., 2012). Rowe et al. (2012) found it

important to consider not only the consumer nutrition knowledge and behavior patterns,

but also desires, needs, and choice. Researchers found it important to understand these

constructs because they could offer a connection between food labels and dietary choice

in populations; however, the gap widens when consumers are perplexed by the

inconsistencies found from label to label (Miller-Soederberg et al., 2015). Inconsistencies

diminish an individual’s ability to overcome barriers associated with reading nutritional

food labels, thus making it hard to encourage change in dietary behavior. In general,

populations express a desire for eating healthy (Barnett & Praetorius, 2015; DiSantis,

Grier, Oakes, & Kumanyika, 2014; Hornick et al., 2012). Amidst efforts to change

nutritional behavior, addressing barriers becomes critical to asserting nutrition

information suggesting it will benefit a person’s daily life. This study attempted to

understand better the lived-experiences of AAW to gain an understanding of the

influences and perceptions of NFLU, as a single short-term intervention, toward healthy

food selection at the point of purchase.

The research study addressed the gap in the literature whereby gaining an

understanding of what influences a person’s perception to incorporate the reading of food

labels at the point of purchase for healthy food choice. This qualitative IPA explored and

examined the lived experience of AAW and their perceptions of NFLU on nutritional

health behavior to discover if this phenomenon was amendable to altering the trajectory

of obesity in this populace. Moustakas (1994) described phenomenology as a drive for

finding underlying meanings in the human experience. The deepest currents of meaning

and knowledge take place within the individual through senses, perceptions, beliefs, and

judgements (Moustakas, 1994). This study sought wholeness and essence of the

participants’ experiences using first person accounts by formal and informal open-ended

questioning during face-to-face interviews. It was furthered hoped this study would

assess AAW’s readiness to change to positive, healthy habits and nutritional behaviors.

Nutrition Literacy

Nutrition literacy (knowledge) may be the initial ingress to introducing NFLU.

Achieving nutrition literacy (food literacy) is concerned with the use of general literacy

skills such as reading and writing to understand basic health messages (Velardo, 2015).

Spronk et al. (2014) used the definition of nutrition literacy as “the degree to which

individuals have the capacity to obtain, process, and understand nutrition information and

skills needed to make appropriate nutrition decisions” (p. 1714). Consumers must believe

nutritional food label information is genuine and will provide accurate information before

they invest the time to read them (Blake, Bell, Freedman, Colabianchi, & Liesa, 2014;

Webb et al., 2014). The behavioral patterns AAW develop in life are often seen in their

grocery shopping activity, which has been constructed by their life experiences. This may

suggest, according to Velardo (2015), conceptualization of health literacy within nutrition

education experiences could be a starting point for understanding nutrition behavior.

Encouraging conscious behavior when grocery shopping could generate a cognitive

connection to NFLU thereby past behaviors break as new practices develop (Guthrie et

al., 2015). Conversely, Williams, Crockett, Harrison, and Thomas (2012) suggested

minorities have identity-based motivations for unhealthy eating habits because of their

cultural attachment to specific foods, preparation methods, and eating patterns.

Consequently, traditional foods have to be integrated into nutrition literacy.

Among other integrated needs, DiSantis et al. (2013) discovered that AAW do not

understand marketing practices and often do not take the information they read as

reliable. Carson et al. (2015) noted incorporating knowledge on aspects of how foods are

marketed might improve adherence to dietary intake and relieve stressors often felt by

AAW regarding consumption. The Institute of Medicine (2013) recommended the need

for adequate nutrition among particular populations; however, guidelines for nutrient

acceptance must be user friendly. The challenge for the adoption of healthful behaviors

further validates nutritional education as a strategy that could develop the motivation and

skills to eat healthily (Williams et al., 2012) despite the social environment of AAW

often plagued by racism, poverty, and ill-equipped grocery stores, which in many cases is

their reality. Convenient stores outnumber grocery stores suggesting this barrier could

impede AAW from participating in healthy interventions directed to combat obesity

(Halbert-Hughes et al., 2013; Sutherland, 2013; Zachary et al., 2013).

The health and social environment of AAW had been connected to their

perceptions and lived experiences formed over time about nutrition; that might create

barriers to changing behaviors if not addressed(Carson et al., 2015). Walker and Gordon

(2014) posited that intergenerational transmission of food habits might add to the obesity

crisis without modification to cognitive and behavioral routines. Similar findings were

shared about working AAW; they may find it stressful to shift toward shopping behavior

specific to healthy food selections without a healthier understanding of the relationship

between high intakes of energy dense foods and obesity (Carson et al., 2015; Serper et

al., 2014). Available grocery shopping alternatives are needed to improve population

health and reduce incongruences (Halbert-Hughes et al., 2013; Zenk et al., 2014).

Despite the fact that food labels documented standard nutritional information

designed to directly influence healthful food selections, (e.g., calories, fat, sugar, and

sodium), AAW see dietary modifications pricey and a deterrent to healthy food purchases

(DiSantis et al., 2014; Miller-Soederberg & Cassady, 2015; Sinclair et al., 2014; Zachary

et al., 2013). Although the price of food is a primary concern of many shoppers and

particularly AAW, there may be a greater likelihood of purchasing healthier food items if

nutrition-conscious behavior grounds decision-making strategies (DiSantis et al., 2014;

Miller-Soederberg et al., 2015). The pursuit of behavior modification, be it the

acknowledgement of NFLU, obesity management, or nutrition behavior, lies in the

progress of self-regulation, which may lead to lasting and sustainable changes

(Agyemang & Powell-Wiley, 2013; Miller-Soederberg et al., 2015; Teixeria et al., 2015).

Several studies have found that personal responsibility can shape the impact of an

obesogenic population with dietary quality (Ortiz, Zimmerman, & Gillam, 2015; Pruchno

et al., 2014), but constructive benefits might need to offset any barriers that may prevent

behavior conversion.

Barriers related to cultural values, social norms, and structural factors that may

shape aspects to nutrition literacy require attention (Velardo, 2015). According to Blake

et al. (2014) and Teixeria et al. (2015), targeting specific audiences shows promising and

meaningful advances to healthy dietary behavior, and participants are more receptive to

educational interventions that embrace the barriers that affect a population’s belief.

Another interesting belief, according to Walters and Long (2012), has to do with the

effects of nutrition knowledge based on intrinsic and extrinsic cues. The ability to process

information is influenced by the knowledge that already existed. For instance, intrinsic

cues are attributes associated with the ingredients that make up a food item that cannot be

altered without causing harm to the physical properties of the product (Walters & Long,

2012). Conversely, extrinsic cues are health and nutrition labels claims, which suggest

the need for cognitive assessment before an action develops into a positive nutrition label

reading behavior (Walters & Long, 2012).

Gibbs and Chapman-Novakofski (2013) disclosed that nutritional education was

essential for increasing successful outcome. These researchers used two tools, the Rapid

Estimate of Adult Literacy in Medicine (REALM) and the Nutrition Literacy Assessment

Instrument (NLAI), to assess the content validity and increasing successful outcome

around nutritional education (Gibbs & Chapman-Novakofski, 2013). Their study

identified a correlation between practitioner’s knowledge and nutrition literacy. The

results of their study uncovered the lack of cohesion between nutrition practitioners when

surveyed if the REALM and NLAI assessment instruments for general health literacy

conformation (Gibbs & Chapman-Novakofski, 2013). The researchers surveyed

participants on basic nutritional health information; they found 12% of the survey

population demonstrated proficiency with 14% of participants had basic nutritional

literacy skills below, and 22% had basic skills (Gibbs & Chapman-Novakofski, 2013).

They found the tools useful but inadequate for use in nutrition education encounters with

clients because they do not identify nutrition literacy. The authors cited almost one-third

(29.5%) of participants believed language/cognitive barriers, readiness to learn, and

ability to purchase and prepare food were lacking (Gibbs & Chapman-Novakofski, 2013).

These data uncovered that while education is important, little discussion on health

literacy within the nutrition literature identified the need for cognitive skills (Gibbs &

Chapman-Novakofski, 2013).

Bisogni et al. (2012) found this concept was essential to how well a person would

comply with dietary recommendations. Priorities that have been constructed over time

require rerouting while shopping, cooking, and eating, but the participants must feel the

perceived value within their lived experiences. Moustakas (1994) emphasized not to lose

sight of a person being present in perception; inevitably, it may lead to the discovery of

meaning. No perception is terminal and conclusive, which means there are avenues for

filling the new perceptual gaps (Moustakas, 1994). In other words, using NFLU as a

means to an end is plausible when cognition and behaviors are tailored toward nutritional

health.

Encouraging behavior change may be hindered by conflicting food

manufacturer’s decisions on which nutrients to highlight on nutritional labels (Miller-

Soederberg & Cassady, 2015; Miller-Soederberg et al., 2015). The layer of mistrust that

consumers share could make it challenging to advocate for NFLU based on the lack of

consistency in food label reporting (Bisogni et al., 2012). Further, experts expressed deep

concern that the public may not be fully aware of how much food labeling and

environmental situations undermine personal responsibility by citing food choice are

often the result of outside influences (Kegler et al., 2014; Ortiz et al., 2015). This may

validate that nutrition literacy, socioeconomic, and environmental circumstance have

some degree of reason for population avoidance of incorporating healthy nutritional

practices (Carbone & Zoellner, 2012; Cornish & Moraes, 2015; Halbert-Hughes et al.,

2013; Velardo, 2015).

Before consumers feel confident to embrace nutritional facts content, expert

practitioners must be able to interpret the knowledge for themselves (Ortiz et al., 2015;

Zimmerman, 2013). The trajectory of obesity and re-enforcing nutritional health

behaviors, in light of this reality, could limit AAW participation in the process if

practitioners, and NFL experts are incapable of influencing decision making and behavior

considerations with NFLU. Carbone and Zoellner (2012) also noted nutrition and health

literacy were overlooked as essential features in helping individuals achieve a level of

understanding and decision making. This is in part because of the practitioners’

unfamiliarity with how to articulate nutrition and health literacy content (Carbone &

Zoellner, 2012; Ortiz et al., 2015; Spronk et al., 2014). Educating consumers on how to

select healthy food items involve practitioner engagement and motivation toward

achieving nutritional health in populations with staggering obesity rates.

Nutrition is a recognized determinant in three (e.g., heart disease, neoplasm, and

cerebrovascular diseases) of the top four leading causes of death in the United States

(Kris-Etherton et al., 2014). Researchers have underscored practitioners in health

professions should be given training in nutritional health to prepare them to educate

populations facing health disparities because of nutrition-related conditions. Polak,

Pojeknic, and Phillips (2015) identified that physicians did not provide enough behavioral

change counseling on concerns of poor nutrition. Conversely, nurses are collaborators

and share responsibility for knowledge on nutrition health by providing lifestyle

counseling and nutritional assessments (Gibbs & Chapman-Novakofski, 2013).

Nutritionists and dietitians, however, carry the majority of weight in transferring

knowledge that translates into healthy food choices that can improve nutritional health

(Gibbs & Chapman-Novakofski, 2013; Higgs, 2015; Kris-Etherton et al., 2014; Raine,

2014; Vaillancourt, Legare, Lapointe, Deschenes, & Desroches, 2012).

Historically, dietitians have been the provider of nutritional health; all the same,

the health profession lacks change agents for promoting nutritional health (Kris-Etherton

et al., 2014). The consequences have made the public question the credibility of their

knowledge on nutrition health (Kris-Etherton et al., 2014; Raine, 2014). Expanding

health and nutritional knowledge to help populations understand the importance of

nutritional health and nutritional behaviors of a high-risk group is the challenge of

practicing and being engaged in nutritional decision-making (Vaillancourt et al., 2012).

The lack of shared decision making between practitioner and participant may be

because of the uncertainty about nutrition treatment knowledge (Higgs, 2015; Kris-

Etherton et al., 2014), but nutrition health might be achievable with NFLU. The physical

environment where AAW live must provide available and affordable healthy foods,

which are obtainable by nutrition practitioners gaining competence that will improve

population health.

Various researchers from across the globe have validated the concern of obesity in

the United States. Higgs (2015) suggested the social norms of eating and food choice

may underlie dietary behaviors that lead to overeating and obesity. The food industry

often promotes palatable, unhealthy food choices, so without nutrition education that

addresses self-control behavior, the conflict between palatable options and immediately

gratifying becomes the dilemma (Salmon, Fennis, DeRidder, Adriaanse, & De Vet,

2014). In addition, deliberate decision making of healthy food choices should consider a

cognitive approach to include self-monitoring, perceived self-efficacy, and self-

regulation, which is the perspective of Bandura’s social cognitive theory (Bandura, 2004;

Salmon et al., 2014). Teixeria et al. (2015) reported successful obesity-related lifestyle

change interventions were limited on a short-term outcome (<12 months) based on the

varied predictors/mediators identified; still, self-regulation skills emerged as the most

consistent predictor in weight concerns. Challenges to address obesity among Black

women have strong implications for the need of behavioral intervention starting with

cognition of nutrition behavior clear from judgement and stereotyping ((Bennett et al.,

2013; Fitzgibbon et al., 2012; Higgs, 2015; Salmon et al., 2014). Interventions tailored

specific to AAW may reveal a positive change in dietary improvement if nutritional food

label content is understood and can be applied to their social identity.

Several researchers have suggested motivation to behavior change could be based

on knowledge inadequacy (Gibbs & Chapman-Novakofski, 2013; King et al., 2012;

Miller-Soederberg et al., 2015; Webb et al., 2014). The need to determine the nutrition

literacy of consumers is critical as defined by health literacy scholars (Agyemang &

Powell-Wiley, 2013; Carbone & Zoellner, 2012; Cornish & Moraes, 2015; Millender,

2014). Health literacy is “the degree to which individuals have the capacity to obtain,

process, and understand basic health information and services needed to make an

appropriate health decision” (Carbone & Zoellner, 2012, p. 254). With health literacy

acknowledged, this research study has the potential to contribute to social change by

demonstrating that NFLU at the point of purchase and with meal preparation may

actually alter habits of eating behavior when integrated into a personal lifestyle.

Webb et al. (2014) found AAW struggle with healthy eating behaviors, although

they self-report their motivation in wanting to consume healthy meals. In opposition,

Millender (2014) stated changing behavior through education was hampered by external

and social factors. Discord between social pressure and health prevention often lack

congruence, which may illustrate why nutrition education may be the one key to

understanding perceptions of individuals regarding food consumption (Antin & Hunt,

2013). Research shows the importance of cognitive function ability before strategy on the

use of food label content could promote healthy eating (Cha et al., 2014; Serper et al.,

2014). Because of the lack of discussion on health literacy within the nutrition literature,

it is vital to increase this knowledge to improve nutrition health outcomes (Gibbs &

Chapman-Novakofski, 2013). Approaches that are multifaceted make it challenging to

comprehend mechanisms behind the change in behavior. Therefore, to improve the health

status of a population, identifying effective measure should include nutrition literacy and

the habit that have influence individual behavior, keeping in mind the low literacy

consumer that may not understand the nutrition label information decreasing the

incentive to use them (Cornish & Moraes, 2015; Serper et al., 2014; Temple & Fraser,

2014).

According to Zimmerman (2013), cognitive habits have been known to permit

learning, and learning can reduce costs if thoughtful deliberation of decisions made

results in positive habit formation of an action such as healthy food choices while grocery

shopping. This requires cognition of behavior that could modify the engagement of old

habits allowing repetition of new habits until the cognitive habit if formed (Zimmerman,

2013). Zimmerman found most health-related behaviors emerge from cognitive habits:

eating behavior was one of those habits, which suggests once the habit if formed, choices

associated with nutritional knowledge and positive nutritional behavior may lessen the

potential costs of obesity related illnesses (Anekwe & Rahkovsky, 2013). A

responsiveness of nutritional panel facts could reduce obesity-related health problems by

reducing the use of pharmacotherapy and surgery, which are costly expenditures. The

cost has been associated with unhealthy nutritional behavior, which often leads to

obesity-related disease (Halbert-Hughes et al., 2013; Millender, 2014; Sutherland, 2013).

The modification in how AAW purchase and prepare their meals can be established after

cognitive and behavioral strategies have been taught (Rowe et al., 2011).

The discovery of what influences food selection is anticipated to come from the

perceptions AAW share about their nutrition knowledge and any barriers they perceive

associated with practicing healthy eating behaviors (Barnett & Praetorius, 2015; Spronk

et al., 2014; Velardo, 2015). The transference of NFLU knowledge into behavior

modification is to identify the motivational influence on food choice. If support systems,

culture factors, environmental circumstances, social, and economics create hindrance

toward embracing NFL, these will have to be addressed before behavioral change can

potentially impact healthy eating habits (Barnett & Praetorius, 2015; Higgs, 2015; Spronk

et al., 2014; Sutherland, 2013; Zimmerman, 2013). A lack of studies focusing on NFLU

as a single-short-term intervention that looks at perception and influence of AAW is the

gap the study will address.

This topic is important based on the limited success of available interventions

directed toward reversing current trends of obesity prevalence. Approaching obesity from

a singular approach with the focus on nutrition literacy and nutrition behavior is not

widespread (Cha et al., 2014; Cornish & Moraes, 2015; Teixeria et al., 2015). Nutritional

health could be dependent upon advancing basic nutritional food labels use in hopes to

improve the health and well-being of AAW (Kegler et al., 2014; James, 2013). Dietary

excess is an obesity contributor and an economic burden. According to various

researchers, nutrition labels could help the understanding of nutrient-dense foods and

nutrients to limit calories, fat (saturated and trans fat), and sugar (Anekwe & Rahkovsky,

2013; Antin & Hunt, 2013; Graham & Mohr, 2014; Sinclair et al., 2014). Anekwe and

Rahkovsky (2013) found it is conceivable to eat healthy for a low cost. However,

nutritional education on nutrient dense foods may require cognitive and behavioral

intervention.

