The Numeracy Role in Diabetes Management

JUNE 26, 2010
Numeracy plays an important role in successfully managing diabetes, but unfortunately many patients struggle with numbers and the basic calculations necessary to attain their goals, according to Kathleen I. Wolff, MSN, APRN, BC-ADM, from the Vanderbilt University Diabetes Center, who spoke today in the session “Health Numeracy—Strategies that Count” at the American Diabetes Association 70th Scientific Sessions.
Numeracy is defined as the ability to use numbers in daily life, which includes basic calculations, interpreting graphs and labels, telling time, and the ability to deduce when to use math and what type of math is needed. This skill is very important for diabetic patients who have to make sure they know when their refills are due, when to make appointments, how to monitor their glucose levels, and the timing and dosing of their medication. It also helps with meal planning and making the appropriate adjustments to their medicine based on their blood sugar and carbohydrates, as well as hypoglycemia.
But Dr. Wolff found that even the most basic of calculations can cause problems for diabetes patients, which can put them at risk when managing their chronic condition. Dr. Wolff administered a Diabetes Numeracy Test, a 48- and 15-item questionnaire with no time limit and the ability to use a calculator, to 398 diabetes patients. The questionnaire contained simple calculations based on previously validated math tests; the mean score among the population was 65% and nobody scored 100%.
This was troubling to hr for several reasons. The population struggled to interpret serving sizes, an important skill for a person with diabetes. The study population also had difficulty with fractions and decimals, and applying titration instructions and identifying numerical hierarchies, which diabetes patients come into contact often when drawing insulin into a syringe. As would be expected, better outcomes were associated with a higher level of education, literacy, diabetes knowledge and the frequency with which the person monitored their blood glucose.
Dr. Wolff also administered a portion size study, which asked diabetes patients to identify how much a serving was, as well as the appropriate amount of fruit juice in a half a cup and other similar questions. For the 164 patients involved in the study, 62-65% were able to estimate portion sizes. She also conducted a food label study in 200 patients who were socioeconomically diverse; 89% claimed that they read food labels pre-study. But apparently not well enough because Dr. Wolff’s study revealed that the average score was less than 70%, with comprehension worse when they needed to apply a serving size. Again, lower health literacy was associated with lower scores.  
Numeracy was also the basis of the Diabetes Literacy and Numeracy Education Tool Kit Study, a randomized, controlled trial of 198 patients at Vanderbilt and the University of North Carolina. The goal of the study was to improve patient-provider communication by simplifying content, avoiding jargon, and utilizing the tool kit. The tool kit uses a 5th grade reading level, is color-coded, includes a large number of pictures, and uses step-by-step instructions to help patients understand the ways to manage their diabetes. The patients also visited with a nutritionist, pharmacist, and nurses and were followed-up with for three months. After three months, the intervention group improved their A1C levels by 1.5%, which was statistically significant from the control group (0.8%). But after six months, the intervention group waned, erasing the significance.
What these studies led Dr. Wolff to conclude was that in order to improve outcomes in diabetes patients with low numeracy, the education must be simplified, maybe even avoiding the use of numbers altogether. Instead of using text, use visual aids like tables and charts, and avoid using fractions and decimals, which are an apparent sore spot among diabetes patients. And with pens and other tools available, eliminating the use of the syringe should also be considered.
Since people deal with numbers everyday their importance is paramount. Dr. Wolff advises that healthcare professionals be prepared to accommodate the needs of their patients with low literacy and numeracy skils and alter their treatment plans accordingly.  

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