Melanie Meachum, MS, RD, LD Nutrition Consultant, Diabetes Section Arkansas Department of Health

1. Diabetes Management in the Older Population31st Arkansas Aging ConferenceOctober 28, 2011 Hot Springs Convention Center Melanie Meachum, MS, RD, LD Nutrition Consultant, Diabetes Section Arkansas Department of Health Diabetes Prevention and Control Program Chronic Disease Branch

2. Objectives • Provide an overview of diabetes. • Describe common barriers to diabetes control in older adults and provide suggestions for coping with barriers. • Review evidence based recommendations for diabetes target control goals. • Recognize healthy food choices to help control diabetes. • Discuss resources available for diabetes management.

3. Introduction • Diabetes is a chronic disease that affects millions of Americans every year. • There is no known cure for diabetes, but there are several treatments which can control the disease. • The treatment and management of diabetes varies from patient to patient. • The doctor and diabetic care team should work with the patient to decide what form of treatment is best.

4. Facts on Diabetes, United States • Diabetes affects 25.8 million people. • 8.3% of the U.S. population. • Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults in the United States. • Diabetes is a major cause of heart disease and stroke. • Diabetes is the seventh leading cause of death in the United States.

5. Estimated Prevalence of Adults Diagnosed with Diabetes, United States 2010

6. Estimated percentage of people aged 20 years or older with diagnosed and undiagnosed diabetes, by age group, United States, 2005–2008

7. Diagnosed and Undiagnosed Diabetes among People Ages 20 Years or Older, United States, 2010

8. Estimated number of new cases of diagnosed diabetes among people aged 20 years or older, United States, 2010 About 1.9 million people aged 20 years or older were newly diagnosed with diabetes in 2010.

9. Diabetes in Arkansas • For the past 15 years, Arkansas has been at or above the national average for prevalence of diabetes. • From 1999 to 2010, there was a 45% increase in the diabetes prevalence rate. • The prevalence of diabetes increases with age. • Persons over the age of 45, have a four times greater prevalence than that among younger persons. • Diabetes was the 6th leading cause of death among all Arkansans in 2007.

10. Prevalence of Diabetes in Arkansas • An estimated 210,000 Arkansas adults were diagnosed with diabetes in 2010. • It was projected that another 105,000 adults living with diabetes were undiagnosed. • An estimated 315,000 adults in the state were affected by diagnosed and undiagnosed diabetes.

11. Percentage of Adults with Diabetes,Arkansas 2010

12. Diabetes Prevalence by Age Group Arkansas, 2010 • Diabetes prevalence increases with age. • The prevalence nearly doubles at every age interval before reaching 65 and over. • The highest prevalence of diabetes was found among adults 65 years of age or older.

13. Age-Adjusted Diabetes Mortality Rate The diabetes mortality rate in Arkansas has increased over the past decade from 23.2 per 100,000 in 1998 to 26.5 per 100,000 in 2007, 14% increase.

14. Prediabetes • Prediabetes is a condition that occurs when a person’s blood glucose levels are high, but not high enough for a diagnosis of diabetes. • People with prediabetes have a higher risk of developing type 2 diabetes, heart disease, and stroke. • In 2005−2008, 35% of U.S. adults aged 20 years or older had prediabetes. • 50% of those were age 65 years or older. • In 2010, an estimated 79 million Americans aged 20 years or older had prediabetes.

15. Diabetes Mellitus • Diabetes is a chronic disease marked by high levels of blood glucose resulting from defects in the insulin production, insulin action, or both. • Insulin is needed to convert sugar, starches and other food into energy the body needs for daily life. • Diabetes can lead to many serious complications including heart disease, blindness, kidney failure, lower extremity amputations, and death.

16. Types of Diabetes • Type 1 Diabetes: • Develops when the body’s immune system destroys pancreatic beta cells. • Accounts for 5-10% of all diagnosed cases of diabetes. • Type 2 Diabetes: • Begins as insulin resistance when the cells do not use insulin properly. The pancreas gradually loses the ability to produce insulin as the need for insulin rises. • Accounts for 90-95% of all diagnosed cases of diabetes. • Gestational Diabetes: • A form of glucose intolerance that develops during pregnancy.