Knowledge of Nutritional Food Labels

Cha et al. (2014) found attitude, previous nutrition education, and

sociodemographic factors (e.g., age and sex) were significant predictors of nutritional

label use behavior. The researchers concluded that improved dietary behaviors require

strategies that are geared toward nutrition and health literacy self-efficacy. Teixeira et al.

(2015) found behavior change in the obesity intervention lies at the point of nutrition

literacy, which moves individuals into self-regulation and is needed to practice healthy

behavioral skills. For AAW, nutritional education is known from various advertisement

avenues (e.g., media, the Internet, newspapers, and magazines); however, in practice

aligning NFLU and point-of-purchase behavior with work/life balance and time scarcity

mixed with the current contemporary food environment, the transition from knowledge to

practice is a conceptual one (Barnett & Praetorius, 2015; Velardo, 2015). Graham and

Mohr (2014) identified a growing consensus that nutritional food panel information is sub

optional for guiding consumers toward healthful choices. Even the FDA, which mandates

the use of food labels, has indicated that food labels could prove useful, but busy

shoppers and low literacy consumers do not understand the information decreasing the

incentive to use them (Agyemang & Powell-Wiley, 2013; Graham & Mohr, 2014).

Acheampong and Haldeman (2013) established when AAW are compared to

Hispanic women on nutritional knowledge, most demonstrated nutritional knowledge,

and yet conceded that target-specific nutrition knowledge could influence nutritional

health. Keith, Hemmerlein, and Clark (2015) compared AAW to European American

women. The researchers reported AAW considered emotional and social support critical

elements of weight interventions; however, in addition, they highlighted health literacy as

a significant obstacle when nutritional food labels were presented. The approach to

dietary behavior attainment was found to be education; however, this research group did

not query its samples’ nutritional literacy (educational status) but used a nutrition

program called Healthy Me as an intervention tool for changing behavior with a poor

result (Keith et al., 2015).

Other studies found AAW demonstrated adaptive potential by going grocery

shopping outside of their neighborhoods to buy nutritious foods, but found the adventure

inconvenient and time-consuming (Sutherland, 2013). This reality is one indication that

self-regulation is plausible if nutrition literacy contributes to reducing poor dietary

choices and increases behavioral patterns that promote healthy lifestyle specific to

nutritional food label (Acheampong & Haldeman, 2013; Carbone & Zoellner, 2012;

Cornish & Moraes, 2015; Lopez et al., 2014; Miller-Soederberg & Cassady, 2015).

Beliefs were found to self-regulate nutritional health, which included food preparation

(Monin & Szczurek, 2014; Spronk, et al.; 2014). Based on some habitual nutrition

practices, the ability to understand nutritional knowledge requires a conditioning process

and the ability to apply learned knowledge to change behavior. Spronk et al. (2014) noted

that declarative knowledge of nutrition and how foods are selected are not of benefit

without considering practical skills and process knowledge. It could further illustrate the

need to explore nutrition literacy on a deeper level to understand how nutritional behavior

practices are developed and how education could tailor and influence change (Gibbs &

Chapman-Novakofski, 2013; Serper et al., 2014).

Some researchers found that probing AAW to disclose their knowledge about

nutritional food labels was awkward because of nutrition literacy (Lopez et al., 2014;

Summers & Klassen, 2014; Velardo, 2015). The effectiveness of the probe is a critical

element that the probability of honest responses from the participants may accurately

reflect the lived-experiences of AAW’s nutritional health known and nutritional behavior

practiced in their past and present, including consuming meals with the family (Summers

& Klassen, 2014). Patterns of behavior can have underlined bias; therefore, uncovering

these realities will require the researcher to be authentic while encouraging AAW to

explore the unconscious to identify its powerful nature to change behavior (Bandura,

1977).

Nutrition Literacy and Nutritional Behavior

Nutrition literacy refers to the individual's capacity to think, reason, and problem

solve, which are all important elements of understanding the discipline of nutritional

health as well as practicing it as a lifestyle (Cornish & Moraes, 2015; Mathers et al.,

2014). Behavior that is associated with nutrition is where the mind meets the body, and

the end product is purchasing and consuming healthy foods (Liu et al., 2014). What

makes these paradigms viable to the influence of NFLU is revealed in the SCT and

Bandura’s beliefs that human behavior interplays between cognition and behavior

(Bandura, 1989). An individual’s ability to change his or her behavior, according to

Bandura, is the uniqueness of the human agent and its habit breaking ability using the

power within to shape life experiences when equipped with the knowledge he or she can

understand and apply to life circumstances (Bandura, 1977; 1989). When people are

contributors and not just spectators of their circumstance, this suggests their nutritional

choices can be deliberate to produce behaviors that develop into positive life-changing

nutritional habits that can reverse obesity (Bandura, 1977; Liu et al., 2014; Zimmerman,

2013).

The behavior or thought that fosters consuming unhealthy food because of its

availability are how Bandura (2001) interjected the strength of self-efficacy and self-

regulation on the human potential. My assertion is that circumstance must not be the

yardstick for behavior associated with poor eating habits. There is no shortage of research

that highlight socioenvironmental factors (circumstances) that impact AAW adoption of

an unhealthy behavior (Barnett & Praetorius, 2015; Higgs, 2015; Keith et al., 2015;

Pruchno et al., 2014; Sutherland, 2013; Walker & Gordon, 2014). Self-efficacy and self-

regulation can monitor decisions that determine dietary intake, which can be taught, and

those tools and skills are two key components of SCT.

Social Cognitive Theory and Nutrition

Bandura’s SCT delineates the presumed sources and mediators of behavior and

behavior change (Anderson, Winett, & Wojcik, 2007). The SCT is widely accepted as the

theoretical stance for assessing health behavior and interventions for change (Bandura,

1977). The implications suggest that NFLU might help AAW develop a sense of self-

efficacy and self-regulatory behavior such as selecting nutritious foods at point of

purchase and preparing meals in the home (Schindler et al., 2013). Nutrition literacy may

be the modifier to self-behavior change because it could lead to comprehension of food

label content and help AAW determine portion size, high calorie, high fat, and high-sugar

foods’ essential knowledge for promoting healthier food consumption (Anderson et al.,

2007; Bandura, 1977; Barnes & Kimbor, 2012; Cornish & Moraes, 2015). Several

researchers have suggested nutritional education is a component of the obesity fight;

however, behavioral lifestyle intervention literature underrepresents NFLU. Tussing-

Humphreys et al. (2013) highlighted various studies that approached the obesity problem

in AAW; nonetheless, the studies lacked specific behavioral strategies that were effective

in promoting long-term weight control.

Maintaining long-term behavior change is the challenge of the obesity epidemic.

The demonstration of nutritional behavior change, being that behavior change cannot be

measured, relies on AAW’s perception of self-efficacy and self-regulation attainment

related to their lived experiences of past situations (Anderson et al., 2007; Bandura, 1977;

Tussing-Humphreys, Fitzgibbon, Kong, & Odom-Young, 2013). Bandura (2001) noted a

person must possess the capacity to exercise control over his or her life, and a conscious

decision will navigate the pursuit of life. Barnes and Kimbor (2012) identified that

identifying the behavior of habit can lead to successful behavior modification such as

limiting fat, decreasing fast foods, and weighting. The possibility of improving nutrition

literacy may help with consumer’s confusion, which might be a predictor of human

behavior not consistent with or directed toward nutritional health.

In one study where the consumer nutritional label knowledge was questionable,

the participants’ ability to process food label content was attached to their knowledge and

understanding (Walters & Long, 2013). Carbone and Zeollner (2012) found similar

results in their meta-analysis study by identifying not only comprehension of nutritional

label content a contributing factor in their use but readability as well. Behavior changes

require levels of self-efficacy and self-regulation, which are two constructs Bandura

(1977) identified in the SCT as critical to positive expectations and the ability of an

individual to achieve a level of accountability to improve nutritional health (Anderson et

al., 2007). Bandura found the behavior change develops from observing others, an aspect

incorporated in the cognitive learning ability. In addition, the SCT assumes how

behaviors are perceived because cognition is a core ingredient in an individual’s

construction of reality and behavior (Bandura, 1977). Controls over human health habits

are the key to reducing health disparities and living healthier and productive lives

(Bandura, 2001).

Humans are capable of avoiding a detrimental path by the detachment of negative

eating patterns possibly when education is used to cultivate new behaviors (Anderson et

al., 2007; Bandura, 2001). SCT places control of self-efficacy and self-regulatory

destinies in the essence of humanness and cognition, which is possible to apply in the

direction of nutrition behavior (Bandura, 1977; 2001). However, an individual’s thoughts

and perceptions are assumed to play a role in actions human take to the engagement of

personal development. The SCT fits this research study in that it provided a framework

for understanding behaviors that infer NFLU is a viable model for healthier nutrition

choices. Behaviors demonstrated by outside influences, such as watching others’ actions,

could reinforce information taught.

Bandura revised his initial theory from social learning therapy to SCT based upon

the learning approaches he observed. Bandura (2001) found that drive was not a

condition of behavior performance. Transformations of behaviors were based on the

cognition after explanation regarding personal reality, combined with guided practice and

success experiences; the result of modeling individual actions (Bandura, 1977) and the

introduction and adoption of self-management skill that can be used consistently and with

confidence (Bandura, 1989; Fitzgibbon et al., 2012). Understanding the relationship

between cognitive and behavioral change could assist in the process of AAW self-

efficacy, strengthening, and maintaining lasting accomplishments such as using the

nutritional food labels as a lifestyle practice and self-regulation, the skill of adjusting

behaviors at the point of purchase, meal planning, and preparations.

Self-Efficacy

Self-efficacy theorizes change in behavior can produce self-confidence by

accomplishing behaviors that exhibit a positive outcome. According to Bandura (1977),

the length of behavior continuous in action incorporates a level of efficacy in the

individual. Nutrition behavior change requires strategies that can be applied to AAW’s

nutritional health inclusive of purchasing and preparing healthier foods (Anderson et al.,

2007; Bandura, 1977). Anderson et al. concluded that efficacy beliefs influence behavior,

and expectations influence the extent that individuals engage in goal setting, self-

monitoring, and other regulatory behaviors. Being mindful of self-perceived capabilities

in attempting to encourage alteration in behavior is necessary to guide behavior in a non-

stressful manner. According to Bandura (2001) and Anderson et al. (2007), self-efficacy

beliefs increases when perceived support from others serve as incentives for behavior

modification. The AAW could adopt similar beliefs when selecting healthier food

choices, which might likely increase self-efficacy and self-regulation attitudes.

Various researchers have considered Bandura’s theory to behaviors could

improve self-efficacy. Cha et al. (2014) noted individuals with higher self-efficacy were

more attentive in healthier diets than were those with lower self-efficacy. Knowledge and

experience played a major role in their performance. Odulana et al. (2014) explained that

health promotions in faith-based settings were connected to cognitive, behavioral, and

environmental influences and were motivating factors for individuals having the

willingness to learn health promotion materials. Zimmerman (2013) noted that cognitive

habits were the building blocks that constitute individual thoughts and behavior. When

benefits from a behavior change are known, positive behavior replaces the sequence of

instruction by undoing habits with education (Cha et al., 2014; Zimmerman, 2013).

Bandura (1977) found that as people process and integrate their capability based on the

information, it allows them to make behavior choices that render positive results.

Self-Regulation

Behavior that helps AAW enact self-regulatory behavior is essential to purchasing

and consuming healthier foods (Anderson et al., 2007; Walker & Gordon, 2014). The

individual must establish the importance of understanding the varying perspectives under

which the skill of label reading might be considered (Liu et al., 2014; Schindler et al.,

2013). Bandura (2001) posited that the ability to change behavior requires a conscious act

of foresight. Self-regulation, as it related to nutrition, has limited space in the literature;

however, it does offer a different direction to healthy eating (Anderson et al., 2007). Most

individuals go through stages of change; subsequently, they find the tangible motivator

that could fuel the incentives to self-direct behavioral change and promote the desired

response may be in the understanding of AAW perception of their eating habits and their

consequences (Webb et al., 2014). Self-regulation has the influence to move individuals

to their destiny; however, the success of this, according to Walker and Gordon (2014), is

assessing the triggers that lead to specific behaviors and attempt to understand the

experiences of that conditioning. Teixeria et al. (2015) found that success and failure in

self-regulation of health behavior were specific to nutrition habits and rooted in values

and self-endorsement. These intention-behavior gaps could impede the implementation of

self-regulatory skills for nutritional health (Teixeria et al., 2015). In this respect, the skill

necessary to process food label information has to be articulated by AAW. Kegler et al.

(2014) reported it was important to evaluate the home food environment where possible

opportunities may exist to shape shopping habits and skills related to self-regulatory

behavior (Anderson et al., 2007). Both cognitive and behavioral motivators that transfer

into skill acquisition are the result of knowledge, comprehension, and commitment,

which are all constructs of behavior.

Summary and Transition

An analysis of the literature for this research study illustrated multiple and

combination therapies for addressing obesity; however, NFLU as a single short-term

intervention is understudied in the literature with AAW in the baby boom era as

participants. The trajectory of obesity in this population are concerns, as the literature has

shown, but long-term results have been disappointing (Fitzgibbon et al., 2012; James,

2013). Research may prove useful if the concentration moves beyond screening for

obesity to knowledge and understanding about the behaviors that leads to an obese state.

Interventions to improve nutritional practices in AAW are necessary to reduce morbidity

and mortality (DiNoiaet al., 2013). According to James (2013), AAW are not likely to

participate in a weight-loss program. The previous statement does not suggest AAW have

not attempted weight programs; research has identified a short-lived process (Teixeria et

al., 2015). NFL programs associated with healthier eating patterns might need to include

cultural influences (e.g., body image, food preferences) in framing target interventions as

a component of nutritional behavior and nutrition literacy (Antin & Hunt, 2013 Cha et al.,

2014; Cornish & Moraes, 2015; James, 2013; Webb et al., 2014). Further, for AAW to

trust nutritional food labels information, the label content has to be easy to read and

understand; otherwise, habits will dictate the items they purchase.

An in-depth examination of the lived experiences of obese AAW’s nutrition

literacy and nutritional behavior with NFLU is the emphasis on the research study and the

gap that was addressed. The aim was to offer obese AAW useful recommendations of the

efficacy of food label content to make healthier dietary choices. The purpose of nutrition

labels on foods is to help consumers make healthier food choices. Unfortunately, the lack

of attention paid to them may be because of nutrition literacy (Graham & Mohr, 2014)

and perception of their usefulness. This research could have the ability to add to existing

literature by amplifying the positive aspect of NFLU, and the ability to influence

behavioral change that affects nutrition choice and nutritional health.

Chapter 2 began with the introduction and then restated the problem and the

purpose of the study. I have identified the literature search strategies and major sections

of the chapter. They include (a) the history of the nutritional food label industry, (b)

nutrition literacy, (b) AAW’s knowledge of food labels, and (c) the constructs of nutrition

literacy and nutritional behavior. The theoretical framework for this study was named

along with the theorist and theory, which was Bandura’s SCT concentrated on self-

efficacy and self-regulation as they applied to NFLU as a single short-term strategy that

resulted in long-term habits suggestive to promote healthy dietary behaviors.

Chapter 3, the methodology section of the research, begins with an introduction. I

restate the purpose of the study and discuss major sections. Major sections include the

research design and rationale, a discussion on the role of the researcher, and the rationale

for the choice of conducting a qualitative IPA methodology design. The research

questions, theoretical framework, and the approach to address the gap in the literature are

shared. This chapter also discusses the recruitment, sample size and population, data

collection process, and the technique for gaining research data for analysis. Issues of

trustworthiness, ethical consideration, the risk of the study to participants, and a summary

are addressed.

Chapter 3: Research Method

Introduction

The purpose of this study was to discover the perceptions and lived experiences

that influenced AAW in the area of NFLU within the context of a single short-term

intervention (6 months). In this chapter, I (a) described the research methodology, (b)

explained the target population and research setting, (c) described the method of

collecting data and the data analysis tool that was used to identify patterns and themes

presented from the research data, (d) addressed the process for verification, (e) covered

ethical considerations, and (f) presented a chapter summary.

Qualitative Research Methodology-Phenomenology

In this study, I used a qualitative phenomenological methodology to develop

emerging descriptions and themes concerning the perceptions and lived experiences that

influenced responses to NFLU on dietary practices for obese AAW born between the

years 1946 and 1964. Creswell (2014) recognized five approaches to the qualitative

methodology: (a) a case study, (b) ethnography, (c) grounded theory, (d) narrative, and

(e) phenomenology. Phenomenology was the approach used to discover the lived

experiences and perceptions of the study participants. The inquiry occurred by recruiting

participants from two Baptist churches in Fort Bend County, Texas.

This study used Interpretative Phenomenological Analysis (IPA), which involved

capturing the experiences of others and reflecting on an analysis that portrayed the

essences of these experiences (Moustakas, 1994). It was a deeper exploration to examine

how individuals assigned meaning to the situations they faced in their environment

(Moustakas, 1994). Human behavior is powerful, and the outcome of demonstrated

actions that surround individual environmental and cultural experiences can affect the

decisions and choices made (Kristen, Ivarsson, Parker, & Ziegert, 2015).

During the 20th century, Edmund Husserl developed scholarly work in

phenomenology to discover the essence of how nature and meaning inhabit the lived

experiences of individuals in the world to include the choices they make (Jacob, 2013;

Moustakas, 1994). Researchers who use phenomenology realize that the experiences

lived by others are something that has no statistical measure, which indicates that the

researcher has a deeper quest for knowledge from essential constituents of the

phenomenon (Moustakas, 1994). Further, in studying the phenomenon of interest in this

study, I discovered the hidden and diverse perspectives of obese AAW that was useful in

understanding whether cognition and behaviors were associated with possible

deficiencies regarding information on nutritional health. The aim of the study was to

address the gap in the literature on better understanding the experiences of AAW and

NFLU as a single, short-term strategy to addressing obesity. The lack of attention given

to the phenomenon was examined and explored for effects nutrition understanding had on

education changing unhealthy nutritional choices.

