Nutritional challenges in the elderly with diabetes

Pre-Emptive and Non-Pre-Emptive Goal Programming Problems for Optimal Menu Planning in Diet Management of Indian Diabetes Mellitus Patients

Diet management or caloric restriction for diabetes mellitus patients is essential in order to reduce the disease's burden. Mathematical programming problems can help in this regard; they have a central role in optimal diet management and in the nutritional balance of food recipes. The present study employed linear optimization models such as linear, pre-emptive, and non-pre-emptive goal programming problems (LPP, PGP and NPGP) to minimize the deviations of over and under achievements of specific nutrients for optimal selection of food menus with various energy (calories) levels. Sixty-two food recipes are considered, all selected because of being commonly available for the Indian population and developed dietary intake for meal planning through optimization models. The results suggest that a variety of Indian food recipes with low glycemic values can be chosen to assist the varying glucose levels (>200 mg/dL) of Indian diabetes patients.

Association of Medication Adherence with Hospital Utilization and Costs Among Elderly with Diabetes Enrolled in a State Pharmaceutical Assistance Program

BACKGROUND

Medication adherence is crucial for the successful treatment among elderly patients with diabetes taking oral antidiabetic medications (OAMs). Cost of medications, lack of insurance coverage, and low income are major contributing factors towards medication nonadherence. State pharmaceutical assistance programs (SPAPs) provide medications at little or no cost to income-eligible patients and have potential to improve medication adherence among elderly patients. Despite this, limited research has focused on the association of medication adherence with health care utilization among elderly patients enrolled in SPAPs, and inclusion of health care costs as an outcome is even rarer.

OBJECTIVE

To evaluate the relationship between adherence to OAMs and hospital utilization and costs among elderly patients with diabetes who were enrolled in a SPAP.

METHODS

This retrospective observational study included elderly patients with diabetes enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program in 2015. Medication adherence was estimated as the proportion of days covered (PDC; adherent: PDC≥80%, nonadherent: PDC < 80%). Hospital utilization and costs were estimated using hospital discharge records from the Pennsylvania Health Care Cost Containment Council. Multiple adjusted regression analyses were used to examine the association of medication adherence with hospital utilization (all-cause and diabetes-related number of inpatient hospital visits and length of stay [LOS]) and costs.

RESULTS

Among 9,497 elderly PACE enrollees with diabetes, 81% were adherent, and 21% were hospitalized. Compared with adherent patients, patients who were nonadherent to OAMs had twice the odds of all-cause and diabetes-related hospitalization. Controlling for covariates, nonadherent patients had 27% more all-cause (95% CI = 9%-36%) and 21% more diabetes-related (95% CI = 5%-40%) hospital visits than adherent patients. Covariate-adjusted LOS for nonadherent patients was 24% longer than that of adherent patients for all-cause hospitalization (95% CI = 1.171-1.311) and 12.7% longer for diabetes-related hospitalization (95% CI = 1.036-1.227). Medication nonadherence was associated with significantly greater all-cause ($22,670 vs. $16,383; P < 0.0001) and diabetes-related ($13,518 vs. $12,634; P = 0.0003) hospitalization costs.

CONCLUSIONS

Among SPAP-enrolled elderly patients, nonadherence to OAMs was significantly associated with increased risk of hospitalization, longer hospital stays, and greater hospitalization costs. Attention is needed to improve medication adherence among elderly receiving financial assistance to pay their prescriptions to reduce economic burden on the health care system.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose.

Community-based interventions to increase dairy intake in healthy populations: a systematic review

Background

Considering the low frequency of dairy intake in the population, interventions aiming to increase its consumption can be a priority for any health system.

Objective

This study aims to summarize community-based interventions for improving dairy consumption and their effectiveness to help policy-makers in designing coherent public health strategies.

Methods

This study was conducted in 2019, using PubMed/MEDLINE, Scopus, EMBASE, Cochrane Library, Web of Science, ProQuest, and Google Scholar. Two independent reviewers selected the eligible studies, and the outcomes of interest were extracted. The quality of eligible studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for randomized controlled trials and quasi-experimental studies.

