The diabetes nutrition education study randomized controlled trial: A comparative effectiveness study of approaches to nutrition in diabetes self-management education

OBJECTIVE

To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support (DSME/S).

METHODS

We randomized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education. The primary outcome was change in HbA1C over 6 months.

RESULTS

At 6 months, HbA1C improved within the plate method [-0.83% (-1.29, -0.33), P<0.001] and carbohydrate counting [-0.63% (-1.03, -0.18), P=0.04] groups but not the control group [P=0.34]. Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months (carbohydrate counting, P=0.36; modified plate method, P=0.08). In a pre-specified subgroup analysis of patients with a baseline HbA1C 7-10%, change in HbA1C from baseline improved in the carbohydrate counting [-0.86% (-1.47, -0.26), P=0.006] and plate method groups [-0.76% (-1.33, -0.19), P=0.01] compared to controls.

CONCLUSION

CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%.

PRACTICE IMPLICATIONS

Both carbohydrate counting and the modified plate method improve glycemic control as part of DSME/S.

Improving risk literacy in surgeons

OBJECTIVE

To effectively practice evidence-based medicine, surgeons need to understand and be able to communicate health-relevant numerical information. We present the first study examining risk literacy in surgeons by assessing numeracy and surgical risk comprehension. Our study also investigated whether visual aids improve risk comprehension in surgeons with limited numeracy.

METHODS

Participants were 292 surgeons from 60 countries who completed an instrument measuring numeracy and evaluated the results of a randomized controlled trial including post-surgical side-effects. Half of the surgeons received this information in numbers. The other half received the information represented visually. Accuracy of risk estimation, reading latency, and estimate latency (i.e., deliberation) were assessed.

RESULTS

Some surgeons have low numeracy and could not correctly interpret surgical risks without additional support. Visual aids made risks transparent and eliminated differences in risk understanding between more and less numerate surgeons, increasing the amount of time that less numerate surgeons spent deliberating about risks.

CONCLUSIONS

Visual aids can be an efficient and inexpensive means of improving risk comprehension and clinical judgement in surgeons with low numerical and statistical skills.

PRACTICE IMPLICATIONS

Programs designed to help professionals represent and communicate health-relevant numerical information in simple transparent graphs may unobtrusively promote informed decision making.

Longitudinal Stability and Growth in Literacy and Numeracy in Australian School Students

We explored the genetic and environmental influence on both stability and growth in literacy and numeracy in 1927 Australian twin pairs from Grade 3 to Grade 9. Participants were tested on reading, spelling, grammar and punctuation, writing, and numeracy. In each domain, performance across time was highly correlated and this stability in performance was primary due to genes. Key findings on growth showed that reading followed a compensatory growth pattern that was largely due to genetic effects, while variation in growth in the other literacy domains was predominantly due to environmental influences. Genes and the shared environment influenced growth in numeracy for girls, while for boys it was influenced by the shared and unique environment. These results suggest that individual differences in growth of reading are primarily due to a genetically influenced developmental delay in the acquisition of necessary skills, while environmental influences, perhaps including different schools or teachers, are more important for the other domains.

Lower parental numeracy is associated with children being under- and overweight

BACKGROUND

In adults, lower numeracy is associated with poorer nutrition label comprehension and higher BMI. It remains unclear whether parental numeracy also impacts children's body weight.

PURPOSE

We examined the relationship between parental numeracy and children's BMI z-scores and analyzed whether weight-related numerical information processing skills-specifically, portion-size estimation skills, comprehension of nutrition labels, and comprehension of growth charts-mediated that relationship.

DESIGN AND METHODS

Numeracy, portion-size estimation skills, comprehension of nutrition labels, and comprehension of growth charts were assessed in face-to-face interviews with 320 parents of children aged 6-12 years in Germany. Parent and child body weight were measured; parents reported both their own height and that of their children.

RESULTS

Lower parental numeracy was significantly associated with having a child who was either underweight (β = 0.126, P = 0.048) or overweight (β = -0.299, P < 0.001). Lower parental numeracy was also associated with poorer portion-size estimation skills (r = -0.08, P = 0.023) and inferior comprehension of growth charts (r = 0.33, P < 0.001) and nutrition labels (r = 0.26, P < 0.001). However, these weight-related numerical information processing skills did not mediate the association between parental numeracy and children's BMI.