The qualitative research paradigm has origins in cultural anthropology and

American sociology with a base of formed words framed in personal belief, value, and

worldview (Creswell, 2014; Guba & Lincoln, 1994). Understanding is gleaned from the

participant’s words and actions that form patterns of lived experiences and perceptions

(Guba & Lincoln, 1994). As a qualitative researcher, my objectives were to illuminate the

phenomenon that was studied by addressing the humanistic view of the why and how

underpinning knowledge about health behaviors (Kristen et al., 2015). These are a

determinant of effective health practices, which facilitate a healthy lifestyle (Kristen et

al., 2015). To develop knowledge of why it is important to have a healthy way of life, as

well as what activities could facilitate positive health behavior, might increase the

participants' motivation to practice healthy lifestyles relating to nutritional health choices.

I used this method of study as a fact-finding approach to understand better the social and

behavioral phenomenon of AAW struggling with obesity. The immersion into the lived

experiences of participants’ perspectives and meaning of their world established a

pathway for current and future research (Creswell, 2014; Miles, Huberman, & Saldana,

2014).

Sample Population and Research Setting

Sample Population

Population sampling is the process of selection from a particular population.

Because this study was not quantitative where statistical analysis was typically

performed, the sample was gained based on the criterion of the qualitative design

(Nachmias & Nachmias, 2008). The convenience sampling approach was the way

potential participants were selected. The study inferred understanding and meaning to the

phenomenon of NFLU.

Sampling Criteria (Inclusion)

Convenience sampling was the deliberate act of selecting participants to be part of

a research study from a specific population. Using an inclusion criterion was an attempt

to understand the perspectives of an obese subset of the population (Brown & Gould,

2013). Established criterion were used in the selection of the sample participants

(Creswell, 2014; Miles et al., 2014; Seidman, 2015). For this study, the study participants

were extracted from obese AAW (between the age of 51 and 64 years) who resided

within the zip code of 77477 in Fort Bend County Texas at the time of data collection.

The BMI must have been ≥ 30 kg/m2 for all participants. Participants must been able to

read and understand English. This final particular criterion was necessary for qualitative

validity. In this qualitative inquiry, focusing on the sample population was critical

throughout the study and the overall research process to maintain rigor, reliability, and

trustworthiness (Burmeister & Aitken, 2012). Conducting qualitative research during the

iterative process demanded attention toward the sampling selection process, the

recruitment technique, the research problem, and the method to avert the risk of error or

bias (Burmeister & Aitken, 2012; Rudestam & Newton, 2015).

Data saturation and content validity were essential elements of the research study

to avoid a negative effect on the study (Fusch & Ness, 2015). Data saturation was the

guiding determinant over sample size based on the goal to gather thick, rich data that

addressed the research topic. In addition, generalization did not occur with this study.

This was hard to achieve because the study was not representative of the entire AAW

population (Lucas, 2014). Individuals who were excluded may have been left out and

possibly could have contributed to the data being skewed could have been obese AAW in

other zip codes in Fort Bend County, Texas. Because the convenience sample was not a

randomized compilation of participants, calculating the probability of members of the

study’s population could not be quantified (Lucas, 2014). Therefore, summary claims

were not a part of this study; thus, generalization could not occur because in-depth

interviewing could only offer subjective data from study participants.

Sample Selection and Recruitment Process

The research selection process exhibited a convenience sampling process. The

AAW residing in the included zip code were invited to participate in the study.

Participants were notified about the study by the church bulletin and word of mouth at

two Baptist churches in Fort Bend County Texas. If the recruitment process had become

stagnant, other strategies would have become necessary to reach potential participants

(e.g., additional zip codes or other church denominations). Additionally, methods would

have included email blasts by the church secretary and personal appearances at the

selected churches to give details about the research project. This mode of communication

would have been a feasible alternative as some of the participants might have had low

literacy levels and may not have understood the magnitude of the research study. It was

also important to note this IPA study deliberately sought participants with a specific set

of criteria to address the phenomenon studied with no effort to generalize to a population

(Burmeister & Aitken, 2012; Rudestam & Newton, 2015). Fortunately, I secured all study

participants by the initial plan.

Research Participant Recruitment Process

Recruitment challenges can occur when conducting qualitative research studies

(Namageyo-Funa et al., 2014). Mindful of this reality, the research participants were

recruited by flyers, at presentations before the congregations, and printed information in

the church bulletins on each Sunday of the month after an approval number was granted

from Walden University Institutional Review Board (IRB). I did not plan to use the

communication boards at the churches because the flyers may have been covered up by

other announcement flyers, according to Namageyo-Funa et al. (2014), which may have

hindered recruitment of participants. Written permission was requested and granted from

the senior pastor of the host Baptist church in Fort Bend Country, Texas. I conducted the

interview sessions in a securely locked classroom in the church. The participants were

asked to read an informed consent that explained the research study, its purpose, and

participant expectation, which included their decision to withdrawal from the study at any

time. After the interview sessions had concluded, debriefing sessions were conducted.

This important step included that the data received from the participants were accurate.

The debriefing sessions further allowed participants to ask any additional questions that

surfaced after the face-to-face interviews. I did not have any follow-up interactions post-

interview sessions by email, phone, or in person.

The aim of the sampling procedure was to identify a subset of a population to use

in the research study. This study employed a non-probability convenience sample, which

meant the participants were not chosen at random, instead they were chosen based on

accessibility and convenience (Creswell, 2014; Nachmias & Nachmias, 2008). This

process was practical because the study involved a personal relationship with the study

participants understanding the perceptions they had on the research topic that they

associated with their lived-experience. My role as the researcher was to absorb the words

and interpretations that were described by the AAW during each interview mindful of the

research questions evolved into the interview questions. For questions that were not

sufficiently answered from lack of clarity during the face-to-face interview sessions, were

rephrased for participants to answer back to the lined questioning.

The selection process included a minimum of 12 and a maximum of 20

participants agreeable to be interviewed. Because of the varying views on sample size in

qualitative research, relying on previous qualitative studies was the method used to

identify sample size. Multiple researchers debated sample size in qualitative studies

making the sample range difficult to gauge. For instance, Robinson (2015) explained

most studies required a provisional decision on sample size at the initial design stage.

Many studies have followed Robinson’s research findings by arbitrarily starting with a

number suggested based on other qualitative research studies or by the saturation point,

which is determined as the study is progressing during the interview process (Fusch &

Ness, 2015; Robinson, 2015).

For IPA studies, Robinson (2015) gave a guideline of 3 to 16 participants for a

single study. Fush and Ness (2015) cautioned no one size fits all and cited that having

specific numbers of participants decided can sometimes invite missed opportunities to

pursue additional data that could add to the depth and breadth of a study. Moreover, a

decided upon sample size may not guarantee the questions the researcher is proposing

will be answered. According to Fush and Ness (2015), more attention should be given to

the rich quality of the data instead of the quantity and size of the sample. Burmeister and

Aitken (2012) agreed the number of participants is not necessarily the key, but the depth

of the data and a sample size that have the best opportunity for in-depth answers that will

yield a quality research project.

Because qualitative researchers must establish an acceptable starting point for the

sample size that will increase the validity and trustworthiness of this study, similar

qualitative research studies were evaluated for their sample size as a way to support the

decision for this study. Galvez, Valencia, Palaomino, Catalado, and Schwingel (2015)

conducted a qualitative study interviewing Chilean women (n = 15) on their eating

behaviors. Collings and Bogue (2015) carried out in-depth interviews with an ageing

population (n = 16) facilitating healthy foods acceptance concerned with age related

conditions that could result from poor nutrition. Sand, Emaus, and Lian (2015) conducted

interviews (n = 12) with young adults identifying cultural norms and lifestyle perceptions

around appearance. Jervis and Drake (2014) conducted research in the field of food

science and considered 10 to 20 participants an acceptable range for interviewing

participants, but had interviewed as many as 28 participants; however, the researchers

found the data hard to manage. Daivadanam, Wahlstrom, Ravindran, Thankappan, and

Ramanathan (2014) conducted 17 individual interviews on dietary behavior change

interventions at the household level and reached saturation with that number of

participants. Gentles, Charles, Ploeg, and McKibbbon (2015) used a flexible sample size

estimation suggested by research tradition and for phenomenology (hermeneutic) of <10

participants based on intensely, < 30 for less intensely. Moreover, sample size attainment

was described as data saturation, recognized as redundancy of information received from

participants as an additional way to determine participant size (Gentles et al., 2015). For

this study, 12 participants will allow for the gathering of significant data on the

phenomena under study using a convenience sample, which is one method a researcher

uses with subjects who are available and willing to participate in the research study

(Brown & Gould, 2013; Lucas, 2014; Nachmias & Nachmias, 2008; Namageyo-Funa et

al., 2014).

Robinson (2015) encouraged monitoring data collection and altering sample size

as data are collected because the sample size is unpredictable. From large qualitative

project with sample sizes of 700 structured interviews to a small project of eight in a

single study. Considerations were given to saturation as it related to recurrent themes and

patterns. Based on varied studies, 12 participants could expand to 20 participants. In this

study, saturation occurred with the 10th participant of the convenience sample, however

to ensure recurrency of words, themes and patterns, two additional participants were

interviewed.

Another way to look at convenience sampling is volunteers being accessible and

agreeing to participate in the study after informed consent has been explained. Although

selections may be unguided, every participant in the study was asked the same questions

(Nachmias & Nachmias, 2008) during the interview process. Each research participant

was given an equal chance to answer the interview questions based on their lived

experiences of the research topic: The influence of NFLU on AAW who were obese and

primary grocery shoppers of the residence. The plan was to conduct interviews within a

one-month period and then take one to two months to analyze the data drawing inferences

from the findings, themes, and patterns of the study.

Data Analysis Plan

Data collected and analyzed in qualitative research are different from quantitative

research in that data are not based on numerical measurements. The instrument in a

qualitative study is the researcher who collects and analyzes data collected from the

inquiry into the lived experiences and perceptions of the study participants. The steps in

the process included the methods of collecting data and a description of the computer

software used to analyze the interviews and taped-recorded information.

There are various methods of data collection: open-ended questioning using

questionnaires, semi-structured interviews, focus groups, participants and case studies.

For this study, a face-to-face, semi-structured interview method was employed. Each

study participant was asked the same interview questions and the same number of

questions in a consistent manner to maintain fairness and impartiality. The goal was to

gain as many perspectives possible on nutrition literacy and nutrition behavior likely to

have impacted healthy eating in obese AAW based on their individual experiences. A

prepared script (list) of questions was used during the interview sessions. The questions

were neutral, asked one at a time, articulated clearly, and free from assumptions

(Creswell, 2014; Turner, 2010). The list of interview questions is included in Appendix

section of this dissertation.

Method of Collecting Data

I conducted the research study using face-to-face semi-structured interviews from

May 12, 2016 to May 23, 2016. I asked open-ended questions to allow participants to

share their perceptions, understanding, and experiences of NFLU. Research participants

were invited to 45-60-minute interview session to answer the interview questions.

Interviewing is used abundantly in qualitative research and often pragmatic to this

research methodology, which was designed to gather information from the population

under study (Doody & Noonan, 2013; Guba & Lincoln, 1994). Further, face-to-face,

semi-structured interviews in qualitative research is a popular approach toward gaining

trust from the study participants to attain insight based on the research questions

(Seidman, 2015). The probing questions and creating a state of epoche’ aided in data

saturation (Fusch & Ness, 2015).

As the researcher, my role was to give the participants my full attention during the

semi-structured, open-ended questioning and to encourage authentic answers. Participants

were encouraged to maintain focus on the research topic during each face-to-face

interview session. During the interviews, I used a voice-activated recorder to assist with

the data collection process. The voice-activated recorder added a layer of protection to

safeguard valuable data that were captured during the interview process. The voice-

activated recorder enabled me to focus entirely on the interview process. In an interview

where open-ended questioning occurs, it was difficult to scribe what the participants were

saying and to pay attention; therefore, to avoid losing valuable interview content from the

participants, the voice-activated recorder assisted me in capturing the answers to the

interview questions. Taking into account the research project involved human

participants; the use of a voice-activated recorder required permission from each

participant who agreed to participate in the study. In addition, informed consent to

conduct the study was required and granted by the participants. It was important to allow

adequate time for each participant to preview the consent form and ask questions. Once

all the participant questions were answered, the women verbalized to become part of the

study and consented with their signature.

An advantage of the face-to-face interviewing method was the ability to establish

relationships with the participants and observe nonverbal expressions during each

interview. When interviews were concluded and transcripts polished, follow-up contacts

with some participants occurred to validate some of their answers. The member checking

technique was a valuable way to ensure true understanding of participant responses,

which is also a consider validity strategy. As the primary researcher, member checking

was similarly an opportunity for include possibly triangulation, and self-reflection

(Creswell, 2014; Robinson, 2015). This helped with the relationships formed by face-to

face interactions. Also, it let the participant know their efforts and voices were heard and

documented in a research study. In light of the positive side of face-to-face interviews,

there were disadvantages to the interview process.

The disadvantage of the interview method and being close to the topic created the

potential for biases and subjective viewpoints to the surface. According to Moustakas

(1994) and Chan et al. (2013), it is necessary to remember phenomenology suggests a

researcher must step out of ingrained influences, perceptions, understandings, and

behaviors (if possible) and become present in the moment of time so that possibly new

meaning to the phenomena emerges. According to Fusch and Ness (2015) and Robinson

(2015), attaining rich and thick data can yield the research objective of addressing the

phenomenon to be studied by discovering themes and patterns that may reflect reaching

the saturation point. Because individuals interpret the world and the circumstances they

experience differently, my assumption as the researcher of this project was that behavior

changes can occur when AAW’s cognitive literacy is heightened regarding nutrition

knowledge; as a result, behavior changes could have surfaced from NFLU experience.

Qualitative research was the best approach to address the research problem and

research questions of the study. Gained knowledge from the participants in an emerging

fashion delivered rich descriptive data that was interpreted into themes and patterns that

conveyed meaning on the lived experiences of AAW’s nutritional literacy and nutritional

behavior. I shared the study results with each participant by way of a one to two-page

summary that is a part of the dissertation project. It was important to show each

participant the interview questions were instrumental and beneficial to the research

project completion.

One central research question and four sub-questions were introduced in this

study. Its intent was to allow AAW to identify and articulate the effects the phenomenon

had on the behaviors that may have attributed to their obese state. The subresearch

questions were probed from a cognitive and behavioral standpoint. For example, the sub-

questions were explored from the participants’ perceptions and understanding of the

benefit of addressing and altering nutritional behavior. In addition, another subquestion

was probed from the participants’ experience of NFLU being a plausible intervention

leading to self-efficacy and self-regulation in nutritional behavior. A third sub-question

encouraged the participants to affirm reasons why NFLU may or may not have been

considered a worthy practice for their nutritional health. The last sub-question explored

and examined if the study participants formed relationship connections between

nutritional knowledge and nutritional behaviors; if so, how was this connection

understood and interpreted by the study participants.

The questions proposed for this study were a pursuit into AAW’s cognitive and

behavior influences toward healthy food choices as a lifestyle accomplishment. Although

I did not conduct a focus group interview, the questions asked were specific and flexible

to make room for unstructured dialogue between researcher and participants (Fusch &

Ness, 2015). Flexibility is essential to receive substantial data. Individual perspective was

central to this study and a qualitative IPA approach. The objective was to gain the

essences of the AAW’s lived- experiences associated with NFLU.

Chan et al. (2013) found the ongoing interactions between researcher and

participant could lead to understanding human behavior. The unique perspective of each

participant’s interaction is a significant piece in a qualitative study. Considering

qualitative methodology over quantitative methodology was based on its descriptive

tenets (Seidman, 2015). Data received from the study participants were individual’s

personal account instead of statistical presentations, which are well known by

quantitative methods. It was equally important to address strategies to minimize personal

beliefs or preconceptions (Chan et al., 2013). The qualitative methodology allowed the

researcher to explore in detail each participant's perceptions and to participate in

another’s experience. The research question and sub-questions follow:

Central Research Question

How does NFLU impact meaning to the obese state of AAW in Fort Bend

County, Texas?

Subresearch Questions

1. How beneficial will of NFLU be to obese AAW?

2. What skills would be helpful for obese AAW to achieve for NFLU to be a

plausible intervention identified by obese for combating obesity?

3. What are some possible reasons NFL may or may not be practiced by AAW who

are obese?

4. How would obese AAW interpret NFL in relationship to the nutritional behaviors

they practice?

Before each participant’s interview, I prepared a secure vanilla envelope for the

signed consent form, interview questions, and contact information. A copy of the signed

inform consent was provided to participants for their records. The same secure envelope

was used to maintain raw data that were transcribed after each interview. Securing data

was my responsibility and an IRB requirement.

Description of the Data Analysis Tool

The computer-assisted qualitative data analysis software CAQDAS was used in

this research study is called QSR NVivo-10, which is distributed by QRS International.

NVivo software is a widely used tool for data analysis and was the desired software used

for this study. NVivo 10 provided support for the data to be analyzed, helped with the

development codes and identifiers, and helped identify document themes that may have

had connections to the research participants’ interview experiences (Edhlund &

McDougall, 2012; Miles et al., 2014; Patton, 2002. CAQDAS programs can help to

analyze data, but are not a replacement tool for the researcher to analyze the collected

data. In addition, in using CAQDAS programs, such as NVivo-10, flexibility, creativity,

and insight from the research project are possible, but the software should never replace

the systematic analysis required by the researcher uncovering the realities of qualitative

data collected (Edhlund & McDougall, 2012). Regardless of whether a computer program

is used in the analysis of data, Onquwuegbuzie et al. (2012) explained researchers are

main instruments in the qualitative research process. They are primarily responsible for

all aspects of the research project. In addition, the researcher is responsible for addressing

biases. According to Chan et al. (2013), biases are inherent human factors and the way to

face them is through a bracketing strategy. I used bracketing for mindfulness regarding

personal values, assumptions, beliefs, and expectations during the interview experience

and captured any self-thoughts by journaling reflections.

