Food Insecurity, Low Literacy, and Diabetes in a Rural 72-Year-Old
Mrs. K is 72, lives in a rural county 45 minutes from the clinic, and has had type 2 diabetes for 12 years, hypertension, and knee osteoarthritis. Her A1c is 9.4% and BP is 158/88. Three weeks ago she was in the ED with a glucose of 48 mg/dL after taking her glipizide without eating because 'the money ran out before the end of the month.' She reads at about a fifth-grade level, has no car, and relies on a neighbor. She brings a shoebox of bottles that includes two separate metformin prescriptions. She says she feels 'fine' and does not see why she needs to come in. She walks with a cane and has fallen once in the bathroom.
1. What do you address in the next three months, and in what order? Justify the order.
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Order by immediacy of harm and reversibility, not by how abnormal the numbers are.
- Hypoglycemia first. A glucose of 48 requiring an ED visit is a foreseeable, potentially fatal event, and it is caused by a drug (glipizide) interacting with an unavoidable circumstance (no food at month's end). In an older adult with food insecurity, falls, and osteoarthritis, tight glycemic control has small benefit and large harm. Reduce or stop the sulfonylurea, individualize the target (roughly 8% for many patients in this situation), ensure she has a glucose source at home, and connect her to food resources before adjusting anything else.
- Regimen simplification and reconciliation. Duplicate metformin is a concrete, correctable error and a burden issue. Fewer pills, once-daily options, one consolidated list.
- Falls and function. Bathroom fall plus cane plus nocturia plus possible hypoglycemia-driven dizziness - ask about nighttime trips and vision.
- BP last. 158/88 matters, but not before she stops having near-fatal lows, and adding a drug she cannot afford would undermine the whole plan.
- Screen for depression. 'I feel fine' plus disengagement from care is worth a PHQ-2/9.
Justification to give her: 'The number I care least about right now is the A1c. The number I care most about is 48.'
2. How do you structure teaching and regimen simplification for a patient with low health literacy who 'feels fine'?
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One behavior per visit, with demonstration. Do not teach the whole regimen.
- Start with the thing that can kill her: recognizing and treating a low. Use the plain-language 15-15 rule - 15 grams of fast sugar, recheck in 15 minutes - then teach-back plus a return demonstration: 'Show me what you would do if you woke up at 3 a.m. shaky and sweaty.' Correct and re-demonstrate until she gets it.
- Plain words, no jargon: 'sugar' rather than 'glycemic,' 'low sugar' rather than 'hypoglycemia.' Large print, pictures, no written-only instruction - she reads at a fifth-grade level and may not read at all under stress.
- Use a physical tool she can operate: a pharmacy-filled, color-coded pillbox aligned to her actual day (she gets up early, eats at the neighbor's some days). Have her fill the next day's box in front of you.
- Anchor to her frame, not yours. 'Feeling fine' is real to her. Reframe: 'The medicine that makes you feel fine is the same one that put you in the ED because you had no food that week. I want you to keep feeling fine.'
- Simplify the regimen to match her life, not her life to the regimen.
3. How do you assess and act on social determinants, and how would you measure whether the plan is working?
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Screen with a structured tool (food insecurity, transportation, medication cost, housing, social isolation) rather than inferring from the shoebox.
Actions, in order of leverage:
- Food: refer to a food bank or produce prescription, help with SNAP enrollment, and time the conversation to the end of the month when the money runs out.
- Cost and access: generic or discounted pricing, 90-day supplies by mail if she can receive them, synchronized refills so she makes one trip, and an explicit cost conversation before any new drug.
- Transportation: verify whether telehealth is feasible (do not assume broadband - she may have only a landline), arrange phone check-ins, and confirm the neighbor's role only with her written permission.
- Do not build the plan on an unpaid neighbor; that relationship is fragile and not a clinical infrastructure.
Measures she helps define:
- Clinical/safety: no further glucose under 70, no ED visits, BP trend, no falls.
- Process: one reconciled medication list in the home, pillbox in use at a spot check, food resource connected.
- Patient-defined: her own goal (e.g., getting to church on Sunday) - the outcome that will actually sustain engagement.
Set follow-up sooner than usual (1–2 weeks, by phone if needed), because the risk is high and access is low.