Diabetes Management Of The Elderly - Research Paper Example

Is nutrition intervention an essential component to the management of diabetes in the elderly Introduction. Diabetes in the elderly Type 2 diabetes mellitus (DM) results from a progressive insulin secretion deficiency on the background of insulin resistance, and it is often associated with severe microvascular (retinopathy, nephropathy, and neuropathy) and cardiovascular complications. It is the most common form of diabetes in adults, accounting for 90-95 percent of diabetes cases. The disease has reached almost epidemic proportions in the United States, as well as in other Western countries, due to the increasing number of elders and the greater prevalence of obesity and sedentary lifestyle (American Diabetes Association, 2008). The prevalence of type 2 DM has nearly doubled over the past 25 years, with certain groups - native Americans, Hispanics, and African-Americans - at particularly high risk of developing the disease (HORNICK & ARON, 2008). Diabetes is the fifth leading cause of death by disease in the United States, killing approximately 225,000 people each year. The direct cost of diabetes is $92 billion a year, representing 11 percent of total health care expenditures in the U.S. (Hayashi, 2007). At least 20% of persons 65 years of age or above and 26% of long-term care facility residents have diabetes, and the annual cost of caring for the latter is estimated at $6 billion (American Diabetes Association, 2008) (Pandya, 2003). Older diabetics are two to three times more likely to need hospital admission than their non-diabetic counterparts (Damsgaard, Froland, & Green, 1987). An analysis of the 1999-2004 National Health and Nutrition Examination Survey (NHANES), including subjects over 65 y.o. and type 2 DM, found an alarmingly high prevalence of comorbid conditions in this population: 31.5% had renal insufficiency, 20.2% had a history of myocardial infarction, and 17.9% had heart failure (Suh, Kim, Choi, & Plauschinat, 2007). 2. Malnutrition in the elderly Physiologic and pathologic changes of ageing may concur to induce malnutrition. After the age of 65, weight loss occurs at rate of up to 0.65 kg/year (Lehmann & Bassey, 1996), although there is substantial variation between individuals. A decline in muscle mass begins from 30 to 40 years of age, and continues into advanced old age (Elia, 1992). Failure to thrive in the elderly was described as "a syndrome manifested by weight loss greater than 5% of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels." (Lonergan, 1991) It is estimated that 15 to 50 percent of Americans over the age of 65 consume too few calories, protein or essential vitamins and minerals for good health. (2007) The various causes of malnutrition can be summarized in a useful mnemonic "Meals On Wheels"(2007): Medications, including digoxin, diuretics, anti-inflammatory agents, antacids, H2-blockers, antidepressants, anticonvulsants etc, which may induce side effects like anorexia, nausea, vomiting, diarrhea, cognitive disturbance and increased metabolism, Emotional problems, such as depression, Anorexia (loss of appetite), commonly due to age-related changes in taste and smell, Late-life paranoia, Swallowing problems (dysphagia), that may arise from poor teeth, ill-fitting dentures, gastroesophageal reflux disease, stroke, Parkinson's disease, or throat tumors, Oral factors, like tooth loss and periodontal disease, Neoplasia, Wandering, in the setting of Alzheimer's disease and other forms of dementia, which are often associated with poor feeding, Hypermetabolic disorders, Enteric problems or malabsorption, Eating difficulties, because of impaired vision, disturbed motor function, or physical disabilities like arthritis or Parkinson's disease, Low-salt and low-cholesterol diets, often resulting in reduced intake due to poor taste, Social problems, including poverty, lack of care, and poor living conditions. There are severals methods that can be used to evaluate the nutritional status in the elderly. The Mini Nutritional Assessment (MNA) (Guigoz, Vellas, & Garry, 1996) is a validated tool that may be used to identify malnutrition. However, a more commonly used instrument in the outpatient and home care setting is the Determine Your Health Checklist (de Groot, Beck, Schroll, & van Staveren, 1998). Other largely used methods are the Subjective Global Assessment (Sacks et al., 2000) and the Malnutrition Universal Screening Tool (Stratton, King, Stroud, Jackson, & Elia, 2007). The prevalence of malnutrition varies from 5-12% in community-dwelling older persons, to 30-61% of hospitalized older persons, and to 40-85% of those in long-term care facilities.