Researcher’s Role in Qualitative Methodology

The researcher was introduced as a full-time doctorate student and primary

researcher of this study; not as a professional, because the researcher did not want to

intimidate the participants. Equally important, my role as a researcher, the primary data

collection instrument, required a disclosure of any assumptions, personal values, and

biases outright before beginning the study. Personal experiences have shaped my

perceptions of obesity and its consequences. In March 2011, I was diagnosed with spinal

stenosis, which restricted my ability to be physically active; subsequently, I became

obese. After two years of taking medication that made me gain weight, I changed my

perspective on obesity. When seeking to correct the situation minus exercise based on the

joint and back pain that limited the ability to exercise early on, I started paying closer

attention to food label content. The primary focus was on nutrient-dense food while being

mindful of calories, portion size, and fat. It is not that the macro and micro-nutrients were

not important, but energy efficient foods were the initial concentration. In addition to the

previously mentioned label information, I increased protein and fiber in my daily

consumption. Within six months of focusing on nutritional food label content, I lost 39

pounds and subsequently lost a total of 50 pounds.

My assertion is that obese AAW, if educated on nutritional food label content,

could change the trajectory of their obese state. Granted, that this may be a bias in this

study; the intent was will be to ensure every effort is made to remain objective and

bracket my experiences and perceptions with journaling and self-reflection as NFLU

attempts to initiate change in nutrition literacy and nutritional behavior among the study

population. Nutrition literacy may be the culprit to nutritional behavior change. The

understanding and awareness NFLU can have on combating obesity may not be well

known in this population; however, the knowledge of curtailing energy-dense diets will

help me reach the participants in the study who are obese and may lack the information

on nutritional labels and how to use them while grocery shopping. As principle

investigator of this study, having a leadership presence to encourage behavior change

through self-regulation and increase in self-efficacy, nutritional health in AAW will be

based on their decision-making ability, willingness to change, and cognitive ability.

My role as the researcher was to make each participant as comfortable as possible,

before, during, and after the interview session. The research interviews were conducted in

a locked classroom for privacy, comfort, and quiet. During the interview process, I

provided light, healthy snacks and bottled water. The restrooms were located in close

proximity to the interview classroom for the participants’ ease of access. The interview

site had comfortable chairs, and I made sure the interview classroom’s temperature was

comfortable. At the end of each interview, the participants received a 10-dollar gift card

for a Starbucks product, and a thank-you card as a gesture of gratitude for their time and

participation.

Threats to Validity in Qualitative Research

Validity refers to the degree to which the researcher measures what he or she

intends to measure (Nachmias & Nachmias, 2008). Validity is concerned with the

question, Am I measuring what I intend to measure? (Nachmias & Nachmias, 2008). In

research studies, regardless of them having a qualitative or quantitative path, the data

findings must be believable. According to Onquwuegbuzie et al. (2012), the constant

comparing of different data allows the researcher to examine their similarities and

differences helpful in collecting themes and patterns. Fusch and Ness (2015) explained

the study should be done in such a way to ensure outside, irrelevant content is not part of

the data to be analyzed. As the researcher and data collection instrument, it was my

responsibility to conduct the research study in such a way to ensure the conclusion of the

study was credible, made sense, and fit the research trajectory without marginalization

content (Maxwell, 2013; Miles et al., 2014; Onquwuegbuzie et al., 2012). The protection

of the raw data gained from the interview processes were essential to avoid interference

with validity (Guba & Lincoln, 1994; Miles et al., 2014). Therefore, awareness of less

than robust data collection practices and my personal views monitored; otherwise, biases

could have influenced results creating unintended consequences of content. For instance,

mindfulness is important if the researcher is of the same ethnic background being studied

or has familiarity with the phenomenon under study. These situations may convey bias.

Consequently, standardizing the process may prevent creditability mishaps. One strategy

suggested by Miles et al. (2014) and clarified by Nachmias and Nachmias (2008) is the

concept of triangulation, which is the practice of using more than one method of data

collection (Fusch & Ness, 2015). The concern of verbal reports and actual behavior may

be a finding that indicates the importance of various forms of validation.

Various methods are often considered when discussing threats to validity or

trustworthiness in qualitative research. Maxwell (2013) and Miles et al. (2014)

recognized the need to validate the word-laden methodology. Judging the goodness of

qualitative research is critical to the meaning inference (Miles et al., 2014). As a

researcher, it was may be necessary to look amid the data and the conclusion to validate

the study by the inclusion of multiple perspectives gained from the phenomenon being

studied (Moustakas, 1994; Nachmias & Nachmias, 2008). Any researcher, although

guided by the research questions, still has an obligation to allow the participants to share

information that may be unique (Chan et al., 2013).

The qualitative research process is inductive where patterns or generalizations

may represent interconnected flexible thoughts or parts linked to the whole phenomenon

as the study design comes into focus (Creswell, 2014; Maxwell, 2013). Brown and Gould

(2013) suggested the interviewer’s characteristics should be a consideration in the

research process because they may improve acceptance of participation and new habit

formation. Consequently, the researcher’s immersion into participants’ voice of reality is

a significant part of the qualitative research experience (Brown & Gould, 2013;

Moustakas, 1994; Onquwuegbuzie et al., 2012). The role as the researcher is objectivity,

and focused should be on how AAW articulated their reality by perceptions,

understanding and experiences. The data to be collected from each participant’s view was

must be validated for trustworthiness.

The process of data collection is from the emic perspective (participant view);

although, as an outsider (etic view), bias could impede the trustworthiness of the study

causing a failure to reach data saturation (Fusch & Ness, 2015; Patton, 2002). Strategies

to help prepare a bias-free study were a high priority for me. One strategy I employed

was to report participant specific words accurately (Chan et al., 2013; Onquwuegbuzie et

al., 2012). Another strategy was to consider the triangulation of the results to reinforce

the validity of findings (Brown & Gould, 2013; Miles et al., 2014; Onquwuegbuzie et al.,

2012). Triangulation validated the methodology by an examination of the results from

several perspectives, which included the participant. This is termed member check, which

is designed to validate the interview content with each participant and make any

corrections needed (Guba & Lincoln, 1994; Patton, 2002). To recap, the benefit of

conducting a qualitative study is the opportunity to understand firsthand how potential

participant’s life circumstances, such as obesity and nutrition, affect the foundation of the

nutrition habits and behaviors that have developed over time. Another benefit is as the

researcher, I can take cues from the study participants that could result in deeper, richer

data by having the option to encourage a collaborative exchange to what participants are

sharing.

Ethical Consideration

Ethical issues are present in any form of research, even with the researcher’s

desire to do good and prevent harm (APA, 2010; Pozgar, 2010; Sullivan, 2011). Ethical

considerations in human research must be a high priority to protect participants and

researchers. The principles under constant consideration are respect for the person,

beneficence, and justice (Moustakas, 1994; Pozgar, 2010; Sullivan, 2011). Diligence in

these areas is essential to reduce bias during the research study. In fact, Moustakas (1994)

warned to bury any preconceived assumptions and prejudgments about the population or

the research outcomes. The immersion of the individual through the experience to gain

the thick data so to understand the perceptions and lived experiences of the participants is

the goal along with ensuring the protection of each study participants (Nachmias &

Nachmias, 2008; Pozgar, 2010).

Participants’ privacy was protected using pseudonyms (e.g., fictitious names, pen

names, reverse initials) or a number system. According to Sullivan (2011), potential

research participants must not be coerced or influenced to participate in the study.

Unethical practices concerning coercion or influential actions occurred during the study.

All participants used the research information letter and research flyer and made the

decision to be an active participant in the study. The research information also shared

with the participants to withdraw, refuse to answer questions, and change their mind on

participating in the study at any time.

I reported the research findings with the utmost care to maintain privacy and

confidentiality. Privacy and confidentiality were my ethical responsibility and imperative

when conducting research on human subjects. The integrity of participants’ data,

respectful of timelines, and securing data in locked cabinets in my home office were a

high priority. Further, there was no association between researcher and participants that

had to do with employment, conflict of interest, or incentives to participate in this

voluntary study project.

The population of this study had a cultural heritage; therefore, describing the

ethnic group properly to prevent labeling was essential. The term African American

women in this study described women born to African American parents and considered

themselves African Americans or Black, which are both acceptable terms because the

term describes a region of origin (APA, 2010). Respecting people's preferences regarding

ethnicity is important. The effort was made to determine the appropriate term to prevent

offensive descriptive labeling (APA, 2010). These considerations are vital before the

research process began and data were collected.

Before any research data were collected, an authorization from Walden

University’s IRB was required. Potential risk and benefits were addressed, along with

data integrity and confidentiality. Approval from the Walden University IRB to protect

the rights of human research participants proved an approval number with an expiration

date. Walden University/Institutional Review Board approval number for this study is 05-

09-16-0124156 and it expires on May 8, 2017. Once the research data were collected

according to the IRB guidelines, all data obtained from the research project will be

maintained on an external storage drive that will have a locked security code within a

locked cabinet in my home office for 5 years.

Summary and Transition

Chapter 3 provided the plan and rationale for using a qualitative, IPA approach as

the methodology in this research study. The research study explored the lived experiences

of obese AAW in an interpretive manner to gain an understanding of nutrition literacy

and nutritional behavior as it relates to NFLU. The objective was to encourage an

intervention that could develop into a habit whereby the selection of healthy food choices

at the point of purchase and dining-out consumption is integrated into the lived

experiences of AAW. Moreover, the constructs of concentration were identified as (a)

nutritional literacy acknowledgment (cognitive ability) and (b) a nutritional behavior

modification tool.

This chapter described (a) the research methodology, (b) the target population and

research setting, (c) the method of collecting data, (d) the data analysis tool considered

for identification of themes and patterns from the research data, (e) trustworthiness, the

process for verification, (f) ethical expectation that complies with the process set in place

by Walden University IRB department, and (g) summary. Chapter 4 began with an

introduction and a brief review. The purpose and research questions were highlighted.

The setting of the study, demographics, a description of the number of study participants,

and any factors that created difficulties interpreting the findings was presented in the

chapter. I shared descriptions of the interview questions with details on the method used

to collect data. The location for the study, the average duration of the interview sessions,

and the recording device used in the study was acknowledged. In Chapter 4, I shared how

the interview process progressed, the organization of the interviews, the use of an audio-

recorder, and the transcription method used. I discussed the computer software program.

Highlights from the themes and patterns emerged from the data collection process were

presented. Finally, I shared the data analysis experience, addressed trustworthiness, and

ended with an overall descriptive summary of the outcome of participant content exposed

from the research questions are revealed.

Chapter 5 reiterated the purpose, nature of the study, and why the study was

conducted. Key findings from the research study were summarized in this chapter. I

described the interpretative findings by comparing or contrasting the peer-reviewed

literature to the study findings. Limitations of the study, recommendations for further

research, and implications for positive social change highlighting the potential impact on

individuals, families, and society were included. I concluded Chapter 5 with a reflection

that encompasses the essence of the study.

Chapter 4: Results

Introduction

In Chapter 4, I briefly summarize the purpose of the study based on the gap found

in the literature, the setting, participant demographics (N =12), data collection process,

data analysis experience using NVivo 10 software that assisted in the formation of

themes and patterns, evidence of trustworthiness, and results of the study grounded by the

research questions. In addition, I highlighted discrepant findings discovered from the

study. Chapter 4 concluded with a summary and the transition into Chapter 5.

Findings

In this study, I interviewed 12 AWW to gain their perspective on nutritional

knowledge and behavior while grocery shopping and dining-out. They shared candid

thoughts and realities about the essence and perception to their nutritional food label

understanding (NFLU). As a result of coding interviews, using NVivo 10 major themes

and minor themes emerged. The emerging themes are presented within the context of the

research questions. The analyzed data unfolded into the findings of this study.

Purpose and Research Questions

This study examined and explored the lived-experiences of AAW living with

obesity concerning NFLU. The intended objectives of this study were to offer an

interpretative understanding into how AAW, in a given situation, makes sense of a

phenomenon (Moustakas, 1994) like NFLU. Nutritional literacy and nutritional behavior

were two constructs in this study that the five research questions guided resulting in rich,

thick data that rendered abundant insight from the participants’ lens. The questions

were(a) How does NFLU impact meaning to the obese state of AAW in FBC, Texas? (b)

How beneficial will NFLU be to obese AAW? (c) What skills would be helpful for obese

AAW to achieve for NFLU to be a plausible intervention for combating obesity? (d)

What are some possible reasons NFL may or may not be practice by AAW who are

obese? (e) How would obese AAW interpret NFL in relation to the nutritional behaviors

they practice? With the assistance of NVivo computer software, the data collected from

the face-to-face interviews, themes were established, organized, coded, and analyzed.

The themes uncovered in this study were communicated many times by the AAW that

was interviewed(Appendix F).

Data Collection Process Overview

Setting and Recruitment

Several Baptist churches were the intended recruitment avenue to identify AAW

in Fort Bend, Texas. The designated interview site was also a Baptist church in Fort Bend

County, Texas within the zip code of 77477. The participants were pleased that the

church setting as the interview site. Comments made by several participants was about

the location of the church which was nearby most participants’ residence. The interview

site, according to various women, was an excellent location for it made them feel safe.

Once participants were identified, invitation letters (Appendix B) and flyers (Appendix

C) were provided with information on the purpose of the study and the inclusion criteria.

AAW that had committed to participate in the study shared letters and flyers with other

church goers. Word of mouth was instrumental and aided in identifying other participants

that agreed to participate in the study. One participant did not meet the inclusion criteria

due to the zip code criteria and therefore excluded. An acknowledgment for her interest

in participating in the study was offered. By the end of the recruitment process, 12 AAW

were identified who participated in the study.

Interview Process

The initial phase of the data collection process was the introduction of the

informed consent. The document was explained and subsequently signed by the 12 AAW

that contacted the principal investigator in the research study (Appendix A). A copy of

the consent form was given to the women, and I retained a copy for my record. The

participants stated they enjoyed talking about NFLU and answering the interview

questions (Appendix F). They stated feeling comfortable, and they enjoyed the

experience. One participant (P6) stated, “ I am 10 minutes from my home…I’m just

down the street from my house.” The 12 interviews (n = 12) were conducted in the

educational wing of the church behind a locked door with good lighting and comfortable

chairs. Bottled water was available during the interview sessions. All participants were

asked the same number of interview questions in the same order (Appendix F). At the end

of each interview, a debriefing period followed. For member checking, I wanted to make

sure the participants had answered all the questions, as they understood them and

addressed any follow-up question. The women participated in approximately a 45-60-

minute session (Appendix F). For accuracy, interviews were transcribed and were

evaluated by each study participant. There were no changes made to the initial data

collected. Participant interviews were conducted between the second and third week of

May 2016 after IRB approval, which occurred on May 9, 2016. Walden

University/Institutional Review Board approval number for this study is 05-09-16-

0124156 and expires on May 8, 2017.

Demographics

The participants recruited in the study were from Fort Bend County, Texas. Fort Bend

County is in the southeast region of Texas. Fort Bend County has been one of the fastest

growing counties in the United States ("Fort Bend County," 2014). The total population

reported as of 2010 was 585, 375 (United States Census Bureau [USC], 2010). African

Americans account for 27% of the total population in the 77477 zip code (USC, 2010).

The participants were residents and or members of area Baptist churches in the 77477 zip

code.

All 12 of the participants were AAW and self-reported that they had been obese

past one year. Participants ranged between 51 to 64 years of age. They all were born

during the baby-boom era (1946-1964). The average age of the participants were 57.7

years (M = 57.7). The average weight were 221.3 pounds (M = 221.3 lbs.). The average

number of days participants dined-out were 3.7 days/week (M = 3.7). All participants

could read, write, understand, and speak fluent English. All of the AAW were the

primary grocery shoppers of their residence and ate out at least three or more times a

week. Table 1 depicts participant ages, self-reported weights, and their dining-out

practices.

Table 1

Participant Data

Participants

Age

Self-report

weight

Dining-

out/week

Participant 1

215

Participant 2

235

Participant 3

200

Participant 4

240

Participant 5

210

Participant 6

230

Participant 7

225

Participant 8

220

Participant 9

230

Participant 10

225

Participant 11

211

Participant 12

215

Participant Profiles

 Participant 1 (P1): 64-year-old AAW, who self-reported that she has been

obese for five years. She reported her weight at 215 pounds. P1 is the primary

grocery shopper of her resident and states she shops at least three times a

month. She lives with her adult son who also is obese. She grocery shops

because it is a necessity. P1 maintains getting in and out of the grocery store is

her primary objective on most occasions. She dines out about three times a

week.

 Participant 2 (P2): 61-year-old AAW, who self-reported her weight as 235

pounds. She is a divorced schoolteacher with one adult son. She stated being a

healthy weight would be a “dream come true.” She stated she had been obese

for over three years. Eating out occurs at least three times during the week due

to her work schedule.

 Participant 3 (P3): 51-year old AAW, who has been obese most of her adult

years. She reports her weight at 200 pounds and made mention that her height

is too short to carry her current weight. She lives with her mother and has

three adult children in the home. She dines out at least five times a week.

 Participant 4 (P4): 59-year old AAW, who has been obese for many years.

She reports her weight at 240 pounds. She stated doctors are not her best

friends and hate to admit it, but does not go to the doctor unless she is sick.

“Thank God, I don’t get sick often.” She owns a day-care, and her husband is

a pastor, both with very busy and demanding schedules. She admits to eating

out too much and cooking quick meals are usually not healthy. She dines out

at least six times a week.

 Participant 5 (P5): 52-year old AAW, who has been obese most of her adult

years. She describes her nutritional health as “not the best…not the worst.”

She reported her weight at 210 pounds. She stated having many failed

attempts with diets, citing not eating vegetables as a reason. She does not like

to cook. She calls it “a necessary evil.” She dines out between 5-7 times

weekly.

 Participant 6 (P6): 64-year-old AAW, who has been obese most of her adult

life. She reported her weight at 230 pounds. P6 is a middle school counselor

and loves her job to the point of always eating on the run. Healthier food

habits is consistently a mindset, but by the end of a week, “became easier to

grab something to eat on the way home.” She dines out at least six times a

week.