17. Who is at Risk for Type 2 Diabetes? • People with impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG). • People over age 45. • People with a family history of diabetes. • People who are overweight. • People who do not exercise regularly. • People with high blood pressure, low high-density lipoprotein (HDL) cholesterol or high triglycerides. • Certain racial and ethnic groups (e.g., Non-Hispanic Blacks, Hispanic/Latino Americans, Asian Americans and Pacific Islanders, and American Indians and Alaska Natives). • Women who had gestational diabetes, or who have had a baby weighing 9 pounds or more at birth.

18. Signs and Symptoms of Diabetes • Excessive urination • Unusual thirst • Frequent infections • Tiredness/Drowsiness • Unusual weight loss • Blurred vision • Extreme hunger • Cuts/bruises that are slow to heal • Tingling/numbness of the hands and feet

19. Morbidity/Complications • Diabetes can cause serious complications like: • Heart disease • Kidney disease • Eye disease • Foot problems • Dental disease • Pregnancy related complications • Diabetic ketoacidosis

20. Economic Impact • The costs due to diabetes include: • Direct medical costs: • Physician visits • Hospitalizations • Pharmacy charges • Indirect medical costs: • Lost days of work • Disability • Premature deaths • The American Diabetes Association (ADA) estimates that the national costs of diabetes exceed $174 billion.

22. Who is considered elderly? • “Young old” 65-75 years • “Old, old” >75 years

23. Common Barriers to Diabetes Control in Older Adults • Taste changes • Dentition, chewing, swallowing issues • Appetite changes • Decreased physical activity • Cognitive changes • Food safety concerns • Food preparation for 1-2 people

24. Common Barriers (cont.) • Changes in taste and smell can get in the way of good nutrition. • Taste and smell tend to decline with age. • Many medications can also affect taste. • Metabolism slows with age. • People on limited budgets might have trouble affording a balanced, healthy diet. • Aging is usually associated with a steady decline in muscle strength and muscle mass, which may result in reduced functional capacity, physical frailty and impaired mobility.

25. Suggestions for Coping with Barriers • Serve foods with a variety of flavors, colors, shapes, textures, and temperatures to increase appetite. • Try using herbs and spices to increase the flavor of foods. • Consider attending nutrition programs for the elderly. • Choose “nutrient-dense” foods, such as milk, eggs, legumes, lean meat, fish or poultry. • Encourage foods containing calcium, fiber, iron, protein and vitamins A, C, and D, which become more important as we age. • Flavors are reduced in very cold and very hot foods.

26. Physical Activity • Physical Activity can help diabetic patients in many ways: • It helps lower glucose levels, maintain a healthy heart, relieve stress, and improve strength, flexibility, and balance. • Set small goals to start. Add a little more activity each day until reaching a minimum of 30 minutes a day, most days a week. • Make activity a daily part of life.

28. Treatment Goals: The ABCs of Diabetes

29. A is for A1c (Hemoglobin A1c) • An A1c test is a lab test that reflects the average blood glucose level over the past 3 months. • The higher the amount of glucose in the blood, the higher the A1c result will be. • Perform an A1c test at least twice a year in patients who are meeting treatment goals. • Treatment Goal: • <7% for most adults

30. B is for Blood Pressure (mmHg) • High blood pressure makes the heart work too hard. • Blood pressure should be checked at each doctor’s visit. • Treatment Goal: • Systolic <130 • Diastolic <80

31. C is for Cholesterol (mg/dl) • Bad cholesterol, or LDL, builds up and clogs arteries. • Cholesterol should be checked at least once a year. • Treatment Goal: • Low-Density Lipoprotein (LDL) Cholesterol <100 • High-Density Lipoprotein (HDL) Cholesterol— Men >40, Women >50 • Triglycerides <150

32. Checking Blood Glucose • Checking blood glucose helps to monitor the effectiveness of one’s diabetes management. • A blood glucose meter and lancing device are needed to check blood glucose. • Patient’s blood glucose targets should be set with the health care team. • The target range for most people is: • Before meals: 70 to 130. • 1 to 2 hours after meals: below 180. • Document blood glucose numbers in a log. • Show log to health care team at every visit.