CONCLUSION

This study is the first to find lower parental numeracy to be a risk factor for children being either over- or underweight. However, portion-size estimation skills, comprehension of nutrition labels, and comprehension of growth charts did not mediate the association between parental numeracy and children's BMI. The present findings thus winnow down the set of mechanisms potentially underlying this association. Parental numeracy is an as yet largely overlooked factor that can be targeted when developing interventions to prevent and treat malnutrition and to achieve and maintain a healthy body weight in children.

Evaluation of an Australian health literacy training program for socially disadvantaged adults attending basic education classes: study protocol for a cluster randomised controlled trial

BACKGROUND

People with low literacy and low health literacy have poorer health outcomes. Literacy and health literacy are distinct but overlapping constructs that impact wellbeing. Interventions that target both could improve health outcomes.

METHODS/DESIGN

This is a cluster randomised controlled trial with a qualitative component. Participants are 300 adults enrolled in basic language, literacy and numeracy programs at adult education colleges across New South Wales, Australia. Each adult education institute (regional administrative centre) contributes (at least) two classes matched for student demographics, which may be at the same or different campuses. Classes (clusters) are randomly allocated to receive either the health literacy intervention (an 18-week program with health knowledge and skills embedded in language, literacy, and numeracy training (LLN)), or the standard Language Literacy and Numeracy (LLN) program (usual LLN classes, specifically excluding health content). The primary outcome is functional health literacy skills - knowing how to use a thermometer, and read and interpret food and medicine labels. The secondary outcomes are self-reported confidence, more advanced health literacy skills; shared decision making skills, patient activation, health knowledge and self-reported health behaviour. Data is collected at baseline, and immediately and 6 months post intervention. A sample of participating teachers, students, and community health workers will be interviewed in-depth about their experiences with the program to better understand implementation issues and to strengthen the potential for scaling up the program.

DISCUSSION

Outcomes will provide evidence regarding real-world implementation of a health literacy training program with health worker involvement in an Australian adult education setting. The evaluation trial will provide insight into translating and scaling up health literacy education for vulnerable populations with low literacy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000213448 .

Health Literacy and Education Predict Nutrient Quality of Diet of Socioeconomically Diverse, Urban Adults

BACKGROUND

Research has shown that health literacy may be a stronger predictor of health than age, employment status, education level, race, and income. Evidence supports a strong link between low health literacy and poor dietary management of chronic diseases.

OBJECTIVE

The aim was to evaluate the relationship of micronutrient quality of diet, health numeracy and health literacy in White and African American adults randomly selected from 13 Baltimore neighborhoods.

DESIGN

Cross-sectional analysis of Wave 3 (2009-2013) of the longitudinal Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study initiated in 2004.

MAIN OUTCOME MEASURES

Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM). Health numeracy was measured using the numeracy subscale of the Test of Functional Health Literacy in Adults (TOFHLA). Nutrient-based diet quality was measured using Mean Adequacy Ratio (MAR-S) scores calculated from 17 micronutrients from diet plus dietary supplement intake.

STATISTICAL ANALYSES

The relationship of MAR-S scores to the health literacy measures were explored with multiple ordinary least square regression models, adjusting for a number of potential confounders.

RESULTS

REALM but not numeracy was associated with MAR-S; significant covariates included age, current cigarette smoking status, and energy intake. The interactions of race and educational attainment, and REALM and educational attainment were significant, with the relationship between REALM and MAR-S becoming stronger as education level increased.

CONCLUSION

There is a synergistic relationship between health literacy and educational attainment in predicting nutrient-based diet quality. Education was a stronger predictor for Whites compared to African Americans emphasizing the need for health professionals to focus on both education and literacy when creating and providing diet and health-related interventions and resources.