 Participant 7 (P7): 54-year old AAW, who has been obese most of her adult

years. She reports her weight at 225 pounds and is mad at herself that she

cannot get a handle on her weight. She states because of a sedentary

occupation and work long hours; it has a lot to do with the source of her

obesity. She called herself a fast-food junky. She dines out at least six times a

week.

 Participant 8 (P8): 60-year old AAW, who has been obese most of her adult

years. She reported her weight at 220 pounds. She goes to the grocery store

often during the month because she had boys; however, the kitchen is not her

favorite place. She states it a necessary place. She dines out at least five times

a week mostly because of her work schedule as a small business owner.

 Participant 9 (P9): 51-year old AAW, who has been obese most of her adult

years. She reports her weight at 230 pounds. She goes to the grocery store at

least the three times a week and dines out at least three times a week.

 Participant 10 (P10): 59-year old AAW, who has been obese for many years.

She reports her weight at 225 pounds. She recently started “juicing” for losing

weight and hopes she can do it for at least a month. She goes to the grocery

store once a week because she keeps her grandchildren several days a week.

She states she eats out at least four times weeks at various eateries.

 Participant 11 (P11): 57- year old AAW that reported her weight to be 211

pounds. She has been obese most of her adult life. She states as she has gotten

older becoming more serious about her health and nutrition is a goal. She

visits the grocery store two to three times a week and eats out two couple time

a week.

 Participant 12 (P12): 61-year old AAW, which reported her weight at 215

pounds. She works outside the home juggling life and ways to better take care

of herself. She feels that working long hours sets herself up for her

obesity…“At the end of the day, all I want to do is eat, sit down, and go to

bed. I’ve been told going to bed after eating is not good.” She dines out at

least five times a week.

Data Collection Discussion

As discussed in Chapter 3, I collected data from participants using a face-to-face

interview approach with the aid of an audio recorder in Fort Bend County, Texas, zip

code 77477. After the data collection process, interviews were transcribed verbatim into a

Microsoft Word document. I transferred all data materials onto a secured flash drive.

Data from the study participant were secured, and passcode protected, then placed in the

locked cabinet in the researcher’s home office. I hired a transcriber after obtaining prior

approval from Walden University IRB department before starting data collection.

Participant data was de-identified before the transcriptist worked with the raw data.

During the data collection process, I encountered no unusual circumstances. The

participants were very courteous, kind, and spoke freely about their lived-experiences

that included sharing perceptions about their nutritional knowledge, behaviors, and

habits. One participant stated she felt safe having her interview sessions at the church.

She felt at peace to open up and be honest when asked the interview questions. As with

many two-way conversations, I expected to clarify some of the interview questions

because some questions sounded similar, though their concentration sought dissimilar

knowledge and behavioral data points.

Data Analysis

The technique for data analysis shadows Goldberg and Allen (2013) and Miles,

Huberman, and Saldana (2014) strategy of the first cycle to the second cycle coding

design. The cycles helped in uncovering the emergent themes and patterns of this study

by following a multi-step technique (Moustakas, 1994). Moustakas (1994) stated these

steps were necessary to a qualitative study to ensure rigor of the analysis stage in

synthesizing the data.

First Cycle Open Coding

The data analysis phase began with the voices of 12 AAW that answered 21-

questions during face-to-face interview sessions at the Baptist church in Fort Bend

County, Texas. The interview questions were open-ended, in-depth, and semi-structured

for the purpose of obtaining thick, rich data (Miles et al., 2014; Robinson, 2015). The

beginning steps of data analysis involved reading every word on the transcripts as a way

to enter into the world of each AAW and experience what the data uncovered. During

the initial process of open coding, the participant words and phrases were read many

times. Analyzing the raw data (interview transcripts) started with open coding with the

second cycle coding for thematic analysis, commonly used in qualitative research to

isolate themes and patterns in the study (Elo, Kaaiainen, Kanste, Utiainen, & Kyngas,

2014; Miles et al., 2014).

Second Cycle Coding

The second step involved a deeper exploration of themes and patterns,

highlighting key words, and statement that shared insight to the lived-experiences of the

AAW of the study. Each AAW shared their interpretative perceptions on their

understanding of NFL as a strategy for nutritional health. For extra protection of the raw

data that was collected from each participant, interviews were audio-recorded with

participants’ permission. During the data analysis process, transcripts were read many

times, underlining reoccurring words and patterns that subsequently were uploaded into

NVivo software. Lastly, themes were developed and grouped in a hierarchical manner

showing major themes. Exposing the themes in the study was an important step in

identifying the “the essence or meaning of data” (Goldberg & Allen, 2013, p. 10). The

raw data of the participant interviews emerged into five major themes. Further, the AAW

defined the consciousness of their nutritional health with descriptive words (Table 2).

Major Themes of Research Study

Adjectives (descriptors) used by the participants to describe their nutritional

health were a part of the themes that evolved from the study are listed in Table 2. The

major themes from this study were: (a) appreciation of NFLU, (b) skills required to

enable NFLU, (c), hurdles in following NFL, (d) usefulness of NFLU, and (e) time

constraint. Figure 1, displays the major themes discovered from the participant responses.

An appreciation of NFLU, time constraint, and skills for NFL use were

predominant themes that reoccurred during the interview sessions. The finding suggested

that NFL use depended upon participants appreciating their usefulness, the design of NFL

is consumer friendly, and easy in read because time was a valuable asset to their lived-

experiences. All the participants stated time was a significant hurdle in their usefulness

(N=12). The AAW who stated they compared food labels when shopping on rare

occasions (P4, P8, and P12), found that NFL had too much “unnecessary” information on

the panel. The women further explained the print was too small to spend the time to read

them. Most of the study participants articulated benefits to NFLU; however, there were

barriers to their actual use and appreciation of their potential.

Figure 1. Major themes from participant interviews.

Descriptors of Central Research Question

The Central Research Question (CRQ) of this study asked AAW to describe their

understanding of NFL, and the impact that understanding might have had to their obese

state. The participants gave various descriptors about their nutritional health as it has

related to obesity. Table 2 displays the descriptors by the 12 participants.

Appreciation of

NFLU Skills for NFL

Hurdles in

following NFL

information

Usefulness of

NFLU Time constriants

Column3 100 90 65 45 100

100

Major Themes

Table 2

Descriptors Associated with Research Questions

Participants

(N=12)

CRQ

Descriptors of

Nutritional

health

RQ1

Benefit of

NFL

RQ2

Skills helpful

for NFL Use

RQ3

Why NFL not

used

RQ4

NFL while

dining- out

Participant 1

Moderate

Know calorie

Willpower

Ingrained habits

Rather enjoy

meal

Participant 2

Medium rare

Weight loss

Math

Time/Confusion

Limited

Participant 3

Poor

Food values

Know-how

Time

Participant 4

Pretty good

Healthy eating

Preparation

Hard to

understand

Not really

Participant 5

Not good or

bad

Healthy

Mindset

Print too small

Sometimes

Participant 6

Bad

Help family

Motivation

Time

Participant 7

Mediocre

Help to eat

better

Preplanning

Time

consuming

Not often

Participant 8

Bad

Know

calorie/fat

Organization

Busy lifestyle

A few times

Participant 9

Very low

Food

information

Commitment

Time/confusing

Rather enjoy

food

Participant 10

Sporadic

Calorie

alertness

Self-control

Lack

understanding

Sometimes

Participant 11

Okay

Nutrition

details

Planning

Busy/time

Participant 12

Fair

Informed

shopper

Math savvy

Confusing/time

Seldom

Bracketing

The experiences and assumptions of the researcher were set aside or “bracketed”

as a way to decrease preconceptions that consciously or unconsciously can occur during

the data collection process. According to Chan et al. (2013), it was important that any

assumption about the research topic, as the principal investigator, be contained; which

allowed the emergent interpretation shared by each AAW regarding their lived-

experiences on NFLU flourish. Bracketing occurred as the way to protect the study

findings from my personal influences regarding the study topic. The voices of 12 AAW

were the dominant authority of this study. The development of major themes and patterns

resulted from AAW sharing the lived-experiences, as they understood their nutritional

knowledge and nutritional, behavioral practices.

Bracketing permitted the engagement with the participants and their data to take

on a deeper and more meaningful way to gain perspective on the essence of their

experiences. The phenomenological process helped me to share the study results in such a

way that provoked deeper insight and emersion into the data content causing thoughtful

appreciation for the subjectivity of each participant (Chen et al., 2013; Moustakas, 1994).

Last, bracketing introduced me to a new appreciation for the lived-experiences of the

study participants. The ability to practice self-reflection and self-awareness during the

data collection and data analysis allowed the construction of a trustworthy research study.

Evidence of Trustworthiness

As described in Chapter 3, the aim of trustworthiness in a qualitative inquiry is to

support the internal validity that the inquiry’s findings are “worth paying attention to”

and free from bias (Lincoln & Guba, 1985, p. 290). Establishing trustworthiness was a

fundamental priority during the data analysis phase of this research study. The findings of

this study are worth paying attention too since understanding the essence of one's

nutritional experience is to embrace their interpretative perception to the phenomenon

and learn from that experience (Elo, Kaaiainen, Kanste, Utiainen, & Kyngas, 2014;

Lincoln & Guba, 1985; Patton, 2002).

In this study, the voices of AAW were interpreted based on nutrition literacy and

nutrition behavior constructs. The contributions of AAW lived-experiences to the benefit

of NFLU as a single short-term intervention for changing nutritional habits, increasing

self-efficacy and self -regulation. When judging qualitative work, Strauss and Corbin

(1990) believe that the "usual canons of 'good science'...require redefinition to fit the

realities of qualitative research" (p. 250).

The foundation of trustworthiness in this study was by member-checking. At

completing each interview, participants asked about the clarity of the questioning to

ensure understanding of the responses they gave for authenticity (Elo et al., 2014; Patton,

2002). The participants were asked to validate if this researcher heard their voice

concerning the perceptions of their lived-experiences about NFL. Member-checking

neutralizes the researcher’s imprint on the phenomenon of nutritional health by relying on

criteria that give justice to the integrity of participants (Elo et al., 2014). Credibility,

transferability, dependability, and confirmability were an additional consideration in this

study as a way to increase the merit of the study (Elo et al., 2014; Lincoln & Guba,

1985). Figure 2 demonstrates the important link of four fundamental elements of

trustworthiness used in this study.

Figure 2. Trustworthiness depiction that demonstrates the important link of four

fundamental constructs used in this study (Elo et al., 2014; Lincoln & Guba, 1985).

Credibility

Adopting a stance of self-awareness and neutrality was my position interpreting

the research findings of this study. Further, establishing credibility for my study

considered adhering to the strict inclusion criteria, transcribing and interpreting verbatim

the raw data (Elo et al., 2014; Lincoln & Guba, 1985). There are debates about the

credibility of a study when using non-random sampling methods (Elo et al., 2014;

Lincoln & Guba, 1985; Patton, 2002). I would argue the credibility of this study lies in

the voices of the AAW, who agreed to participate in the interview process and share their

lived experiences of nutritional health. The goal was not to prove or disprove the

phenomenon under study or manipulate the data for personal gain but to offer insight into

the gap in the literature on the nutritional literacy and nutritional behavior not well

Trustworthiness

Credibility

Transferability

Dependability

Confirmability

addressed in AAW (born in baby-boom era) with obesity. Respecting and embracing the

perceptions and lived experiences as they emerge from each AAW exposes new

knowledge through the lenses of another.

Transferability

Transferability refers to the potential for extrapolation (Elo et al., 2014; Lincoln &

Guba, 1985; Polit & Beck, 2012). Often transferability is the decision of the one reading

the research study. This study is an invitation for researchers and scholars to concern

themselves with the findings to the point of considering future research studies on the

topic of nutritional health of other populations. The findings of this study are not

generalizable; however, with a larger sample population the more the study can

generalize the results. It is conceivable a different methodology (quantitative) the

findings of this study could be transferred to other populations or groups for comparative

evaluations (Elo et al., 2014; Lincoln & Guba, 1985; Polit & Beck, 2012).

Dependability

The dependability of this qualitative study was grounded in the knowledge and

skill required for conducting and completing a qualitative study. Putting those skills in

practice demonstrated the stability of this research study. This step was critical in the

articulating the participant’s lived-experience on NFLU. The continued drive while

conducting the study was focused on the gap found in the literature. Concentration to the

gap was the driver in formulating this study. The method of collecting my data, which

ensured participant privacy and confidentiality, interpretation of the findings and

reporting the findings as presented was done and without bias. In Chapter 3, I disclosed

the process for selecting the AAW participants, the method for the collected data (face-

to-face interview method), and using a computer assisted data software (NVino 10)

designed to assist in the data analysis phase for coding, theme, and pattern formation for

study results were disclosed.

Confirmability

Conformability refers to the objectivity, the potential for the investigator to bring

a perspective to the study topic by way of the participants (Lincoln & Guba, 1985). A

personal reflective journey was helpful while data collection and data analysis process

unfolded. Data accuracy, relevance, and meaning in this study was confirmed by the

AAW, who participated in the study by taking advantage of the time spent with each

lengthy interview. Participants were encouraged to speak open and candid so they could

express themselves on their live-experiences of NFL. There were several times often

during the interview sessions as a researcher; I repeated back participant’s responses for

clarity and validation and the avoidance of distorted data (Elo et al., 2014). I also

incorporated the technique of audit trail as emphasized by Miles et al. (2014), which

aided in the management of the large amounts of data unfolds into discovery. It also

became a method of synthesizing data as the research data took form.

Each AAW were given an opportunity to add any additional information at the

completion of the face-to face interview session. Comments made were added to the data

collected for a deeper understanding of the AAW viewpoints. The findings reflected the

participants’ voice and not the researcher’s biases, motivations, or perspectives (Lincoln

& Guba, 1985; Polit & Beck, 2012). In Chapter 3, it was important that my biases early

in the research process were acknowledged which allowed me to have a reflective

analysis of the research topic and still maintained reserve as the data from the research

participants were provided.

Study Results

The theme exposed in this research study were based on the compilation of 12 in-

depth interviews from AAW living with obesity and their understanding and perception

of NFL and dining-out practices. The findings of this research study were guided by one

central research question (CRQ) and four subquestions (SQR) detailed in Chapters 1 and

3(Appendix F). Five major themes were discovered during the data analysis phase along

with minor themes.

Research Questions Revisited

Major and minor themes exposed during the analysis of the data for each research

question offered insight into the perception and essences of the participant’s reality.

Subthemes exposed from participant responses on nutritional health were validation for

the nutrition communities to develop material that consumers will appreciate and

incorporate into lifelong practices. NFL must enhance believability and comprehension.

Major Theme: CRQ- Self-Health Perception

How does NFLU impact meaning to the obese state of AAW in Fort Bend

County, Texas? This question became the foundation for which themes emerged.

Participants were asked to describe nutritional health. The major theme that emerged

from the question aligned with current perceptions of the meanings placed on nutrition in

AAW of this study. The major theme was Self-Health Perception. Based on the

descriptors used by the AAW that explained their nutritional health conveyed opportunity

to evaluate label reading as a practitioner for possible motivators for nutritional change.

All of the women had their own descriptors of their nutritional health. Data analyzed

showed the women’s view of nutritional health were intermingled and described based on

internal and external influences that had attributed to nutritional practices they

articulated. A few were very interesting. P2 said, “My nutritional health is medium rare.”

P3 stated, “My nutritional health is not the best actually, it is poor.” P9 explained, “My

nutrition health is very low.” P10 exclaimed, “Sporadic. My health is a factor in how I

eat, but I’m off track more than not.” These comments identified the women were self-

aware of the problems with their nutritional health. Table 2 has more examples.

The depiction of subthemes that evolved from asking participants their

perceptions about their nutritional health stirred an inward examination of the nutritional

behaviors (See Figure 3).

Figure 3. Subthemes1 of CRQ Self Health Perception.

Concious Good Not Good Result of short

term action

Series1 67% 17% 58% 33%

10%

20%

30%

40%

50%

60%

70%

Self Health Perception

Only 17% of the participants perceived their nutritional health to be balanced. The

overwhelming majority of 67% expressed that they were concerned of conscious about

their nutritional health, or considered to be not in good health nutritionally. P6 stated, “I

consider my nutritional health to be bad...and I know that it is. I’m not eating the way I

should.” P7 said, “…we have certain habits that we enjoy and certain foods that we like

to eat that we can’t seem to give up and make them go fast away.”

Major Theme: SRQ 1-Usefulness of NFLU

How beneficial will NFLU be to obese AAW? The major theme discovered from

this question was the Usefulness of NFLU. Although participants stated they had some

understanding of the benefit NFL, several responses were contrary to their portrayal of

nutritional behavior at the grocery store experiences and when dining-out. The interview

questions sought to determine if participant understanding of NFL was useful to healthy

eating, and if so, what would motivate them to practice food labels use based on current

relationship to food decisions. None of the participants (N=12) voiced an association

between food labels and preparing meals, and nutritional information while dining-out.

Participants expressed mixed views. Most of the comments were associated with

enjoying meals versus knowing nutritional values (See Figure 3). P9 decided, “I deserve

to splurge when I am eating out. I eat to get full and left overs maybe lunch at work.” P11

talked about a specific eatery, “love pasta and bread at Italian restaurants, surely that is

not the time to count calories. I want to enjoy my food. You would think with my weight;

I would have more motivation.” It was apparent from the interview sessions; the struggle

to do better with nutrition practices was something that would require time and patience.

Even with the reality of being obese, habits and patterns to how one processes eating

behaviors were unsettling for the women. Sub-themes were (a) awareness with education,

(b) boring, and (c) good understand would be the incentive to read NFL, (d) impacts

physique, (e) specific foods(juicing), and (g) vague understanding. The subthemes in

these categories are discussed next.

Figure 4. Subthemes 1 SRQ 1: Perceptions of Healthy Eating.

