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Diabetes Educ. 2014 Sep-Oct;40(5):581-604. doi: 10.1177/0145721714540220. Epub 2014 Jun 19.

Update on health literacy and diabetes.

Author information

Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA (Dr Bailey)
Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA (Dr Brega)
Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA (Ms Crutchfield)
Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN, USA (Drs Elasy, Osborn, and Rothman)
Brown School of Social Work, Washington University in St Louis, St Louis, MO, USA (Ms Herr and Dr Moreland-Russell)
Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St Louis, St Louis, MO, USA (Dr Kaphingst)
Kaiser Permanente Division of Research, Oakland, CA, USA (Dr Karter)
Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA (Dr Pignone)
Vanderbilt Center for Health Services Research, Nashville, TN, USA (Dr Rothman)
Division of General Internal Medicine, University of California San Francisco, and Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA, USA (Dr Schillinger)



Inadequate literacy is common among patients with diabetes and may lead to adverse outcomes. The authors reviewed the relationship between literacy and health outcomes in patients with diabetes and potential interventions to improve outcomes.


We reviewed 79 articles covering 3 key domains: (1) evaluation of screening tools to identify inadequate literacy and numeracy, (2) the relationships of a range of diabetes-related health outcomes with literacy and numeracy, and (3) interventions to reduce literacy-related differences in health outcomes.


Several screening tools are available to assess patients' print literacy and numeracy skills, some specifically addressing diabetes. Literacy and numeracy are consistently associated with diabetes-related knowledge. Some studies suggest literacy and numeracy are associated with intermediate outcomes, including self-efficacy, communication, and self-care (including adherence), but the relationship between literacy and glycemic control is mixed. Few studies have assessed more distal health outcomes, including diabetes-related complications, health care utilization, safety, or quality of life, but available studies suggest low literacy may be associated with increased risk of complications, including hypoglycemia. Several interventions appear to be effective in improving diabetes-related outcomes regardless of literacy status, but it is unclear if these interventions can reduce literacy-related differences in outcomes.


Low literacy is associated with less diabetes-related knowledge and may be related to other important health outcomes. Further studies are needed to better elucidate pathways by which literacy skills affect health outcomes. Promising interventions are available to improve diabetes outcomes for patients with low literacy; more research is needed to determine their effectiveness outside of research settings.

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