Breast Cancer Risk Perceptions among Relatives of Women with Uninformative Negative BRCA1/2 Test Results: The Moderating Effect of the Amount of Shared Information

The most common result of BRCA1/2 mutation testing when performed in a family without a previously identified mutation is an uninformative negative test result. Women in these families may have an increased risk for breast cancer because of mutations in non-BRCA breast cancer predisposition genes, including moderate- or low-risk genes, or shared environmental factors. Genetic counselors often encourage counselees to share information with family members, however it is unclear how much information counselees share and the impact that shared information may have on accuracy of risk perception in family members. We evaluated 85 sisters and daughters of women who received uninformative negative BRCA1/2 results. We measured accuracy of risk perception using a latent variable model where accuracy was represented as the correlation between perceived risk (indicators = verbal and quantitative measures) and calculated risk (indicators = Claus and BRCAPRO). Participants who reported more information was shared with them by their sister or mother about her genetic counseling session had greater accuracy of risk perception (0.707, p = 0.000) than those who reported little information was shared (0.326, p = 0.003). However, counselees shared very little information; nearly 20 % of family members reported their sister or mother shared nothing with them about her genetic counseling. Family members were generally not aware of the existence of a genetic counseling summary letter. Our findings underscore the need for effective strategies that facilitate counselees to share information about their genetic counseling sessions. Such communication may help their relatives better understand their cancer risks and enhance risk appropriate cancer prevention.

ABCs or 123s? The independent contributions of literacy and numeracy skills on health task performance among older adults

OBJECTIVE

To investigate the relationship between literacy and numeracy and their association with health task performance.

METHODS

Older adults (n=304) completed commonly used measures of literacy and numeracy. Single factor literacy and numeracy scores were calculated and used to predict performance on an established set of health self-management tasks, including: (i) responding to spoken information; (ii) comprehension of print and (iii) multimedia information; and (iv) organizing and dosing medication. Total and sub-scale scores were calculated.

RESULTS

Literacy and numeracy measures were highly correlated (rs=0.68; ps<0.001). In multivariable models adjusted for age, gender, race, education, and comorbidity, lower literacy (β=0.44, p<0.001) and numeracy (β=0.44, p<0.001) were independently associated with worse overall task performance and all sub-scales (literacy range, β=0.23-0.45, ps<0.001; numeracy range, β=0.31-0.41, ps<0.001). Multivariable analyses with both constructs entered explained more variance in overall health task performance compared with separate literacy and numeracy models (8.2% and 10% respectively, ps<0.001).

CONCLUSION

Literacy and numeracy were highly correlated, but independent predictors of health task performance. These skill sets are complementary and both are important for health self-management.

PRACTICE IMPLICATIONS

Self-management interventions may be more effective if they consider both literacy and numeracy skills rather than focusing on one specific ability.

Importance of Numeracy as a Risk Factor for Elder Financial Exploitation in a Community Sample

OBJECTIVES

To examine the role of numeracy, or comfort with numbers, as a potential risk factor for financial elder exploitation in a community sample.

METHOD

Individually administered surveys were given to 201 independent, community-dwelling adults aged 60 and older. Risk for financial elder exploitation was assessed using the Older Adult Financial Exploitation Measure (OAFEM). Other variables of interest included numeracy, executive functioning, and other risk factors identified from the literature. Assessments were completed individually at the Wood Lab at Scripps College in Claremont, CA and neighboring community centers.

RESULTS

After controlling for other variables, including education, lower numeracy was related to higher scores on the OAFEM consistent with higher risk for financial exploitation. Self-reported physical and mental health, male gender, and younger age were also related to increased risk.

CONCLUSIONS

Results indicated that numeracy is a significant risk factor for elder financial exploitation after controlling for other commonly reported variables. These findings are consistent with the broader literature relating numeracy to wealth and debt levels and extend them to the area of elder financial exploitation.

Experimental philosophy of actual and counterfactual free will intuitions

Five experiments suggested that everyday free will and moral responsibility judgments about some hypothetical thought examples differed from free will and moral responsibility judgments about the actual world. Experiment 1 (N=106) showed that free will intuitions about the actual world measured by the FAD-Plus poorly predicted free will intuitions about a hypothetical person performing a determined action (r=.13). Experiments 2-5 replicated this result and found the relations between actual free will judgments and free will judgments about hypothetical determined or fated actions (rs=.22-.35) were much smaller than the differences between them (ηp(2)=.2-.55). These results put some pressure on theoretical accounts of everyday intuitions about freedom and moral responsibility.