The most dominant subthemes were “boring” and “vague understanding”, while

only 25% people expressed to have a good understanding of the value of healthy eating.

Another 25% of the participants related healthy eating to restrictive food selection.

Boring

Healthy eating was considered boring by 42% of the participants (Figure 4). The

underlying perception seemed to be that watching for dietary labels, and monitoring type

of food a person is eating is restrictive in nature and takes away the recreational aspect of

food and dining.

Awareness

with

Education

Boring

Good

Understandi

Impacts

Physique

Specific

Foods

Vague

Understandi

Series1 8% 42% 25% 17% 25% 50%

10%

20%

30%

40%

50%

60%

Perceptions of Healthy Eating

100

P8 said:

“Boring… Boring ‘cause whenever I try to do it, I second guess my cooking

skills that don’t match up, so then I would get bored with whatever I was eating

although it may not have been working.” While P1 expressed, “I understanding

that healthy eating is good for you because all of my life before I got grown we

ate healthy. After I got grown, I started eating like I wanted to eat.”

Understanding Food Labels

Figure 5. Subthemes 2 SRQ 1: Understanding Food Labels.

Concern was demonstrated about deciphering the food labels. Where some

participants complained about food labels being too confusing, others simply admitted

that food labels do not have any value to them personally, and therefore they pay no

attention to NFLU (Figure 5). Half of the participants demonstrated a vague

understanding about healthy eating that seemed to be based on certain stereotypes.

Expressed viewed that were collected under this subtheme demonstrated that participants

Confusing Don't Pay

Attention

Limited to canned

food

Vague

understanding

Series1 25% 42% 33% 50%

10%

20%

30%

40%

50%

60%

Understanding Food Labels

101

attached their understanding of healthy eating with types of foods as opposed to the

actual content of the food. Towards maintaining a healthy diet, P5 expressed, “Um…

Maybe fruit, I use one percent milk, toast. Every now and then I’ll eat a piece of egg or a

piece of sausage.” “I don’t think it’s difficult.” P11 covered the concept of healthy eating

as “Uh, I know about the vegetables and the portions and the starch and um, the

cholesterol and stuff that’s high in cholesterol and stuff like that.”

Specific Foods

A group of participants expressed their concept of healthy eating in term of

specific food items as opposed to the nutritional values. These participants expressed

their views in greater detail than the vague expressions discussed in the previous

subtheme. P10 as an example stated, “healthy meal would be, to me, probably some

baked Salmon fish, um, some rice, brown rice, and maybe some broccoli.” P11

explained, “I guess my vegetables and my meat if it’s not fried or pretty much if it’s

grilled or something like that, I know I’m doing a healthy meal.

Good Understanding

Participants who demonstrated a good understanding of a balanced diet were

more specific in explaining their approach towards healthy eating. P4 explained, “There

was always a pyramid of foods. I can see it clearly in my mind right now… the cereals

and breads and the proteins, the meats and the fruits and the vegetables and the dairy.”

P2 provided similar details and explained that “a balanced level of the nutritional

components that make up a healthy diet… for example, having your vegetables, your

fruits, your meats, your snacks, and your beverages.”

102

Influence of NFLU in Daily Living

Towards understanding the influence of NFLU on a person’s daily living a series

of questions were asked to explore to what extent food labels impact some of the

decision-making processes of individuals. Two decision-making points that were

explored in particular were meal planning and ordering food at a restaurant.

Figure 6. Subthemes 3 for SQR 1: Influence of NFLU in Daily Living.

Meal Planning

Responses demonstrated that none of the participants considered information

provided on the food labels while planning their daily or weekly meals (Figure 6).

Response from Participant 11 summed up similar responses collected from all

participants. P11 stated, “Um, not too good. Uh, I can plan a meal, but as far as it being

all good and healthy- not so much...rarely would I turn over a box and look at the label to

plan or cook a meal… because I’m going to add a little this, this, and a little of that.”

No NFLU in Meal

Planning

May use NFLU in

Restaurants

Use NFLU if on

Restricted Diet

No NFLU used in

Restaurants

Series1 100% 33% 8% 67%

20%

40%

60%

80%

100%

120%

Influence of NFLU in Daily Living

103

Dining Out

More than half the participants (67%) expressed that they do not consider asking

for food labels or nutrient information about the meal while ordering food at a restaurant.

Among the rest, 33% indicated that they may consider looking into nutrients if the food

was particularly very unhealthy for their personal consumption. Another 8% of the

responses suggested the only possibility of looking into nutrient information ordering

food at a restaurant would be where the participant had a dietary or medical restriction. In

the words of P4, “I will ask them in a minute, ‘How is this prepared? Is there any extra…

I’m lactose intolerant, so I don’t do the milk, and I don’t do dairy a lot, so I need to

know… It’s probably a challenge for a lot of us. Knowing what to eat and buy.”

Major Theme: SRQ2: Skills Required To Enable NFLU

Figure 7. Major Themes for SRQ2.

What skills would be helpful for obese AAW to achieve for NFLU to be a

plausible intervention for treating obesity? The second research question aimed to

Understanding

(appreciation) Medical Need Time

Series1 31% 19% 50%

10%

20%

30%

40%

50%

60%

Skills Required to Enable NFLU

104

explore what were some of the perceived skills that the participants considered were

required to make good use of NFLU while making dietary decisions in the daily lives. I

developed four interview questions for the participants to answer. The lines of

questioning were to stimulate dialogue about skills associated with behavioral practices

AAW felt were required for NFLU.

Many of the women had deep-rooted habits they felt would require sincere effort

to change. Busy schedules and foods they had enjoyed for years would be difficult to give

up. Not knowing how many calories in a meal, especially when dining-out would not

necessarily deter them from consuming a meal, like Whataburger meal, for instance.

Skills necessary to achieve a level of understanding for participants to determine if the

use of NFL was plausible are identified in Table 1. The major theme of RQ2 was the

importance of skills required to enable NFLU. Some women, P1, P7, P8, and P10, had

concerns with eating habits and a medical condition. They felt understanding NFL were

important for their obese state. P7 and P8 were concerned with blood pressure and

cholesterol issues, but admitted to the struggles of following a restricted diet. P8 stated,

“Healthy eating is boring even knowing I have to watch my blood pressure.” P6 says, “It

requires much patience to learn new eating habits after years of bad habits.”

P2: shared similar thoughts:

“Healthy eating is always a goal I set for myself. I have to take into consideration

what food I buy even at the restaurant and try to understand how the breakdown

of what the food has in it in order to make better food choices.”

105

The findings uncovered that taking control of nutritional habits were an aspect most

women realized was key to eating behaviors they currently practiced. Mindfulness for

preparing meals or eating out was evident but not necessary a control factor to eating

habits for most women. P4 was the only participant that felt she had a handle on proper

eating. P4 said, “I know the food pyramid is what I cook by and when dining out. I am

keen on watching salt and especially sugar mostly because of my husband’s health.”

Three minor themes were dominant in SRQ2. They were (a) understanding with

appreciation, (b) medical needs, and (c) time to embrace the acquired skill required for

self-discipline (Figure 7). Time to learn the skill and understanding the food label content

were shared the most.

Time to Embrace the Acquired Skill

Half of the participants mentioned time as a major factor related to their ability to

make use of NFLU information. The predominant context of time was in term of making

a commitment to develop a personal skill habits around referencing NFLU. “Frankly,

changing habits at my age would really take some committed effort” expressed by P1.

P9 stated:

“Changing the way I do things takes a lot of energy that I don’t have most time.

Getting up early for work, working with teenagers all day and adding extra time

to read labels at a grocery store would really take a lot of work for me. I could do

it Um...but the effort would be the hardest part especially with the extra weight

I’m carrying. Effort and a lot of practice and time.”

106

Understanding the Need

Developing a good understanding for the need to use NFLU was also considered

as a required skill set by 31% of the participants. Understanding seemed to be connected

with both time and medical needs, the other subthemes identified under RQ2. Participants

conveyed a concept that understanding the need to use food labels is not only time

consuming but is better suited for those who are bound to use the food labels due to

dietary restrictions. P10 stated, “Um, I just need to know the importance of reading

them.” P3 explained, “know I wouldn’t do it every time I went to the grocery store, I

know that, but, like, if my doctor said, you know, ‘you’re going to die’ and such and

such, I would put more effort into it. So based on circumstance or situation, someone

saying something to trigger bad eating habits, I’d try to do better that time, for that

moment.”

Major Theme: SRQ3- Hurdles In Following NFL

Figure 8. Hurdles in following NFL-SRQ3.

Lack of Appreciation Time Eating Habits

Series1 70% 40% 10%

10%

20%

30%

40%

50%

60%

70%

80%

Hurdles in Following NFL

107

The third research question was designed to probe at the perceived confounding

or enabling reasons behind utilizing food label information while making routine dietary

decisions. What are some possible reasons NFL may or may not be a practice by AAW

who are obese? For SRQ-3, I asked five interview questions. The questions were directed

toward nutritional practices (past and present). Participants were asked to articulate if

NFL information was important to incorporate into grocery shopping, meal preparation,

and dining-out experiences. The major theme of SRQ3 was the hurdle to overcome in

following NFL as a lifestyle practice (Figure 8). Lack of understanding and lack of time

re-emerged as the underlying themes for RQ 3 as well.

Several perspectives of the women were articulated regarding their nutritional

behaviors associated with NFL. For most, incorporating NFL meant accountability of

facing truths that may have resulted in their gaining weight. The majority of the

participants (70%) related their lack of utilizing NFLU information to lack of

understanding the need of the practice (Figure 8). Others related to the lack time to focus

on such details. A new theme that emerged in this context was eating habits. Eating

habits were considered an obstacle by 10% of the women in considering to read food

labels.

P1 exclaimed:

I use coupons sometimes. Mixing the reading of coupons and food labels for me

would be difficult. Too much to think about at the same time, not to mention the

small print. I would really need an understanding of what the labels means, and

how the information on the label improves my eating habits.

108

P3 talked about loving sweets:

I have diabetes. The amount of sugar that is in food I am supposed to control.

That is why I will make a list, but if its food I like and the grandchildren like

pizza rolls and Chex Mix, I’m going to grab a bag because we love them.

Other women felt eating healthy all the time would deprive or restrict them to

foods that taste good. P9 stated, “I am going to make a better effort to improve my eating

habits. However, if I use food labels, I have to understand the information.” P9 goes on to

say, “If there’s something that I really like at this particular restaurant, cause I’m kind of

a creature of habit…I’m not really good at changing my choices.” The finding uncovered

hurdles to overcome regarding nutritional habits practiced at the current stage in the

AAW life. Several women expressed NFL might restrict the meals and foods they

enjoyed. Also, busy lifestyles kept them from a dedicated relationship with the use of

NFL. Making time to attain the skills and practice NFL use was not articulated like an

urgent task even with participants’ being obese.

P5 shared:

I think knowing ahead of time this is not fattening, and then sometimes you find

out the calories in something and you’re like, WOW, not what I thought. I would

have to sit back and tell myself that this is what I’m going to do; buy the meal I

want versus letting the information change my mind. I haven’t gotten to that point

yet. If I’m getting a burger and some fries, then I already know that it’s loaded. P5

mentioned, “I am concerned about the weight that I have gained over the

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years…It is an issue I need to face. I just have to get myself into the practice of

doing something about it.

P6 described similar thoughts:

“I eat out a lot. I try to be mindful of what I eat, but not being a menu planner. I

don’t know how to incorporate nutrition information I know is helpful to losing

weight. Mm, that a hard one. I can check the food labels and look at menu

information, but I would have to do research to see what is in the food I’m eating,

so I can see if the calories are low.” I don’t know what would motivate me…I

hate to say that.”

Major Theme: SRQ4: Avoidance of NFLU

Figure 9. Avoidance of NFLU.

The fourth research question was aimed at exploring how the participants would

approach reading food labels if they were asked to do so. How would obese AAW

interpret NFL relationship to the nutritional behaviors they practice? Participants

Baked is

better

than fried

Calorie

counts

Canned

food is bad Cholestrol

Fish is the

healthiest

meat

Indicators

of vitamins Sodium

Series1 17% 58% 8% 17% 25% 8% 42%

10%

20%

30%

40%

50%

60%

70%

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answered six interview questions. The questioning explored the perception of AAW

regarding their dining-out practices considering NFL information on dining out menus.

Several studies identified the association between nutrition, obesity, and the chronic

diseases that subsequently can adversely affect one's health and livelihood (Hieke &

Taylor, 2012; Millender, 2014; Velardo, 2015). The dynamics of AAW interpretation of

nutrition fact on the menu were critical elements in the study. As the study unfolded, it

was clear that major areas of disconnect centered around understanding how to make

sense of the facts printed on food or menu labels(Figure 9). The lack of appreciation for

the benefit of NFLU was noticeable from the comments gained during the interviews.

Almost 60% of the participants focused on calorie count without understanding the

information in context with the serving size (see Figure 9). The nutrition knowledge and

nutrition behaviors the women had acquired over the years revealed some personal

responsibility to their obesity.

Four participants, P2, P5, P8, and P10, stated they would look at nutritional values

before ordering a meal, however using the information as a reason to select a low fat, low

calorie, low sugar, and low sodium meal would not be a purchase detriment.

P2 explained:

“Label reading does offer a way to know if certain foods are low in calories…at

some point, I did read labels and was able to determine the calorie count, but the

other information on the label, I’m sure has a purpose that I might not know how

to use. The label.. fish meal looks healthy, but the hamburger meal is scary to

think one meal can have that many calories and fat. Based on the information you

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provided, I could be missing important information…we either don’t know, but

surely need to learn.”

Another perspective came from P5:

Food labels are so different; the size of them, the information on them makes it

hard to want to use them all the time. The food labels would really have to

improve to the point where the information is easy to determine if a food item is

healthy.

P8 indicated that her busy lifestyle was her excuse for not having better

eating practices:

If I eat badly for lunch, I’ll eat badly for dinner because of the leftovers I bring

home. I would love to be more focused, more structured, but using food labels to

do it requires understanding percentages and what that means to my diet. At least

I learned from you that I could actually eat another piece of fish looking at these

labels. I need to take what the label say to heart, but during the normal week, it

would be difficult.

An upward of 40% of the participants demonstrated a similar approach toward the

sodium component of the food labels provided (Figure 9). According to P10, “anytime

you have canned stuff, they have to put a lot of sodium in it to keep it.” P1, P4, P6, and

P9 shared sodium concerns. P9 shared, “It doesn’t surprise me that the fish dinner sodium

is much lower...I know the hamburger and fries is full of salt.”

To gain further insight into the avoidance of NFL, P10 talked about juicing as a

way to avoid using food label information although she indicated she had knowledge

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about them because she had to watch her sugar. Only a few participants had something to

say about the sugar content in the menu labels. P2 exclaimed, “I think carbs are sugar and

the hamburger meal has a total of 61 grams…way too much.” P8 said, “I see that coke. I

would drink it knowing it has a lot of sugar in it.”

P10:

I’m aware of the labels, but I don’t plan a meal based on a food label. I would

need more information on the facts of why I need to read the food labels because I

know a little bit about nutrition from years ago, and um, everyday living, learning

what’s good for me and what’s not good for me. The label examples you showed

me was helpful cause as a pastor’s wife church members are always baking cakes

and cookies, and I never know how much sugar and fat they have…even though

they are usually so good.

The minor theme from this question centered on “not knowing.” About 25% of

participants described the fish meal as a better meal choice, however, the enjoyment of

dining-out was the priority. Even through some participants ate out up to six times a

week, nutritional values when dining-out meals was acknowledged as an awareness that

some foods are not as nutritious as others, but not as much a concern for the participants

in this study.

Not Knowing

When participants were asked about dining-out practices, most, except one P4,

waivered about menu labels in context with their predetermined mindset about the

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healthiness of dietary practices. Almost 15% of the responses demonstrated a concern

about the cholesterol indicators. Over 40% felt sodium was a potential health concern.

Effects of Nutritional Health Awareness

The structure of the interview questions in the study were framed around nutrition

literacy and nutrition behavior associated with the rise in obesity within the baby boom

population of AAW. Appreciative to the courageous AAW, who examined their lived

experiences in a personal way and shared their perceptions about the positive and

negative aspects of NFL in their grocery shopping experiences, during meal preparation,

and nutritional attentiveness while dining out. The benefit of this study was strengthened

by the use of a qualitative methodology whereby the voice of the participants provided

the building blocks for the themes that emerged on NFLU as one strategy to cultivate

change in practice on nutritional health in this populace. Also, the study findings

underscored there is an urgency for nutritional facts to display clear nutritional

information so all consumers that read them understand their foundation (Collings &

Bogue, 2015; Velardo, 2015). All the participants were aware of food labels attached to

grocery items. Most of the AAW had noticed nutritional information while dining out,

but the majority stated because of their busy lifestyles, paying attention to the NFL would

not be a priority unless the content of the fact panels were easily viewed at the shelf level.

Taking food items on and off the grocery shelves to read the labels were too time

consuming and likely would not happen on a regular basis without obvious changes to the

current design.

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When the question was asked about dining out, P1 stated, “I just want to enjoy my

meal and not worry about how many calories and how big the serving size is or how

much fat is in the meal.” P5 stated, “ I enjoy eating out. It is something I do a lot, so let

me enjoy my food without counting calories or fat.” When participants were asked about

the three meal label examples shown, every AAW were surprised at the amount of

calories and fat, sugar and sodium in the Whataburger meal (Appendix K). Participants

mentioned other dining-out eateries. However, all the participant stated they would enjoy

their meal away from home and not monitor the nutritional values of the items they

ordered.

The AAW felt that if they had a deeper understanding of how to incorporate food

and menu content information into their lifestyle routine for improved nutritional health.

They could visualize their self-efficacy increased based on their acknowledgment of self-

regulatory behavior engrained from deep-rooted nutrition practices. When the

understanding of cognitive concerns and nutritional behavior that center on unhealthy

nutrition practices are assessed. All but one participant stated they planned to incorporate

what they understood from this study experience.

