Volume 13 Number 3, 2000, Page 149
Carbohydrate Counting: A Return to Basics
Carbohydrate Counting for Older Patients
Susan Saffel-Shrier, MS, RD, CD, Certified Gerontologist
Aging is associated with a decrease in glucose tolerance, which has been estimated to occur in >60% of adults over age 60. This condition is thought to be the result of decreased insulin sensitivity and impaired pancreatic -cell function.1 Increased body mass and adiposity with a decrease in physical activity are factors in the onset of the hyperglycemia of aging.2 The normal aging process is thought to be responsible for 20% of the hyperglycemia of aging.3
Diabetes occurs in ~20% of the population over age 65, with 50% of all people with diabetes being over 60 years of age.4 The prevalence of diabetes in individuals over 80 years old has been suggested to be as high as 40%.
Diabetes accelerates the aging process such that older people with diabetes are on average 10 years older than their chronological age. Morbidity and mortality has been demonstrated to increase in the older diabetic population due to renal disease, vision loss, peripheral vascular disease, and coronary artery disease.5 In addition, functional impairments in all dimensionsphysical, emotional, cognitive, and socialmore adversely affect older people with diabetes. These individuals have also been shown to have a more rapid decline in functional status than age-matched people without diabetes.6 Impaired functional status is both a risk factor and indicator of poor nutritional status.
Although the data are limited regarding the long-term benefits of glycemic control in older people with type 2 diabetes, acute control of hyperglycemia does reduce morbidity and increase quality of life.5,7 The American Diabetes Association has published a position statement supporting glycemic control for people with type 2 diabetes.8
Functional assessment evaluates disabilities in physical, mental, and social status and can provide guidance in determining patients' abilities to understand and practice carbohydrate counting. Geriatric specialists use a variety of tools to assess functional status, including Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Geriatric Depression Scale (GDS), and the Mini Mental State Examination (MMSE).9,10 However, the administration of these tools can be time consuming and may result in limiting time to address specific nutrition issues.
Using a functional screen can streamline patient-provider encounters. Figure 1 shows one functional status screening tool. The screening tool asks questions indicative of a high level of function (low levels of disabilities) to determine if a complete assessment tool is needed.
For example, shopping (Fig. 1, item 2) is the most difficult task of the IADL. Asking patients if they can go shopping independently can reveal potential compliance obstacles for a prescribed meal plan. Lack of access to adequate and appropriate food is a common underlying theme among the older population. If a meal plan includes several servings or grams of carbohydrate from fresh fruit and vegetables daily and the patient only has an opportunity to shop once a month, the recommendation is counterproductive. If a patient cannot shop, this indicates the need for the full IADL assessment.
Screening for depression (item 18) and cognition (items 8 and 9) is important because this diagnosis can be detrimental to the success of medical nutrition therapy (MNT). People with diabetes have been found to be at higher risk for depression with subsequent major functional impairments.11,12 Depression in older patients most commonly results in poor appetite, skipped meals, and weight loss. Cognitive losses may not be apparent in the early stages of dementia, and caregivers develop compensatory mechanisms to mask deficits.
Some questions on the screening tool do directly correspond to specific assessment tools but still furnish valuable information about functional status. Mobility (item 3), balance (item 4), falls (item 5), and vision problems (item 11), for example, can be translated to difficulty in food acquisition, preparation, and eating skills. These, in turn, can be further translated into difficulties in measuring portion size and counting carbohydrate grams. It is important to first assess patients' status and then note any assistance provided by caregivers. If functional status is poor, instruction should include caregivers. Individual patient encounters will determine the need for a full or partial screen. It should be noted that even the most experienced provider can be surprised at the results of this screen. The full screen should be performed via direct questioning or observation and completed at future visits.
Portion size determination, an integral part of carbohydrate counting, can be quite challenging when interviewing older patients. Providers must be very thorough and should use visual aids, such as food models and measuring tools, to help determine actual amounts consumed. Several age-related traits can impede the accuracy of portion size estimates. These include:
Food records provide data that set the stage for carbohydrate counting and a discussion of healthy eating. This, in turn, should lead to reviewing the adequacy of patients' diet and assessment of possible dietary deficiencies. It is also advantageous to discuss disease prevention applicable to aging and diabetes, such as osteoporosis and heart disease. Care providers in our clinic routinely order laboratory determination of vitamin B12, RBC folate, homocysteine, and vitamin D blood levels because deficiencies in these nutrients are common among older people.
A.C. was diagnosed with type 2 diabetes 20 years ago and does not recall receiving any diabetes education. Her fasting blood glucose levels, performed in her physician's office, are between 200 and 250 mg/dl. Her most recent HbA1c is 10.5%. She does not check her blood glucose because, she says, her meter is broken. Her medications include glyburide, 10 mg twice daily; hydrochlothiazide, 50 mg every morning; verapamil SR, 240 mg every morning; and doxazosin mesylate, 8 mg every evening. She takes a vitamin B6 supplement, 25 mg daily.
The functional screening and nutrition assessment results for A.C. and J.P. are shown in Tables 1 and 2.
