1. HEATHER GIBBS, M.S., R.D., L.D.N. PH.D. CANDIDATE, UNIVERSITY OF ILLINOIS MODULE 2: IMPORTANCE OF CLINICIAN ATTENTION TO HEALTH LITERACY

2. OBJECTIVES Participants will be able to: Describe the relationship of health literacy to chronic disease Describe the relationship of health literacy to self- care Discuss the importance of assessment of nutrition literacy

3. HEALTH LITERACY AND CHRONIC DISEASE OBJECTIVE 1

4. ASSOCIATIONS OF LOW HEALTH LITERACY SCORES Decreased knowledge of illness and management Increased hospitalization rates Decreased use of preventive care services Increased cost of health care Neilson-Bowman, Lynn. Institute of Medicine. The extent and associations of limited health literacy. In: Health literacy: A prescription to end confusion. Washington D.C.: National Academies Press, 2004. p.59-107.

5. DECREASED KNOWLEDGE OF DISEASE Hypertension (n=402) For those with inadequate health literacy: 42% could identify normal blood pressure readings 40% knew exercise lowers blood pressure 63% knew canned vegetables are high in salt Diabetes (n=114) For those with inadequate health literacy: 58% knew normal blood glucose values 50% knew signs of low blood glucose 38% knew how to treat symptoms of low blood glucose Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. Arch Intern Med. 1998;158:166-172. Patients with hypertension and diabetes were evaluated for functional health literacy (measured by TOFHLA) and knowledge of disease.

6. INCREASED HOSPITALIZATIONS 3260 new Medicare managed care enrollees in 4 US cities were evaluated for health literacy (TOFHLA) and number of hospitalizations for a 18-24 month period. Rates of hospitalization were significantly different for those with inadequate and marginal health literacy compared with adequate health literacy (p<0.001). Of the 29.5% who were hospitalized: 34.9% inadequate health literacy 33.9% marginal health literacy 26.7% adequate health literacy Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, Ren J, Peel J. Functional health literacy and the risk of hospital admission among medicare managed care enrollees. American Journal of Public Health. 2002;92(8):1278-1283.

7. DECREASED USE OF PREVENTIVE CARE Evaluated the relationship of health literacy and self-reported preventive care. Nationally representative sample of 18,000 adults from the 2003 National Assessment of Adult Literacy (NAAL) White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: A national study. Am J Health Behav. 2008;32(3):227-242. Preventive Services Measured Self-reported dental check-up Vision checkup Osteoporosis screening Colon cancer screening Pneumonia shot (>65 yrs) Flu shot Pap smear (women < 65 yrs) Mammogram (women) Prostate cancer screening (men) Results: Low health literacy was associated with a decrease in: Ages >65 yrs: all preventive measures Ages 16-39 yrs: Pap smear and vision checkup Ages 40-64 yrs: dental care and prostate cancer screening

8. INCREASED COST Review of 10 studies evaluating associated costs of reduced health literacy. Findings: Costs due to limited health literacy in the US account for 3- 5% of total health care spending (Vernon et al., 2007) Additional health care expenditures for those with limited health literacy range $143 - $7,798 per person per year Eichler K, Wieser S, Brügger U. The costs of limited health literacy: A systematic review. Int J Public Health. 2009;54:313-324.

9. OUTCOMES IN DIABETES Evaluated the relationship between health literacy and outcomes in type 2 diabetes Outcomes measured: HbA 1c and retinopathy Health literacy measured by s-TOFHLA Results 28% with inadequate health literacy had HbA 1c ≤ 7.2% (tight control) vs. 33% of those with adequate health literacy 30% with inadequate health literacy had HbA 1c ≥ 9.5% (poor control) vs. 20% of those with adequate health literacy Those with inadequate health literacy had 2 times odds of having retinopathy Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman AB. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475- 482.

10. NUTRITION LITERACY HEALTH LITERACY IN A NUTRITION CONTEXT

11. “NUTRITION LITERACY” the degree to which individuals have the capacity to obtain, process, and understand nutrition information and skills needed in order to make appropriate nutrition decisions (definition adapted from the IOM definition of health literacy)

12. IMPORTANCE OF NUTRITION EDUCATION A sampling of conditions with relationship to nutrition 66% Overweight or obese adults (CDC, 2004) Heart Disease: #1 cause of death among US Adults Diabetes: 7.8% estimated prevalence for all ages (CDC, 2007) Cancer: 60% prevalence in ages > 65 yrs (NCI, 2006) Hypertension: 1 in 3 adults

13. NUTRITION INFORMATION IS COMPLEX Confusion abounds. Examples: Nutrition claims on food labels; i.e. “sugar-free” Diet industry: “Carrots are high GI, so don’t eat them” Should we use the word “portion” or “serving”? What is a standard serving of peanut butter? Is peanut butter in the meat group or fats and oils? How about cheese? Fats and oils are different but they both provide fat

14. ASSESSING NUTRITION LITERACY An assessment of client/patient needs is essential to providing adequate nutrition care and is included in the Nutrition Care Process. Level of education completed does not adequately predict actual literacy or health literacy Our 2008 preliminary study of 3 ADA DPGs found 79% of participants (n=125)did not conduct an objective assessment of health literacy. No assessment measures are specific to nutrition Most only identify print literacy and/or numeracy How to assess? Subject of next module…