Who are maximizers? Future oriented and highly numerate individuals

Two studies investigated cognitive mechanisms that may be associated with people's tendency to maximize. Maximizers are individuals who are spending a great amount of effort in order to find the very best option in a decision situation, rather than stopping the decision process when they encounter a satisfying option. These studies show that maximizers are more future oriented than other people, which may motivate them to invest the extra energy into optimal choices. Maximizers also have higher numerical skills, possibly facilitating the cognitive processes involved with decision trade-offs.

Modeling individual differences in response time and accuracy in numeracy

In the study of numeracy, some hypotheses have been based on response time (RT) as a dependent variable and some on accuracy, and considerable controversy has arisen about the presence or absence of correlations between RT and accuracy, between RT or accuracy and individual differences like IQ and math ability, and between various numeracy tasks. In this article, we show that an integration of the two dependent variables is required, which we accomplish with a theory-based model of decision making. We report data from four tasks: numerosity discrimination, number discrimination, memory for two-digit numbers, and memory for three-digit numbers. Accuracy correlated across tasks, as did RTs. However, the negative correlations that might be expected between RT and accuracy were not obtained; if a subject was accurate, it did not mean that they were fast (and vice versa). When the diffusion decision-making model was applied to the data (Ratcliff, 1978), we found significant correlations across the tasks between the quality of the numeracy information (drift rate) driving the decision process and between the speed/accuracy criterion settings, suggesting that similar numeracy skills and similar speed-accuracy settings are involved in the four tasks. In the model, accuracy is related to drift rate and RT is related to speed-accuracy criteria, but drift rate and criteria are not related to each other across subjects. This provides a theoretical basis for understanding why negative correlations were not obtained between accuracy and RT. We also manipulated criteria by instructing subjects to maximize either speed or accuracy, but still found correlations between the criteria settings between and within tasks, suggesting that the settings may represent an individual trait that can be modulated but not equated across subjects. Our results demonstrate that a decision-making model may provide a way to reconcile inconsistent and sometimes contradictory results in numeracy research.

Refining the quantitative pathway of the Pathways to Mathematics model

In the current study, we adopted the Pathways to Mathematics model of LeFevre et al. (2010). In this model, there are three cognitive domains--labeled as the quantitative, linguistic, and working memory pathways--that make unique contributions to children's mathematical development. We attempted to refine the quantitative pathway by combining children's (N=141 in Grades 2 and 3) subitizing, counting, and symbolic magnitude comparison skills using principal components analysis. The quantitative pathway was examined in relation to dependent numerical measures (backward counting, arithmetic fluency, calculation, and number system knowledge) and a dependent reading measure, while simultaneously accounting for linguistic and working memory skills. Analyses controlled for processing speed, parental education, and gender. We hypothesized that the quantitative, linguistic, and working memory pathways would account for unique variance in the numerical outcomes; this was the case for backward counting and arithmetic fluency. However, only the quantitative and linguistic pathways (not working memory) accounted for unique variance in calculation and number system knowledge. Not surprisingly, only the linguistic pathway accounted for unique variance in the reading measure. These findings suggest that the relative contributions of quantitative, linguistic, and working memory skills vary depending on the specific cognitive task.

Glycemic control in young children with diabetes: the role of parental health literacy

OBJECTIVE

This cross sectional study examined the relationship between parental health literacy (HL), diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample of young children with Type 1 DM.

METHODS

Seventy primary caregivers of children (age 3-9 years) with Type 1 DM were recruited and surveyed at diabetes outpatient clinic visits. Patients' medical histories were obtained by medical chart review.

RESULTS

Parental diabetes related numeracy (r=-.52, p<01), but not reading skills (r=-.25, p=NS) were inversely correlated with the child's glycemic control (HbA1c). Parental perceived diabetes self-efficacy was also negatively correlated to their child's HbA1c (r=-.47, p<01). When numeracy and parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant (F=12.93, p<.01) with both numeracy (β=-.46, p<.01) and parental perceived diabetes self-efficacy (β=-.36, p=.01) as significant predictors of HbA1c.

CONCLUSIONS

Data from this study highlight the importance of considering the role of parental numeracy, in health outcomes for children with Type 1 DM.

