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Part II Nutrition Assessment, Consequences, and Implications

multivitamin supplement may be appropriate for older adults, especially those with reduced energy intake. There is also insufficient evidence to support the routine use of micronutrients such as chromium, mag- nesium, and vitamin D as well as the use of cinnamon or other herb/supplements for the treatment of diabetes (9).

Alcohol

Because of reduced alcohol tolerance with age, alcohol ingestion by older adults should be examined carefully. Just as for the general public, individuals with diabetes who choose to drink alcohol should limit their intake to one drink per day or less for women and two drinks per day or less for men (9). When light to moderate amounts of alcohol are consumed with food, blood glucose and insulin levels are not affected (18). For individuals using insulin or insulin secretagogues, alcohol should be consumed with food to prevent hypoglycemia. Alcoholic beverages should be consid- ered an addition to the regular eating plan for all those with diabetes. No food should be omitted.

Special Considerations

for Type 2 Diabetes Previously, nutrition advice focused on losing weight and avoiding sugars. However, current nutrition therapy focuses on lifestyle strategies that will improve control of hyperglycemia, dyslipidemia, and hypertension. Because many persons with type 2 dia- betes are insulin resistant and overweight or obese, nutrition therapy often begins with lifestyle strategies that focus on a nutrient-dense eating pattern with a reduced energy intake, increased energy expenditure through physical activity, and education and support. A healthy eating pattern and improved glycemia are the goals, not weight loss.

Special Considerations for Insulin-Treated Diabetes

If insulin is needed, the eating plan should be based on the individual’s appetite, preferred foods, and usual schedule of meals and physical activity. After an eating plan is agreed on, insulin therapy can be inte- grated into the usual food and physical activity sched- ules. Intensive or physiological insulin regimens, consisting of basal (background) insulin and bolus (premeal, rapid-acting) insulin or insulin pump therapy, provide increased flexibility in timing and fre- quency of meals, amount of carbohydrate eaten at meals, and timing of physical activity. Carbohydrate is the nutrient that most affects postprandial glucose and is the major determinant of the bolus (premeal) insulin doses. By knowing the amount of carbohydrate and

MEAL-PLANNING OPTIONS IN

NURSING FACILITIES It is estimated that 25% of long-term care nursing facil- ity residents have diagnosed diabetes. Many older adults with diabetes requiring long-term care have mul- tiple comorbidities and diabetes-related complications, and delivery of diabetes nutrition interventions is chal- lenging. Changes in care emphasize improved quality of life. Increased awareness for the need to individual- ize and liberalize diets to enhance enjoyment of food, allow for personal food preferences, and improve dining experience has been an important part of these culture change initiatives. Specialized diabetic diets have not been shown to be beneficial in such settings (19). Therefore, the imposition of dietary restrictions on older, diabetic residents in nursing facilities is not warranted (19,20). There is absolutely no evidence to support the prescribing of diets such as “no concen- trated sweets” or “no sugar added,” which are often served to older adults in nursing facilities. Residents with diabetes should be offered a regular (unrestricted) menu, with consistent amounts of carbohydrates offered at meals and snacks. It is usually preferable to make medication changes to control blood glucose than to implement food restrictions.

PHYSICAL ACTIVITY

Diabetes education of older adults must include encouragement for physical activity to the limit of ability. Regular participation in physical activity, pref- erably in a variety of forms, will improve not only car- diorespiratory status but also diabetes control (21). Suggestions for increasing physical activity should be individualized according to the person’s interests, resources, and abilities. Regular activity programs should start slowly and gradually increase in intensity and duration with time. However, even patients with poorer health status benefit from modest increases in physical activity (3).

DRUG THERAPY OPTIONS As the disease process of diabetes progresses, it usually becomes necessary to combine glucose-lowering medi- cations with MNT. Blood glucose data and HbA1c values are used to determine when therapy needs to be

the amount of insulin needed to cover it, an insu- lin-to-carbohydrate ratio can be determined. Adjustments in bolus insulin doses can then be made for alterations from the usual amount of carbohydrate ingested at meals (9). For individuals not self-adjust- ing their insulin doses, consistency in the day-to-day carbohydrate content of meals, as well as timing of meals, is important.