(Thomas, 1999) Malnutrition can lead to many physiological disorders: (2007; Dorner, 2007) weight loss; muscle wasting resulting in weakness, loss of mobility, decreased independence, and falls; slower recovery from acute illness, a tendency toward poor healing, pressure ulcers, and anemia; immune system impairment and higher risk of infection; effects on the gastrointestinal tract, with diminished secretions and malabsorption. These can contribute to progressive decline in health, reduced physical and cognitive functional status, increased need for health care services, premature institutionalization, and higher mortality. In one study, a weight loss of 5% or more was associated with a 67% increase in the risk of death (Newman et al., 2001). 3. Diabetes and malnutrition - an uncommon combination Although type 2 DM in younger individuals is usually associated with obesity and with the metabolic syndrome, little is known about the nutritional status of older diabetics. However, it has been demonstrated that the prevalence of obesity and the association between obesity and the incidence of diabetes both decrease with age. The prevalence of the metabolic syndrome in younger type2 diabetic adults reaches >80%, but only 40% in older diabetics, and this is mainly due to the low prevalence of obesity and dyslipidemia (Bonin-Guillaume et al., 2006). In addition to the previously mentioned general causes, the presence of diabetes may contribute to malnutrition by association with several specific risk factors, such as: poorly controlled hyperglycemia (American Diabetes Association, 2006); multiple dietary restrictions (Fonseca & Wall, 1995); appetite suppression by oral glucose-lowering agents, like metformin (Lee & Morley, 1998); diabetes-associated gastrointestinal disorders (gastroparesis, diarrhea, constipation) (Nompleggi, Bell, Blackburn, & Bistrian, 1989); periodontal disease and other oral complications of diabetes (infection, dry mouth, dental caries etc) (Southerland, Taylor, & Offenbacher, 2005); inadequate food preparation, due to poor eyesight (from diabetic retinopathy), and inadequate motor and cognitive functions (from cerebrovascular disease) (Thomas, 1999); infections (Scrimshaw & SanGiovanni, 1997); diabetic renal disease (Pupim, Cuppari, & Ikizler, 2002). British researchers found that 52% of diabetic residents from nursing homes had a lower daily energy intake than currently recommended (Benbow, Hoyte, & Gill, 2001). In a case-controlled study including community-dwelling volunteers over the age of 65, with DM vs no DM, the diabetes group scored significantly lower on the MNA and had significantly lower albumin scores when compared with the control group (Turnbull & Sinclair, 2002). 4. General principles of medical nutrition therapy (MNT) in diabetes In all diabetic individuals, regardless of age or comorbidities, the goals of MNT, according to the American Diabetes Association (ADA) (Bantle et al., 2008), are the following: 1) To achieve and maintain blood glucose levels in the normal range or as close to normal as is safely possible, a lipid and lipoprotein profile that reduces the risk for vascular disease, blood pressure levels in the normal range or as close to normal as is safely possible; 2) To prevent or, at least, to slow the rate of development of the chronic complications of diabetes, by modifying nutrient intake and lifestyle; 3) To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change; 4) To maintain the pleasure of eating, by only limiting food choices when indicated by scientific evidence. ADA recommendations for controlling diabetes (secondary prevention) (Bantle et al., 2008): Carbohydrate A dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health. (level of evidence B) Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation, remains a key strategy in achieving glycemic control. (A) Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose-lowering medications. (A) As for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods. (B) Sugar alcohols and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the FDA. (A) Fat and cholesterol Limit saturated fat to Read More