Using servings rather than actual carbohydrate-gram counting is also important for older people with cognitive impairments. As can be seen from the 24-hour recalls of the patients in Case #1 and Case #2, distribution of carbohydrates is a major concern, as well as food choices and appropriate number of food group servings. The following points can assist providers in educating older patients and developing a meal plan:
Determining kilocalorie and carbohydrate needs for older patients can be difficult due to loss of lean body mass (from both the aging process and a sedentary lifestyle), lack of anthropometric data for this population, and inaccurate estimates of physical activity on the part of these patients. Tailoring kilocalorie and carbohydrate requirements from current food records, weight, height, and BMI can ease the initial determination.
Future visits can present an opportune time to discuss an exercise program that includes strength training. Aerobic exercise has been found to increase insulin-mediated glucose disposal and decrease insulin responses in older men.14 Sarcopenia occurs with age mainly due to inactivity. Strength training increases lean body mass and can assist in reducing upper body fat, leading to improved glucose tolerance.15 In addition, a recent study suggests that physical activity is important for type 2 diabetes prevention among older women.16 Patients can be referred to physical therapy for reconditioning if there are problems with balance or lower body strength.
Application and Care Plan
Improved glucose control, facilitated by a meal plan emphasizing appropriate carbohydrate distribution via the food groups, may help to resolve her impaired cognition and dizziness. Currently, her problems with cognition and dizziness have dictated her food choices and carbohydrate distribution towards shelf-stable and restaurant-prepared foods. With an improvement in cognition, carbohydrate distribution at breakfast and lunch could be balanced. This can be accomplished through diabetes teaching emphasizing carbohydrate distribution via the food groups and restaurant strategies.
Because older people typically find restaurant meals too large to consume in one sitting, suggesting that A.C. eat half-portions of these meals and take leftovers home can also help in the distribution of carbohydrate. She can eat the other half of the restaurant meal on a day she does not go out. This suggestion also appeals to patients on a fixed income.
An aerobic and strength training exercise program with the goal of a 510 lb weight loss and increase in lean body mass should be incorporated into the goals and care plan.
The functional and nutritional data in Case #2 indicate that the main limiting factors for J.P. are access to food and cognitive deficits. The functional data results prompted doing a fingerstick blood glucose, which was 353 mg/dl. Additional laboratory orders were for glucose and HbA1c determinations.
Before any carbohydrate counting goals can be accomplished, improved food availability must occur. Coordination of senior services, such as shopping assistance and home- delivered meals for J.P. and his wife, should be pursued in conjunction with home health care assistance for diabetes care and meal preparation.
Because J.P. has multiple cognitive deficits, nutrition education should be directed toward his wife. Food groups should first be introduced and, depending on her abilities, followed with carbohydrate counting. J.P.'s enjoyment of sweets and lack of ability to understand restrictions would suggest including these foods as snacks. His weight loss supports a need for investigating malnutrition and protein status. Healthful eating for diabetic patients should be introduced in stages with consistent follow-up on carbohydrate distribution techniques.
2Morley JE, Mooradian AD, Rosenthal MJ, Kaiser FE: Diabetes in elderly patients: is it different? Am J Med 83:533-44, 1987.
3Zavoroni I, Dall'Aglio E, Bruschi F, Bonora E, Allpi O, Pezzarossa A, Bullurini U: Effect of age and environmental factors on glucose tolerance and insulin secretion in a worker population. J Am Geriatr Soc 34:271-78, 1986.
4Mooradian AD, McLaughlin S, Boyer CC, Winter J: Diabetes care for older adults. Diabetes Spectrum 12:70-77, 1999.
5Morley, JE: An overview of diabetes mellitus in older persons. Clin Geriatr Med 15:211-24, 1999.
6O'Connor PJ, Jacobson AM: Functional status measurement in elderly diabetic patients. Clin Geriatr Med 6:865-82, 1990.
7Fonseca V, Wall J: Diet and diabetes in the elderly. Clin Geriatr Med 11:613-24, 1995.
8American Diabetes Association: Position statement: Implications of the Diabetes Control and Complications Trial. Diabetes Care 23 (Suppl 1): S24-26, 2000.
9Katz S, Downs TD, Cash HR: Progress in the development of the index of ADL. Gerontologist 10:20-30, 1970.
10Lawton MP, Brody EM: Assessment of older people: self-monitoring and instrumental activities of daily living. Gerontologist 9:179-86, 1969.
11Peyrot M, Rubin RR: Levels of risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care 20:585-90, 1997.
12Steward AL, Greenfield S, Hayes RD: Functional status and well-being of patients with chronic conditions: results from the Medical Outcome Study. JAMA 262:907-13, 1989.
13American Diabetes Association, The American Dietetic Association: The First Step in Diabetes Meal Planning. Alexandria, Va., Chicago, American Diabetes Association, The American Dietetic Association, 1995.
14Dengel DR, Pratley RE, Hagberg JM, Rogus EM, Goldberg AP: Distinct effects of aerobic exercise training and weight loss on glucose homeostasis in obese sedentary men. J Appl Physiol 81:318-35, 1996.
15Kotz CM, Billington CJ, Levine AS: Obesity and aging. Clin Geriatr Med 15:391-412, 1999.
16Folsom AR, Kushi LH, Hong CP: Physical activity and incident diabetes mellitus in postmenopausal women. Am J Public Health 90:134-38, 2000.
Susan Saffel-Shrier, MS, RD, CD, Certified Gerontologist, is an assistant professor in the Department of Family and Preventive Medicine at the University of Utah School of Medicine. She is the director of the Geriatric Clinic for the Department's Family Practice Residency Program.
Copyright © 2000 American Diabetes Association
Last updated: 9/00