Results

Out of 521 initially identified articles, 25 studies were included. Interventions reported in 19 studies were effective in increasing dairy consumption. Interventions in high-income countries were more effective than those in middle- and low-income countries. Interventions in health centers and supermarkets were more effective than the community and school-level interventions. Interventions in supermarkets and adolescents as target groups were more effective than children, middle-aged people, and the elderly. Also, educational interventions and changing buying/selling pattern were more effective than multiple interventions. Interventions longer than 24 and 48 weeks were more effective than shorter interventions.

Conclusion

Three policy options including educational interventions, multiple interventions, and changing the purchase pattern are suggested. It seems that applying all of the interventions together can be more effective. Also, long-term and well-designed future studies in different settings are recommended to confirm these results.

Clinical and socio-demographic parameters contributing to treatment incompliance in Palestinian patients with diabetes

BACKGROUND

This research study investigates the degree of medication-related satisfaction experienced by Palestinian patients with diabetes. In addition, this study further assesses the association between certain clinical and socio-demographic factors and the degree of satisfaction among the patients.

METHODS

This cross-sectional, descriptive study design consisted of 415 randomly selected patients from the Palestine Medical Complex (PMC), the Palestinian Ministry of Health Clinics, and from the Palestinian Diabetes Institute (also known as: Al-Bireh Medical Center). The Diabetes Medication Satisfaction (DiabMedSat) questionnaire measured patients' satisfaction levels regarding their medications.

RESULTS

Odds ratios from binomial logistic analysis and the analysis of variance determined statistically significant correlations. The analysis has displayed the presence of significant associations between clinical and socio-demographic factors and treatment satisfaction. Significance was determined at p values < 0.05 and p values < 0.01.

CONCLUSION

This research identified statistically significant associations between certain clinical and socio-demographic factors and diabetic patients' satisfaction regarding their treatment. Addressing the concerns and difficulties experienced by the patients may impede treatment incompliance and hinder the development of complications, or at least postpone them.

The effect of frailty should be considered in the management plan of older people with Type 2 diabetes

The prevalence of diabetes is increasing especially in older age due to increased life expectancy. In old age, diabetes is associated with high comorbidity burden and increased prevalence of geriatric syndromes including frailty in addition to micro- and macro-vascular complications. The emergence of frailty may change the natural history of Type 2 diabetes from a progressive to a regressive course with increased risk of hypoglycemia. This may result in normalization of blood glucose levels and lead to a state of burnt-out diabetes in frail older people with significant weight loss. Although guidelines suggest relaxed glycemic control in frail elderly with diabetes, complete withdrawal of hypoglycemic medications may be necessary in these frail populations to reduce the risk of hypoglycemia.

Lay abstract: Diabetes is a common disease especially in older people. Aging is associated with reduced appetite and reduced food intake due to lack of exercise and diminished energy consumption. In certain individuals this may be significant leading to weight loss, malnutrition and the development of frailty. As a result the doses of diabetes medications may be too strong for this frail population especially if they have organ dysfunction reducing medication clearance and increasing the risk of low blood glucose level events. Therefore, reduction or complete withdrawal of diabetes medications may be considered in this frail group.

Low HbA1c and Increased Mortality Risk-is Frailty a Confounding Factor?

Diabetes mellitus is increasingly becoming an older person disease due to the increased survival and aging of the population. Previous studies which showed benefits of tight glycemic control and a linear relationship between HbA1c and mortality have largely included younger patients newly diagnosed with diabetes and with less comorbidities. Recent studies, which included older population with diabetes, have shown a U-shaped relationship of increased mortality associated with low HbA1c. The mechanism of such relationship is unclear. There was no direct causal link between low HbA1c and mortality. It appears that malnutrition, inflammation and functional decline are characteristics shared by the populations that showed increased mortality and low HbA1c. In these studies functional status, disability or frailty was not routinely measured. Therefore, although adjustment for comorbidities was made there may be a residual confounding by unmeasured factors such as frailty. Thus, frailty or decline in functional reserve may be the main confounding factor explaining the relationship between increased mortality risk and low HbA1c.