PRACTICE IMPLICATIONS

Practitioners should assess parental health literacy and consider intervention when needed.

The development and testing of a brief ('gist-based') supplementary colorectal cancer screening information leaflet

OBJECTIVE

To design and user-test a 'gist-based' colorectal cancer screening information leaflet, which promotes comprehension of the screening offer.

METHODS

Twenty-eight individuals approaching screening age were recruited from organisations in deprived areas of England. Using a between-subjects design, we tested iterations of a newly-designed gist-based information leaflet. Participants read the leaflet and answered 8 'true' or 'false' comprehension statements. For the leaflet to be considered fit-for-purpose, all statements had to be answered correctly by at least 80% of participants in each round. Alterations were made if this threshold was not met and additional rounds of testing were undertaken.

RESULTS

At round 1, answers to 2/8 statements did not meet the threshold. After changes, answers in round 2 did not reach the threshold for 1/8 statements. In round 3, all answers were adequate and the leaflet was deemed fit-for-purpose. Qualitative data offered solutions such as language and layout changes which led to improved comprehension of the leaflet.

CONCLUSION

User-testing substantially improved the design and subsequent comprehensibility of a theory-driven gist-based colorectal cancer screening information leaflet.

PRACTICAL IMPLICATIONS

This leaflet will be evaluated as part of a large national randomised controlled trial designed to reduce socioeconomic inequalities in colorectal cancer screening participation.

Communicating global cardiovascular risk: are icon arrays better than numerical estimates in improving understanding, recall and perception of risk?

OBJECTIVE

Experts recommend that adults have their global cardiovascular risk assessed. We investigated whether icon arrays increase understanding, recall, perception of CVR, and behavioral intent as compared with numerical information.

METHODS

Male outpatient veterans, at an intermediate to high cardiovascular risk participated in a randomized controlled trial of a computer tutorial presenting individualized risk. Message format was presented in 3 formats: percentages, frequencies, and frequencies with icon arrays. We assessed understanding immediately (T1) and recall at 20 min (T2) and 2 weeks (T3) after the intervention. We assessed perceptions of importance/seriousness, intent to adhere, and self-efficacy at T1. Self-reported adherence was assessed at T3.

RESULTS

One-hundred and twenty male veterans participated. Age, education, race, health literacy and numeracy were comparable at baseline. There were no differences in understanding at T1 [p = .31] and recall at T3 [p = .10]. Accuracy was inferior with frequencies with icon arrays than percentages or frequencies at T2 [p ≤ .001]. There were no differences in perception of seriousness and importance for heart disease, behavioral intent, self-efficacy, actual adherence and satisfaction.

CONCLUSION

Icon arrays may impair short-term recall of CVR.

PRACTICE IMPLICATIONS

Icon arrays will not necessarily result in better understanding and recall of medical risk in all patients.

The effect of school status and academic skills on the reporting of premarital sexual behavior: evidence from a longitudinal study in rural Malawi

PURPOSE

Reliable data on sexual behavior are needed to identify adolescents at risk of acquiring human immunodeficiency virus or other sexually transmitted diseases, as well as unintended pregnancies. This study aimed to investigate whether schooling status and literacy and numeracy skills affect adolescents' reports of premarital sex, collected using audio computer-assisted self-interviews.

METHODS

We analyzed data on 2,320 participants in the first three rounds of the Malawi Schooling and Adolescent Study to estimate the level of inconsistency in reporting premarital sex among rural Malawian adolescents. We used multivariate logistic regressions to examine the relationships between school status and academic skills and premarital sexual behavior reports.

RESULTS

Males were more likely than females to report premarital sex at baseline, whereas females were more likely than males to report sex inconsistently within and across rounds. School-going females and males were more likely to report never having had sex at baseline and to retract reports of ever having sex across rounds than were their peers who had recently left school. School-going females were also more likely to report sex inconsistently at baseline. Literate and numerate respondents were less likely to report sex inconsistently at baseline; however, they were more likely to retract sex reports across rounds.

CONCLUSIONS

The level of inconsistency both within a survey round and across rounds reflects the difficulties in collecting reliable sexual behavior data from young people in settings such as rural Malawi, where education levels are low and sex among school-going females is not socially accepted.