Diabetes Spectrum
Volume 13 Number 3, 2000, Page 149
From Research to Practice/ Medical Nutrition Therapy

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 beta.gif (968 bytes)-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 dimensions—physical, emotional, cognitive, and social—more 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

Population Description
This article focuses on a population of older people receiving care through a university medical center family practice network, which includes community-based clinics involved in family practice residency training. Approximately 85% of the diabetic patients seen in this setting are over age 60 and have a diagnosis of type 2 diabetes with a treatment regimen of diet, exercise, and oral hypoglycemic medications. Medicare is the only insurance of ~85% of the older patients. The author has established both a nutrition clinic and a geriatric clinic.

Functional Assessment
A meal plan based on carbohydrate counting can be an integral part of improving glycemic control. However, patients' functional status should be assessed to identify conditions that might impede carbohydrate counting. Due to the heterogeneity of the older population and accelerated aging process in diabetes, age alone is not indicative of functional status. At any particular age, older people can differ greatly in every aspect of the bio-psycho-social schematic. A thorough investigation of functional status can eliminate possible noncompliance issues related to carbohydrate counting.

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.

pg159 fig1.gif (114066 bytes)
Figure 1. Functional status screening tool. Copyright Susan Saffel-Shrier. Reprinted with permission.

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.

Nutrition Assessment
Whenever possible, patients should be asked to complete a 3-day food record before their the first visit. Reviewing a food record can provide quick information on patients' current distribution of carbohydrate that will usually complement the functional status results. Such dietary information includes consumption of fresh foods, frequency of food shopping, cooking ability, and food budget. Food records typically provide more accurate information than a 24-hour recall, especially if the food is recorded when the food is consumed. Food records help to alleviate concerns about possible memory deficit, which are common among older people. If a food record is not available, obtain a 24-hour recall.

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:

  • Overestimation of the adequacy of the diet due to gradual decreases in intake.
  • Fear of losing independence leading to overcompensating when stating amount or types of food eaten. For example, a patient suggests that certain foods or recipes involving advanced culinary skills or appliances are used regularly.
  • Memory impairment.
  • Generalization of responses, such as "We have enough food."
  • Preference for grazing or eating multiple small meals.

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.

Case #1
A.C. is an 80-year-old Italian woman referred to the nutrition clinic from another university clinic for diabetes education. She is 64 inches tall, weighs 157 lb, and has a body mass index (BMI) of 33. She has also been diagnosed with hypertension. She has not completed a food record.

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.

Case #2
J.P. is a 67-year-old man who wanted to establish care at the geriatric clinic. The geriatric team consists of a geriatrician, a nutritionist, and a pharmacist. At 71 inches tall and weighing 181 lb (BMI 25), he has been the main caregiver to his wife for the past 8 years and has not seen a physician during that time. His chief complaint is falling. He was not prescribed any medications.

Table 1. Functional Screening Results

Case #1

Case #2

  • Restricted shopping due to vision loss
  • Dizziness but no falls
  • Failed clock drawing
  • Hearing deficit more pronounced in right ear
  • Risk of depression; patient states she has a strong support group of widows
  • Registers 1 in 3 memory items
  • Sentence incomplete
  • Failed clock drawing
  • Frequent falls
  • 15-lb weight loss in 8–10 months
  • No incontinence but polyuria and polydipsia

The functional screening and nutrition assessment results for A.C. and J.P. are shown in Tables 1 and 2.

Table 2. Nutrition Assessment Results
The 24-hour recalls for the patients in Case #1 and Case #2 were as follows:

Case #1

Case #2

Breakfast:

1 slice dry toast
Coffee

2 pecan sweet rolls
20 oz. chocolate milk

 

Lunch:

Restaurant 4 times/week
Salad bar
5–6 oz meat
1 large baked potato
2 T sour cream
1/2 cup vegetable
1 roll with margarine
Dessert
Water

 

4 cups cold cereal (low sugar)
2 cups 2% milk
Dinner:

1–2 cups canned soup
3–4 saltine crackers

1 apple

Nutrition Education
The initial nutrition education includes the use of "The First Step in Diabetes Meal Planning," a simple brochure developed by the American Dietetic Association and the American Diabetes Association.13 This tool is preferred for its visual appeal as well as its basic information. Carbohydrate counting and distribution are accomplished by recommending a specific number of servings in each of the food groups and devising a daily meal plan. This process accommodates mathematical skills that may be inadequate among older women due to lack of cultural emphasis and usage.

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:

  • Older patients usually have been previously exposed to various food group educational material, such as Basic 7 and Basic 4, and introducing a new concept could lead to confusion.
  • Explain that the bread group includes starchy vegetables and legumes.
  • Emphasize fresh fruits and vegetables to increase fiber intake, alleviating constipation and improving glucose control. Dentition should be discussed.
  • Tailor milk consumption or calcium and vitamin D supplementation to hormonal replacement therapy.
  • Adequate protein intake (1 g/kg/day) should be translated into meat group servings. Dentition should be discussed.
  • Reinforce the importance of adequate fluid consumption.
  • Recommend vitamin supplementation when appropriate.

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
Combining the functional status and nutrition information can guide goal setting and the care plan for older patients. In Case #1, A.C. is still selectively driving a car, but the functional screen has detected hearing, vision, and cognitive impairments requiring further assessment. These functional impairments can limit or threaten her independence. A.C. lives alone and depends heavily on her ability to drive for access to food (as shown by her frequent lunch meals at a local restaurant). Her ability to go out also provides important socialization and emotional support. Referral to an audiologist and ophthalmologist for an evaluation and treatment could lead to improved hearing and sight.

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 5–10 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.

Table 3. Key Points to Consider When Developing MNT for Geriatric Patients
  • Initial interview begins with the functional status assessment.
  • Be aware of valuable functional status information.
  • Screening for depression is very important.
  • Portion size determination can be challenging.
  • Consider routinely ordering vitamin B12, RBC folate, homocysteine, and vitamin D blood levels.
  • Initial nutrition education begins with "The First Step in Diabetes Meal Planning."
  • Use servings rather than actual carbohydrate counting when older patients have cognitive impairments.
  • Recommend vitamin supplements when appropriate.
  • Access to food is the primary indicator of functional and nutritional problems.
  • Make full use of senior services available in your area.

Conclusion
Assessing the nutritional status of older patients with the assistance of functional screening can lead to a better understanding of factors that may impede adherence to the diabetes plan. Understanding age-related limitations and how to accommodate them will facilitate implementing MNT (Table 3), including simplified carbohydrate counting.


References
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10Lawton MP, Brody EM: Assessment of older people: self-monitoring and instrumental activities of daily living. Gerontologist 9:179-86, 1969.

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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.


Acknowledgment
The author wishes to thank Steven M. Thiese, MS, research associate and scientific editor for the Department of Family and Preventive Medicine, for his advice and assistance in the preparation of this article.


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.


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