Hypoglycemia in older people - a less well recognized risk factor for frailty

Recurrent hypoglycemia is common in older people with diabetes and is likely to be less recognized and under reported by patients and health care professionals. Hypoglycemia in this age group is associated with significant morbidities leading to both physical and cognitive dysfunction. Repeated hospital admissions due to frequent hypoglycemia are also associated with further deterioration in patients' general health. This negative impact of hypoglycemia is likely to eventually lead to frailty, disability and poor outcomes. It appears that the relationship between hypoglycemia and frailty is bidirectional and mediated through a series of influences including under nutrition. Therefore, attention should be paid to the management of under nutrition in the general elderly population by improving energy intake and maintaining muscle mass. Increasing physical activity and having a more conservative approach to glycemic targets in frail older people with diabetes may be worthwhile.

Dietary compliance, dietary supplementation and traditional remedy usage of type 2 diabetic patients with and without cardiovascular disease

This analytical cross-sectional study examined the nutrient intakes, dietary compliance, dietary supplementation and traditional remedy usage in type 2 diabetes mellitus (T2DM) patients from selected tertiary hospitals in multi-racial Malaysia. We compared the different characteristics of T2DM patients with and without cardiovascular disease (CVD). Socio-demographic status, dietary intakes, dietary supplementation, traditional remedy use, medical history, anthropometric measurements and clinical characteristics were obtained from face-to-face interviews. A total of 313 patients who were treated for T2DM participated in this study, in which 36.1% of them had CVD. The mean age of study subjects was 55.7 ± 9.2 years; mean diabetes duration was 10.1 ± 8.1 years; 52.1% were females; and 47.0% were Malays. The mean total energy intake of the subjects was 1674 ± 694 kcal/day, and patients with CVD consumed higher total calories (p = 0.001). Likewise, the mean carbohydrate, protein and total fat intake of CVD patients were significantly higher than non-CVD patients (p < 0.05), while mean intakes of cholesterol, fibre, minerals and all vitamins were comparable between CVD and non-CVD patients. Regardless of CVD status, a notably high proportion of the subjects did not meet the recommendations of the Medical Nutrition Therapy Guidelines for Type 2 Diabetes for total energy, carbohydrate, protein, total fat, and fibre intakes. Meanwhile, 52.4% used at least one dietary supplement and 12.1% took single traditional remedy or in various combinations. Traditional remedies and supplement intake did not differ between CVD and non-CVD subjects. It is suggested that T2DM patients should be educated based on their personalized dietary intake, dietary supplementation and traditional remedy usage. The recommendations for T2DM patients shall be met to achieve the optimal metabolic goals and minimize the potential diabetic complications.

Does nutritional education improve the risk factors for cardiovascular diseases among elderly patients with type 2 diabetes? A randomized controlled trial based on an educational model

BACKGROUND

To evaluate the effects of a nutritional education program on cardiovascular risk among elderly patients with type 2 diabetes (T2D).

METHODS

Ninety-seven elderly patients with T2D were enrolled in the present randomized controlled educational trial study. Patients were divided into intervention and control groups. The belief, attitude, subjective norm, enabling factors (BASNEF) educational model was used to design the educational intervention. Patients in the control group received their usual care during the study. Anthropometric data, lipid profiles and blood pressure measurements were collected at baseline and Week 12 in each group.

RESULTS

Significant declines were observed in the intervention compared with control group in terms of body weight (-1.3 ± 1.1 vs. 0.11 ± 0.58 kg, respectively), body mass index (-0.48 ± 0.37 vs. 0.05 ± 0.22 kg/m2, respectively), serum triglyceride levels (-18.25 ± 32.15 vs. -3.67 ± 22.61 mg/dL, respectively; P < 0.05 for all), and the waist-to-hip ratio (P = 0.03). There were no significant differences between the intervention and control groups in terms of high-density lipoprotein-cholesterol (-1.02 ± 4.35 vs. -1.10 ± 6.93 mg/dL, respectively; P = 0.9) or low-density lipoprotein-cholesterol (-4.04 ± 11.64 vs. -1.08 ± 4.35 mg/dL, respectively; P = 0.2).

CONCLUSIONS

Short-term nutritional education based on the BASNEF educational model improves serum triglyceride levels and anthropometric indices in elderly patients with T2D.