The women shared many reasons why their nutritional health was difficult to

maintain even if it were established. New nutritional practices to include NFL were

challenging based on confusion, time, habit, knowledge, and mindset. Each women used

descriptors to describe their nutritional health. Words articulated were poor (P1, P3),

medium rare (P2), not the best, not the worse (P5), bad (P6, P8,); very low (P9), sporadic

(P10), okay (P11), and fair (P12). P4 was the only participant that declared her nutritional

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health was pretty good (See Table 2). Over half of the participants voiced the lack of

NFL use was mostly related to the confusing panel verbiage and congested food label

with small print.

Most of the AAW felt that their dining-out experiences should be enjoyed and not

determined by nutritional facts. While some women stated they might have glanced at the

nutritional values, if it was available on the menu, asserted their taste buds determined

their menu item ordered and not how many calories, fat, sugar, and sodium was a part of

the meal. They considered nutritional fact information healthful, but the urge to enjoy a

meal away from home superseded nutritional value. Most concerning, regardless of the

themes exposed in this study, consuming high caloric, high fat, high sugar, and high salt

meals are the foundation for chronic health issues. It is worth mentioning that although

understanding NFL is a step toward healthier eating practices, some of the AAW had

limited self-regulation skills embedded to increase self-efficacy qualities.

Altering current nutrition practices to address the lack of knowledge and behavior

practices concerning their year’s lived-experiences was uncovered by the ambivalence of

wanting to do better, but lifestyles and busy schedules were often hindrances. Figure 10

depicts the connection between the SCT (self-efficacy and self-regulation) and NFLU.

Self-efficacy and self-regulation were key constructs gleaned from Bandura’s SCT theory

(Bandura, 2001). Bandura elaborated that when knowledge is attained, it equals behavior

realized (Bandura, 2001). According to Bandura (2001), the understanding of knowledge

gained by an individual is the stimulus for behavior adaptation, which over time increases

self-efficacy and self-regulation skills and actions.

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Figure 10. The connection between the SCT (self-efficacy and self-regulation) and

NFLU.

As a final point, all discoveries gained from the study participants were assumed

to have contributed to their obese state. Discoveries from this study also illuminated that

nutritional health is not necessarily associated with participants understanding NFL

content, although most found the knowledge eye opening specifically when they

compared the label information on the three meals, Whataburger, Wolf Chili, and Fish

dinner meals. They were astounded by the high calorie and fat content on the serving size

of the food label examples. Despite the information on the meal examples, dining out was

considered necessary, especially after long working days, but admitted careful

considerations would be given to the fast food menus with high calorie and fat content.

Cultural southern eating patterns can affect AAW with obesity. How behavioral patterns

are shaped associated with meal planning had to be considered during this study.

Nutritional practices in African-American communities have developed over generations,

which could breed future obesity problems to the future generation. Finding nutritional

NFLU

Social Cognitive

Theory

Self -Regulation

Nutrition

Behavior

Knowledge=Behavior

Self -Efficacy

Nutrition

Literacy

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health practices that tie into southern eating was a high priority for the majority of AAW

that participated in the study. Dealing with the reversal of obesity in AAW lacked

attention within the literature; including nutrition literacy and nutrition behavior as

constructs to understand NFL benefits’ to nutritional health. The research study, “The

Influences of Nutritional Food Label Understanding in AAW with Obesity” was

conducted to gain a retrospective and current interpretation from AAW to the essence of

the lived-experience on the practicality NFLU.

Discrepant Findings

This study uncovered several discrepant findings. Some AAW admitted their

embarrassment on the knowledge they thought they knew concerning NFL content. What

some considered misunderstood information of food labels was their knowledge deficit. I

shared discrepant findings from P1, P4, P7, P10, and P11.

P1 talked about her aspiration to eat better. She explains, “Eating better would

improve my health and weight.” However, when asked to describe healthy eating and the

benefits associated with healthy eating, she felt that the greatest benefit occurred during

her childhood because someone else was responsible for preparing her meals. She

stated,” I understand that healthy eating is good for me because all of my life before I got

grown, I ate healthily.”

P4 was the only participant who declared her nutritional health was very good. P4

explained:

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My understanding of healthy eating is eating from the four basic food groups

three times a day, and if you need to snack, snack within boundaries, don’t overdo

it at any point… I avoid sweets and half the time I don’t eat what I cook.

P4 talked about her knowledge on the four basic food groups but did not eat most of the

things she cooks. P7 verbalized the importance of calorie counting.

P7 explained:

But to do it as a lifestyle would be based on a health problem that would force me

to make strict changes. I have high cholesterol. If we (talking about her husband)

decide to try to lose some weight, that’s when we would focus on trying to eat

nutritious meals.

During the interview session, P7 talked about her high cholesterol. It was hard to

pinpoint if she considered hypercholesterolemia a health problem. Heike and Taylor

(2013) linked low literacy skills with knowledge deficits of nutrition labels and health

problems. Constructing healthy food choice behaviors requires self-ownership to attain

skills attributed to nutritional health and subsequently leads to self-efficacy and self-

regulation actions (Bandura, 2001; Hieke & Taylor, 2012).

P10 indicated she was very knowledge about nutrition and healthy eating, but

when asked about her nutritional health she stated, “I’m half-way where I want to

be…I’m juicing, just started today.” She further stated, “I don’t do food labels…never

paid much attention to the labels because what I eat is usually repeated many times.”

There appeared to be disconnected understanding to her current nutritional practices and

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her state of obesity. “Avoiding fried stuff “and not reading food labels was contrary to

her perceptions of understanding of healthy eating.

P11 discussed her busy schedule as the reason it was difficult for her to read food

labels while grocery shopping and paying attention to calorie information while dining

out. Her health conditions, she mentioned, “because of my high blood pressure and

borderline high cholesterol, I have to watch my sodium.” To know the sodium amount in

food items, this participant would have to consult the nutritional label, which was not a

result during the interview session.

Summary of Findings

In summary, Chapter 4 presented the findings based on the qualitative analysis

from 12-face-to face interviews from AAW born during the baby-boom era. The findings

were exposed, and themes were discovered by a concentrated exploration of the data. The

data was analyzed using a deductive and iterative process, which Miles et al. (2014)

consider being essential for making inferences and drawing conclusions. The responses to

the interview questions and an analysis of the data obtained in this research study

highlighted a significant need for the study population to embrace an overall appreciation

for NFL into their nutritional practices. The understanding could yield long-term

nutritional health outcomes because their knowledge and behavior will match their

actions while grocery shopping and dining-out.

Minor themes that emerged about NFL use during the analysis of data were (a)

boring, (b) medical need, (c) impacts looks, (d) restricted diet, (e) have a reason to break

a habit. The participants did not feel that the time involved reading NFL equated to

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healthy eating. Counting calories instead of enjoying a meal, especially when dining out

was not something most of the participant were willing to consider.

Chapter 4 reported the findings of the study using themes derived from the AAW

in-depth interview sessions. NVivo software was a productive way to analyze the data

and form patterns and theme presented in this study. I utilized the data to address the

research questions, using many quotes from the participant interviews. Further, I found it

important to share discrepant findings based on how participants articulated their

perceptions on NFLU; some of their comments were contrary to how they answered

some of the interview questions. I felt it was important to highlight these comments,

which corroborated that although some AAW stated they understood the importance of

NFL information, their years living with obesity and eating behaviors, revealed a

different reality recognized during the data collection phase. Chapter 5 will offer an

interpretation of these findings, report on the limitation of the study, discuss the

implications for positive social change and conclude with recommendations for future

research and the importance of the research study.

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Chapter 5: Discussion, Conclusions, and Recommendations

Introduction

The purpose of this study was to understand the influence of NFLU on AAW with

obesity. A qualitative interpretative phenomenological analysis(IPA) approach supported

the fulfillment of in-depth, rich and thick data that uncovered the phenomenon of

nutrition literacy and nutrition behavior regarding healthier food choice at the grocery

store and while dining-out. The research study was motivated by the necessity to examine

and explore NFLU connectedness to nutritional literacy and nutritional behavioral with

AAW. In the literature, the obesity rates are alarmingly higher in the baby-boom era of

AAW (Adult obesity, 2013; Colby & Ortman, 2014; Ogden, Carroll, Kit, & Flegal,

2013).

The knowledge gained from 12 AAW on NFLU offered an insightful view on the

nutritional practices that might had potentially influenced their obese state. Nutritional

literacy and that might translate understanding into nutritional behavior engagements

played a role in the lived-experiences of their nutritional health. One woman in the study

had additional concerns of as she aged; her vision and lack of their ability to comprehend

and process NFL information were realities of the baby-boomer generation. P1 was

concerned about her vision. One observation made during the interview sessions were 7

of 12 women wore glasses. The participants that wore glasses may not have voiced the

concern regarding their vision, but it could potentially be a factor in the avoidance of

NFL use. NFL is written in varied sizes based on the item size. Efforts to read the fine

print and challenged by the calculations to determine nutritional worth might also deter

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food label use for the AAW. The overall findings from the study brought a realization

that a holistic approach to nutritional health is essential.

The perspective Bandura’s SCT brought into this study centered on the thought

that individuals possess a self-system that occupies the whole being (Bandura, 1986).

When cognition and behavior efforts are challenged and then recognized, the outcome

can be increased self-efficacy and ground self-regulation skills (Bandura, 1986, 2001).

The research questions were intended to trigger a retrospective and current awareness of

nutrition practices. The awareness provided the AAW insight into their nutritional health

behaviors. Bandura (2001) explained that how individuals become self-regulated had a

lot to do with the ability to control and reinforce behaviors that influenced their level of

self-confidence to succeed.

Research has acknowledged the importance nutritional health had on reducing

various risk factors associated with obesity. Life-altering conditions have affected many

lives. Elevated cholesterol, heart disease, hypertension; gall bladder disease, sleep apnea,

and some cancers are problematical (CDC, 2014b; DiNoia et al., 2013; Mastin et al.,

2012; Rowe et al., 2011; Sutherland, 2013; Walker & Gordon, 2014). Nutrition

knowledge has been associated with health literacy, which suggests education is essential

to positive and lasting behavior changes (Gills & Chapman-Novakofski, 2014; Spronk et

al., 2014). This study highlighted the important role that nutrition literacy and nutrition

behaviors may influence dietary risk factors associated with obesity in AAW. The study

further suggests that regular use of nutritional facts at the grocery store and while dining-

out for nutritional health effectiveness is multi-layered (Dimitri & Rogus, 2014).

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New Changes to Nutrition Facts Label

The blended conversation about making healthy food choices from consumers

within communities and nutritional health experts have brought an awareness to NFL

content. Attention around nutritional health has received increased attention over the past

few years. The FDA has recently reported on the new facelift of NFL, after 20 years

(FDA, 2015). Changes include (a) refreshed design, (b) updated information about

nutrition science, (c) serving size requirement and (d) compliance date requirements

(FDA, 2015). Manufacturers will have until July 2018 to comply with NFL requirements

(FDA, 2015). This is helpful information for AAW in that the new food label look may

encourage the population of this study and other consumers to view NFL as a routine

practice. The refreshed design includes font size increase and bolding text for calories

and serving size wording. The decision to enhance NFL was based on information

consumers felt would help them visualized nutritional information and how foods are

consumed. Further, serving size will display a realistic reflection of how much an

individual eats in one setting (FDA, 2015).

Nutrition science researchers have addressed added sugar and actual amount of

vitamin D, calcium, iron, and potassium and the removal of Vitamin A and C will occur.

The type of fat, which is more important for monitoring obesity and risk factors (FDA,

2015), replaces calories from fat. Footnotes will explain how much nutrients contribute to

a daily intake (FDA, 2015). Serving size and labeling requirements of what people eat is

the new rule. Multiple labels will be required if manufacturers produce items for “per

serving” and “per package”/ “per unit” basis (FDA, 2015). According to the FDA (2015),

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these changes positively affect the public health concerning nutrition practices. In this

study, many of the new changes in the refreshed food label design were concerns of the

AAW with the current design of NFL of this study.

P1 said, “Trying to understand the information takes extra effort. You can’t

pronounce half of the information, but you set there, and you try, but it’s just not

understandable.” P5 stated, “The main ingredient information in food items should be

visible…that would be the motivation to use food labels.” P7 goes on to say, “since time

is a factor for me, it would be helpful to see all the information at a glance…that would

be helpful for me.” P12 expounded, “Most of the labels I think the general populous is

not clear about what labeling is, and the nutrition value mean on labels.”

Interpretation of the Findings

The five research questions introduced into this study addressed the influence

NFLU had on AAW who are obese and how nutritional literacy and nutritional behavior

can guide the decisions AAW made concerning a nutritional choice (See Table 2). In

comparing this study to existing literature, the findings found that having an appreciation

and the time to invest in NFL were hurdles to long-term use of NFL. Although the

aspiration to address their obese state was consistent, without a simplified, user-friendly

fact panel, most AAW would avoid their use versus consulting them.

The lack of attention given to NFL as a short-term strategy documented in

Chapter 2 demanded exploration that examined ways of reversing obesity. Nutrition

literacy and nutrition behaviors were two perspectives possible in optimizing nutritional

health in this population. It became obvious after interviewing the AAW the benefit of

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NFLU was clouded by what they thought they understood (cognition) and how that

understanding operationalized on nutritional health behavior. All the women based on

their responses valued their nutritional health; however, individual demonstration of

actual practices (the past and present), affected their dietary choices.

One participant shared her healthy eating was linked to her childhood. The

literature has documented that healthy eating is important across the lifespan and

practiced would be seen in adulthood with identified self-regulation skills, such as self-

monitoring (Collings & Bogue, 2015; Flegal, Carroll, Kit, & Ogden, 2012; Teixeria et al.,

2015). Her current nutritional behaviors and habits that developed as an adult appeared to

supersede her upbringing.

Nutritional information has been available to AAW to make healthy food choices.

In a society where obesity is a continual problem in AAW, NFL information, according

to the participants in this study, stressed that food labels need clear content and visually

assessable. Reading the NFL information from the shelf would encourage their use.

The FDA has echoed the same thought. As of May 2016, the FDA concerning

NFL announced recent changes to food label panels (“Nutritional Facts Label, 2016).

Recently, the new nutrition facts' label resulted from the updated scientific information

that linked obesity and chronic disease to nutrition ("Nutritional Facts Label," 2016, p. 1).

This important element was an attempt to help consumers, like AAW in this study, to

make better-informed and healthier food choices.

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Participant Realization of NFL

Several AAW admitted their embarrassment on the knowledge they thought they

knew regarding the written information on NFL in the grocery store. Misunderstood

information on NFL was connected to the knowledge deficits AAW verbalized. How to

calculate the amount of calories, fat, sugar and sodium in relation to portion size was

confusing. The study discovered that P1, P3, P4, P9, P10, and P12 indicated they had

some knowledge about food labels content; however, when questioned about how they

would determine the number of calories per serving; they failed to look at the total

serving size to determine total calories. Several AAW, P5, P6, P9, and P11 did not link

portion size to the calorie information with the food labels provided (Appendix, I, J, K)

during the interview sessions. Also, when preparing a nutritious meal, a few AAW stated

they would use NFL facts as a guide.

As P5 reported, “I understand healthy eating. I do not think it is difficult; but

when you cook for the family, it’sis to make enough food for everyone.” P6 stated, “I

would prepare what was readily available in my home. Chances are, I have made the

meal before. It is more important to have enough food to feed my family than what a

label reads.” P10 explained, “I know about nutrition, so um; I would know what to

prepare for everyday living because I have learned what is good and what is not good for

me.”

The importance of portion size when viewing NFL is one method to control

calories, fat, sugar, and sodium (Zhang, Kantor, & WenYen, 2016). It was evident that

participants were not focused on that section of the food label. According to Zhang et al.

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(2016), there is widespread misunderstanding about serving size, suggesting the need for

clearer NFL or enhanced education efforts (p.181).When the NFL examples were

provided, none of the participants referred to the portion size to calorie amount. Portions

size are directly related to the caloric value of a complete food item packaged (Hieke &

Taylor, 2012; Velardo, 2015). One of the food labels had six servings in the package with

250 calories per serving. Many participants failed to verbalize the calories /portion ratio

on the food label shown during the interview session. With six servings at 250 calories

per serving, had the food item been consumed, the participant would have eaten 1,500

calories in one meal (See Appendix I).

Participant Realization of Dining-Out

Several of the AAW indicated no real interest of caloric values or portion size

information when dining out. Dining-out was considered a time to enjoy their meal with

family and friends. It was not a time to worry about calories or how much food they

consumed. Dining-out was a break away from the kitchen; a time of enjoyment, eating

meals that they would not normally had purchased grocery shopping. P1 mentioned,

“Honestly, I would rather just enjoy my meal…sometimes I just want to eat without

worrying about how many calories are in the food.”

P2 beamed:

I may try to keep a healthy eating framework. My mind thinks healthy when I am

out eating, but my eyes and taste buds are on a different page when I see the

menu. I will usually go for what I like versus the things that are just low in

calories, so the use is limited.

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In a study conducted by Hammond, Lillico, Vanderlee, White, and Reid ( 2015)

participants reported looking at nutritional information, and some reported nutritional

information influenced the choice they made in their meal which validates the NFL

information is helpful for individuals with poor eating habits. P3 and P10 emphasize NFL

information is good to know, however when dining-out, the focus would not be on

nutritional information as much as enjoying a good meal.

P 3 articulated:

I have no relationship to calories and the nutritional value at the restaurant; I

usually order what I want to eat…and I don’t think about calories or the

nutritional value if I order something, my goal is to eat half of it and try to take

half with me.

Participant 10 explained:

When I go out to eat, calories or what is in the food is not a priority. Enjoying my

meal is what I set out to do. This is not to say I would not pay attention to the

calorie information; I have looked at the information on occasion, but when I go

out to eat or ‘whatever’ I plan to eat it full of calories or not. Eating out should be

fun, not full of pressure to eat the lowest calorie meal in the restaurant.

