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Part II Nutrition Assessment, Consequences, and Implications

TABLE 13.1 Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults with Diabetes

Patient Characteristics

Healthy (few coexisting chronic illnesses, intact cognitive and functional status)

Complex/intermediate (multiple coexisting chronic illnesses or mild to moderate cognitive impairment)

Very complex/poor health (long-term care or end- stage chronic illnesses or moderate to severe

cognitive impairment or 2+ activities of daily living dependencies)

Reasonable HbA1c Goala

< 7.5%

Fasting or Preprandial Glucose (mg/dL)

90–130

Bedtime Glucose (mg/dL)

90–150

Blood Pressure (mm Hg)

< 140/90

Lipids

Statin unless contraindicated or not tolerated

< 8% 90–150 100–180 < 140/90

Statin unless contraindicated or not tolerated

< 8.5% 100–180 110–200 < 150/90

Consider likelihood of benefit with statin (secondary

prevention more than primary)

a A lower goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.

Source: Adapted with permission from American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2015;38(suppl 1):S67-S69.

DIABETES NUTRITION THERAPY Medical nutrition therapy (MNT) has been documented to be beneficial in older adults with diabetes and plays a critical role in diabetes management (8). Though energy needs decline with age, micronutrient needs are similar throughout adulthood. Meeting micronutrient needs with lower caloric intake is challenging; there- fore, older adults with diabetes are at higher risk for nutritional deficiencies (3). Overly restrictive eating patterns, either self-imposed or provider-directed, may contribute to the risk for undernutrition. Although individualization of MNT is essential for all individuals with diabetes (9), individualization takes on added importance for older adults with diabe- tes. Nutrition therapy interventions must consider the individual’s culture, preferences, support systems, per- sonal goals, and, perhaps most importantly, willingness and ability to make lifestyle changes. For nutritionally vulnerable older adults, identifying community resources such as Meals on Wheels, senior centers, and the US Department of Agriculture’s Older Americans Nutrition Program may help maintain independent living status (3).

The nutrient needs of the older adult with diabetes should first be met when developing a healthful eating plan. The Dietary Reference Intake (DRI) for older adults specifies nutrient needs for adults 51 to 70 years and needs for those above 70 years (10). Although overweight and obesity may be prevalent among older adults, unintentional weight loss in the older adult has been shown to increase morbidity and mortality (11). Intentional weight loss in overweight and obese older adults can potentially worsen sarcopenia, bone mineral density, and nutrition deficits (12,13). Therefore, weight loss and caloric restriction are not encouraged in older adults with diabetes and should only be con- sidered and implemented with caution (4). Any nutritional intervention must start with a thor- ough assessment that includes a clinical and nutritional history and a psychosocial and environmental evalua- tion. The Mini Nutritional Assessment (MNA), specifi- cally designed for older adults, is a validated nutrition screening tool for adults 65 and older (www.mna-el- derly.com/). It is completed by the adult and identifies older adults who are malnourished or at risk of malnu- trition and require further assessment.