33. What can raise or lower blood glucose levels? Blood glucose may get too high if one: Blood glucose may get too low if one: Eats less than usual Delays or skip a meal Exercises more than normal Takes too much insulin or other diabetes medication • Eats more than usual • Eats foods high in sugar • Exercises less than normal • Has a lot of stress • Has an infection or other illness • Takes certain medicines • Does not take enough insulin or other diabetes medication

35. Goals for Individualized Nutrition Education for Older Adults with Diabetes • Avoidance of hypoglycemia: • Regular meal times. • Consistent carbohydrate intake at meals and snacks. • Available treatment for hypoglycemia at all times. • Consumption of a healthy diet/blood lipid management: • Three meals daily. • Lean meat, fish, poultry, or legumes every day. • At least one serving of low-fat dairy products a day. • At least two servings of fruits and vegetables a day. • Six or more cups of fluids a day. • Maintenance of a reasonable weight: • Social meal times. • Smaller portions if consuming high-fat or high-carbohydrate foods.

36. Meal Planning:What Can I Eat? • Carb Counting • Plate Method (Portion Control) • Food Label Reading • Healthy Meal Planning

37. Carb Counting • Everyone needs different amounts of carbohydrates, depending on factors such as height, weight, age, activity level, medications, and weight loss goals. • A general guideline is: • Women: 45-60 carb grams per meal (3-4 carb choices) • Men: 60-75 carb grams per meal (4-5 carb choices) • 15-30 carb grams per snack (1-2 carb choices)

38. Plate Method • To create balanced meals that stay within recommended carb and calorie allowances, let a 9-inch plate be the guide. • The Plate Method: • Fill 1/2 of the plate with 2 servings of nonstarchy vegetables. • Fill 1/4 of the plate with lean meat (3 ounces cooked) or other high-protein food. • Fill 1/4 of the plate with a starchy vegetable or whole grain serving. • Include a serving of fruit and/or dairy.

39. Nutrition Facts Label

40. Food Label Reading • Use the nutrition facts label to eat healthier: • Check the serving size and number of servings. • Calories count, so pay attention to the amount. • Look for foods that are rich in nutrients: Vitamins A and C, potassium, calcium, and iron. • Know your fats and reduce sodium for your health. • Reach for healthy, wholesome carbohydrates. • For protein, choose foods that are lower in fat. • The % Daily Value is a key to a balanced diet.

41. Healthy Meal Planning • Consume at least half of all grains as whole grains. • Eat 5 or more servings of fruits and vegetables. • Choose low-fat or fat free milk. • Vary protein sources. • Limit fat, salt (sodium), added sugars, and alcohol.

43. Diabetes Self Management Education (DSME) • Diabetes self-management education (DSME) is an important part of diabetes care “for all individuals with diabetes who want to achieve successful health-related outcomes,” regardless of their age. • The goal of DSME is to allow patients to obtain better diabetes management. • Both the American Association of Diabetes Educators (AADE) and the American Geriatric Society (AGS) guidelines understand that the care of older adults with diabetes is complicated by their clinical and functional differences.

44. DSME Sites in Arkansas, 2008

45. Guiding Principles for DSME for Older Adults • Individualize Diabetes Self Management Education (DSME): • Consider clinical and functional variables. • Consider personal preferences. • Weigh potential benefits versus potential risks: • Consider quality of life. • Consider life expectancy. • Involve multiple disciplines as needed. • Involve care partner as needed.

46. DSME for Older Adults with Physical Limitations or Cognitive Dysfunction • Monitoring • Insulin • Medications • Hyperglycemia • Hypoglycemia • General adaptation of educational materials

47. Monitoring • Use meters with the following features: • Large display windows with bold numbering. • Easy to hold. • No coding or handling of strips.

48. Insulin • Simplify the insulin regimen. • Consider changing to an insulin pen or use prefilled syringes. • Involve the caregiver if available. • Use syringe magnifiers if pens are not an option. • Discuss with the patient’s health care provider whether discontinuing insulin is an option.

49. Medications • Make sure the medication list is accurate. • Ask patients to bring their pill bottles with them to visits and have them read the pill bottle instructions aloud. • Use memory aids for taking medications. • Involve a family member or friend if available. • Make sure patients understand why they are taking each pill. • Refer to a visiting nurse if needed. • Discuss simplifying the regimen with the provider.

50. Hyperglycemia and Hypoglycemia Hyperglycemia Hypoglycemia Avoid hypoglycemia among frail elders. Emphasize recognition of symptoms, such as dizziness, weakness, and confusion. Emphasize importance of monitoring particularly before driving. Do not rely on patient reports alone to determine whether low blood glucose episodes are occurring. • May have less polyuria(excessive volume of urination) and less polydipsia (excessive thirst). • Emphasize need for regular hydration and increased monitoring, particularly on sick days. • Give very specific guidelines of when to call the health care provider.