The reality of the above comments highlighted the importance of introducing

healthy dietary patterns early in the life cycle like NFL that may limit poor dietary habits

later in life (Hammond, Lillico, Vanderlee, White, & Reid, 2015; Zhang et al., 2016).

Understanding decisions about nutrition behavioral suggested they were ingrained;

although from a personal perspective, most AAW desired to benefit from understanding

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nutritional health information. The availability of nutrition information while dining-out

may be marginalized based on the lived-experiences and the struggles AAW had to

incorporate lifestyle changes attributed toward defeating obesity. Bandura states (2001)

change does require mindfulness and motivation to alter human behavior; however, an

essential reality is that latent action causes a retreat to old ways if external behaviors do

not monitor inner forces. Nutritional practices that would govern decisions concerning

NFL need commitment and sacrifice that involved self-efficacy and self-regulation

connection (Bandura, 2001; Hieke & Taylor, 2012; Velardo, 2015). Increased awareness

about nutritional health will likely be a lifelong journey that affects every consumer in

some way (Hammond et al., 2015). Moustakas (1994) stated the approach needed to

arrive at new realities of lived-experiences is ongoing and slowly achieved.

Summary

In summary, key findings revealed AAW expressed a limited appreciation for the

use of NFL. The appreciation declined even further when associated with dining-out

experiences. The study exposed a realization that linked nutrition literacy and nutrition

behavior influenced nutritional practices. The study revealed that food purchased at the

grocery store or consumed while dining-out, AAW in this study shared very similar

perspectives; NFL were rarely considered while grocery shopping and hardly considered

while dining-out. The lack of NFL use was the norm in this study. Participants shared

many reasons nutritional information use was inconsequential. One participant discussed

dining-out on a special occasion (Mother’s Day) however; nutritional information was

not a consideration. For a large majority of participants in this study a deliberate effort is

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crucial for NFLU. Nutritional information at any juncture (i.e., grocery shopping or

dining-out) should embrace the lived-experiences of all. Parenting our nutritional health

over time invites a consciousness on understanding nutrition content.

The study further uncovered the AAW had vague understanding and short term

behaviors that impacted NFL compliance. Most of the women verbalized the

development of long-term dietary practices that, by their own admission, may prove

challenging to overcome. Even for the women who talked about health needs fell short of

a commitment to embrace NFL as a lifestyle. The women considered the use of NFL

restricted to food choice. P8 stated, “ the practice is easier said than done." Even with the

information shared about the prevalence of obesity in AAW, self-efficacy and self-

regulation affirmation was limited. This point was consistent with previous findings in

the literature that suggested to change ingrained nutritional habits targeted strategies are

needed for successful outcomes (Dimitri & Rogus, 2014; James, 2013). It was apparent

from the conversations with the women; it would take continual encouragement to

appreciate NFL use for the identification of nutrient-dense foods. Stressing the benefits

provided to nutritional health may influence foods purchased and consumed over time.

All 12 AAW had some understanding of NFL; however, understanding was unsuccessful

in its translation into an oath directed toward the use of NFL for obesity awareness and

current habits and behaviors.

With the update from the FDA on NFL information, the new design and panel

facts will have more effects on purchase intentions while grocery shopping, meal

planning, and dining-out. Due to the complexity of human behavior, it may continue to

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be a challenge to change behavior based on knowledge attainment. Providing the

understanding of NFL is one factor in breaking habits associated with nutrition. However,

this study has many important features that provide an opportunity for growth and

development in nutrition perception.

Limitations of the Study

The study had several limitations that merit mentioning based on possible

influences that affected how the findings were interpreted (Huberman & Miles, 1994;

Simon, 2011). First, a purposeful approach was used to obtained study participants. By

using this method, also called a convenience sampling approach, recruitment was age-

specific, culturally limited, and geographically detailed. The study only considered

AAW, who were obese, born during the baby-boom era (1946-1964), residents and

churchgoers within as specific zip code (77477) that self-reported their weight. Such

specifics could have created a level of prejudice due to the lack of randomization (Brown

& Gould, 2013; Miller-Soederberg & Cassady, 2015; Robinson, 2015). Interpretations of

results are limited to the study group during this research venture.

Second, the methodology could be considered a limitation. Nachmias and

Nachmias (2008) suggested that although quantitative studies can achieve statistical

significance and use power of analysis to determine an adequate sample size(Rudestam &

Newton, 2015), the qualitative method used in the study invited participants to express

their perceptions of their lived-experiences on understanding NFL in words. Qualitative

methods search for understanding about the phenomenon under study. Subjective

responses in qualitative methods is a limitation that could bias the outcome of the study.

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Nutritional health and obesity topics can often arouse sensitive feelings, including guilt

and shame, especially if past attempts at weight loss had failed.

The hesitancy to offer honest responses on nutritional habits and behavioral

experiences might be withheld during face-to- face interviews (Agyemang & Powell-

Wiley, 2013; James, 2013). Hence, the advantage of a quantitative study over qualitative

study is that it removes the researcher from personal contact, and the study population

can be generalizable (Robinson, 2015). Research studies done in the natural setting create

replication dilemmas over which control is limited.

The third limitation was the size of the sample used for the study. The study was

limited to 12 AAW. The sample used for this study is a small percentage to the AAW

population in Fort Bend County, Texas, and not representative of the total AAW

population of this county. Because of this, transferability of the findings are subject to

individual interpretation of the study to link the study to lived-experiences on nutritional

literacy and nutritional behaviors.

Fourth, the acknowledgment of the researcher’s perceptions was essential to the

study finding. In a qualitative study, biases can influence the conclusions of the study.

Bracketing was an important piece of this study to maintain a cognitive awareness of

personal reflections. Without this step in the study process, trustworthiness might be

questioned with qualitative approaches (Strauss & Corbin, 1990). Despite the limitations

to the study, it is important to help AAW understand the implications of cognitive and

behavior pursuit of nutritional healthiness.

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Overcoming the limitations above through future research could be achieved by

approaching the study using a different design or methodology. Instead of using a

convenience sampling approach, conducting a quantitative study with population

randomization using a blind survey with a larger populace categorized by statistical

outcomes of trends or impact of an intervention. Whereas saturation is the benchmark for

a qualitative study, blind survey responses would lessen biases and perhaps yield a

numerical justification about nutritional literacy and nutritional behavioral.

Many researchers have noted there are no rules for sample size in qualitative

studies; however, it remains a topic of conversation among the scholars (Patton, 2002;

Robinson, 2015). For the credibility, the trade-off might be based on conducting a

quantitative study randomly assigning groups for a specific intervention to be tested. This

type of method can isolate whether an assigned treatment was effective or influenced by

internal or external factors. Last, the researcher’s experiences with the topic of nutritional

understanding and nutritional behaviors needed addressing because of personal struggles

with obesity and some insight into other that struggle with nutritional health choices.

Without this acknowledgment, the propensity for this study to be worthwhile would have

been limited. Personal experiences on nutritional health and the struggle with obesity as

the researcher were important to acknowledge. By participating in a phenomenological

research methodology, it afforded the opportunity to be present in another’s experience

and capture the essence of AAW. In conclusion, by offering a basic understanding of

perceptions of AAW as it related to NFLU, the findings offer some insight into how

AAW with obesity perceived their lived-experiences.

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Recommendations for Further Research

Although prior research inquiry produced worthwhile approaches, much more

needs to be discovered about the effectiveness of nutritional literacy and nutritional

behavior related to NFLU. The findings from this study addressed the gap found in the

literature to the lack of attention given to NFLU for as a strategy for confronting the

epidemic of obesity in AAW of the baby-boom generation. The study revealed the need

for further research to explore ways to engage AAW to marry NFL when grocery

shopping and when dining-out. The complexity of human behavior and habit will require

years of study to expose a better understanding of how built-in behaviors are changed.

NFLU can be part of the resolution to healthy food selection; however, food labels must

offer clear interpretation, larger print, and shelf level views of multiple items for

comparative shopping. These avenues must be explored deeper for the consumers' sake

and public health.

The dining-out nutrition labeling that was implemented by the enactment of the

Patient Protection and Affordable Care Act(PPACA) attempted to address obesity rates

for all population levels (Dimitri & Rogus, 2014; Edwards-Corby, 2012). The nutritional

clause on nutrition labeling in dining-out restaurants can be found in Section 4205 of the

PPACA; its enactment was a forward move to inform consumers for the perceived

potential benefit by providing caloric and nutrition information supportive of fighting

obesity (Edwards-Corby, 2012). This area of study has become increasingly important, as

the busy lifestyles of consumers have resulted in dining-out more, and prepared meals at

home have lessened. Despite persons eating out more, (N=4.4) times a week in this

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study) nutritional health does not have to be compromised. For consumers to notice and

take advantage of nutritional information that could ultimately influence meal choice, it

has to be easy to comprehend and readily available (Hammond et al., 2015). This

statement was contrary to the population of this study. The role nutrition information may

had played with AAW dining out was ineffective. Nutritional information were mostly

disregarded. Edwards-Corby (2012) argued the purpose of providing information is to

assist consumers in maintaining healthy dietary practices (p. 7). Despite the current

behaviors and habits of the study population, Guthrie et al. (2015) encouraging behavior

change is the approach that is important to develop and promote healthful practices;

realizing nutritional information may not always be the deterrent to changing or

improving food choices. Nutrition behavior will always be about choice; influenced

lifestyle and lived-experiences. Greater allegiance to improved nutritional practices while

dining-out will likely build from the individual level as motivation increases, nutritional

information will effect decision-making about healthy food choice and obesity rates in

AAW of this study.

The rate of obesity in the AAW baby-boom population is critical and requires a

stiffer analysis into ways to influence nutritional accountability for life-long results

(Edwards-Corby, 2012; Hammond et al., 2015; Hieke & Taylor, 2012). The AAW, who

agreed to participate in this study, demonstrated a desire to improve their nutrition health.

P5 stated:

I know eating a lot of fat is not a good thing. When you showed me the menu

label examples, right away I knew the fish dinner meal was the better choice; I

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have to practice picking more choices with fewer fats and calories. P8 talked

about her fight within herself about meal choices. She mentioned:

If I start off eating bad for lunch and save some of my meals, then I eat bad for

dinner. I try to start off making healthy food choices, but falling back on old

habits happened so quickly. I guess that is why I’m fat.

P12 explained in her words:

A lot of foods I eat have just too many empty calories, no nutritional value at all,

so if I want to work on a healthy weight and lifestyle longevity, those are

important facts I have to consider since I know I have high cholesterol. I need to

work on getting it down.

AAW on nutritional health forms deeper analyses into how the attainment of

commitment is activated based on behavioral awareness would be a topic for future

research. A quantitative methodology and possibly a dissimilar age group of other

populations may share a statistical perspective data for strengths and weakness in

nutritional health. With this in mind, it may be possible to change a population’s

nutritional health by understanding the role literacy plays with behavioral aspects that

influence the obstacles they may perhaps face.

Implications Positive Social Change

The potential for positive social change within the AAW populace concerning

nutritional health is great. Due to the lack of substantial literature, available regarding the

understanding of the cognitive and behavioral association of NFL content is the

contribution this study will add to the current body of literature. Nutritional health is

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essential for social change because it can affect real-life experiences associated with

healthy nutritional practices. The health of AAW living with obesity in our society should

have the opportunity to gain an awareness to the importance of NFL. Portion size, calorie

amount, fat, sugar, and sodium are all key components of nutritional health. Practitioners

are social change agents and expected to break down obstacles that impede positive

nutrition and health outcomes.

The impact of positive social change commands a transformation from various

avenues. Individual, community or society are not exempt from influencing or

participating in opportunities that improve nutrition health outcomes. The advantage of

understanding nutritional knowledge attached to NFL is decision-making choices about

the direction of healthier food selections when grocery shopping and dining-out. As an

agent of change, engagement into social change actions starts with sharing information

that is essential to empower and bridge gaps that might help to improve nutrition

practices near and far. Further, stakeholders must be willing to go into their communities

and help to ensure consumers understand NF content and how it applies to nutritional

health. They should also lobby for grocery stores to have clear and concise NFL that

identifies healthful food items for the encouraging nutrient-dense foods. Identifying

behaviors associated with nutritional habits can support AAW in new ways of nutrition

decision-making. An individual’s motivation to change their nutritional practices because

of knowledge attainment can fuel social change action in communities and ultimately

influence nutritional health globally. This study has shown that human behavior is

learned overtime and challenging to modify, however, change to the nutritional practice

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of individual behavior could eventually change the trajectory of obesity rates in AAW.

The understanding of NFL has the propensity to improved nutritional health, and this

becomes a benefit to society. The desire to use the knowledge gained from this research

project is for the greater good of humanity and as a social change agent within society.

Conclusion

This qualitative study was conducted to heighten and bring awareness of the

essence of NFLU in AAW with obesity. Understanding the importance of NFL is an

essential component of nutritional health in society. Phenomenology was the framework

in the study and served as the rationale to understanding the lived-experiences of AAW

and the emphasis they placed to those experiences. Food labels have a long history. The

United States have been required nutritional facts on packaged foods for several decades

(FDA, 2015). The purpose of NFL has been to inform consumers about the nutritional

value of the food they purchased at the grocery store and consumed while dining-out.

AAW appropriately shown how to understand NFL facts could be the motivation

necessary to achieve nutritional health and weight reduction.

Participants in this study verbalized the skills they felt would assist them to

concentrate on healthy eating practices using NFL as a guide. Skills that the participants

felt essential were willpower(P1), math(P2), know-how(P3), preparation(P4), mind-

set(P5), motivation(P6), preplanning(P7), organization(P8), commitment(P9), self-

control(P10), planning(P11), and math savvy(P12). Behavioral effects might not take

place without acknowledging the realities of these perspectives. Many AAW from this

study acknowledged the need to improve their nutritional habits. They further admitted

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nutrition information was a helpful way for making healthy food choices. Their biggest

hurdle was the decisions to put NFL into practice. The women had limited motivation to

incorporate NFL into their lived-experiences although there was perceived interest to

change nutrition behaviors.

The purpose of this study was to determine if NFLU is a plausible strategy to

combat obesity in AAW. It is documented throughout the literature how obesity threatens

the future of Americans. As a population, AAW must become motivated to improve their

nutritional health for the prevention of obesity-related risk factors. The AAW validated

self-discipline was an important element to reverse long- term behaviors. The route that

led to unhealthy eating behaviors contributing to obesity is not impassable for any person.

The literature has produced vast amounts of research on the factors that influence

behavior and food choice(e.g.; price, supermarket location, culture, time restraints), but

decisions based on habits need circumventing and replaced with purposeful nutritional

choices(Dimitri & Rogus, 2014). Changing nutritional practices could be considered

enormous but not an impossible achievement if understanding NFL grows into a self-

conscious effort.

This study argues that the valuation of nutritional cognition and nutritional

behavior be a necessary step to understand the essence of AAW living with obesity. This

study uncovered NFL use were connected to cognitive and behavioral constructs. Self-

efficacy and self-regulation operate best when decision-making capacities are realized

and attached to lifestyle shift toward the selection of healthier foods at the point-of-

purchase and while dining-out. The findings from this study established that maximizing

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lifestyle modification skills for AAW required cognition to increase self-efficacy and

ground self-regulation behaviors related to understanding NFL content. Some participants

suggested label information had to be identifiable with the shelf level. Taking various

food items off the shelves to compare calories or fat content, for example, was too time-

consuming.

The reality is reversing the trajectory of obesity in AAW of the baby-boom era

will require diligence on an individual, community, and societal level. Nutritional literacy

and nutritional behavior as constructs to improving eating patterns may be less complex

and lead to a positive lifestyle and behavioral modification if explained in an

understandable fashion. The theoretical foundations of the study were significant to

Bandura’s SCT, which focused on self-efficacy, and self-regulatory performance. The

efforts that address nutritional health will continue to be vital in African-American

communities and especially AAW. There are dietary behavior paradigms can be

reconditioned one AAW at a time. Change is possible if individuals have a cognitive

awareness for the importance of nutritional health. Self-efficacy and self-regulatory

behavior will increase because AAW would have acquired the skills to implement new

behaviors.

The study aimed to understand NFL use in AAW and what motivated them to

develop long-term healthy consumption practices. Eating behaviors develops over time,

and in general; most are not taught to use NFL while grocery shopping or evaluate a

menu with nutrient values content while dining out. The latter, menu labeling on dining-

out menus is a fairly new phenomenon since the Patient Protection and Affordable Care

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Act (PPACA) of 2010 mandated that calorie content be added to menu boards of dining-

out establishments. Since starting this project, the FDA has revealed the new nutrition

label guidelines from scientific information that may assist in new practices for society.

The implications for the advancement toward social change were demonstrated by

the findings of this study. The lack of appreciation and awareness of what one

understands about nutritional health grocery shopping or dining-out based on ingrained

behaviors dictates actions associated with nutritional health practices. Removing the veil

of time restraints and busy lifestyles to help AAW understand it takes time and effort to

attain healthy eating practices. It will be the responsibility of AAW to modify their

behaviors suggestive of nutritional health accomplishments. Further, it will take

individuals, community activists, political leaders, nutritionist, and nutrition agencies

uniting to keep the emphasis on obesity resolutions and lasting nutritional health

interventions (Dimitri & Rogus, 2014; Hieke & Taylor, 2012; Miller-Soederberg &

Cassady, 2015). The effort will take time, but the cost savings that are possible from the

decline in obesity-related complications are worth the challenge.

Many life-long nutritional habits were shared during this study. Many participants

stated their nutritional habits they would be hard to break. The importance of the study

centers on the AAW in this study and their acknowledgment of poor eating behaviors that

led to obesity. This acknowledgment starts the conversation toward change processes

necessary to focus on improved nutritional habits. When self-behaviors are identified,

time is needed to nurture new behaviors and put them into practice, grocery shopping and

while dining-out. Healthy nutritional practices become the investments against obesity-

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related health conditions. Going forward, the impact of NFLU hinges on nutritional

literacy and nutritional behavior addressing purchasing decisions.

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