April 2017 Issue

Diabetes Prevention in Older Adults
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today's Dietitian
Vol. 19, No. 4, P. 30

With the introduction of the Medicare Diabetes Prevention Program, dietitians will have even more ammunition to help prevent this costly disease.

The number of people in the United States aged 65 and older is estimated to reach more than 98 million by 2060,1 and as this aging population continues to grow, there will be more cases of type 2 diabetes. The Centers for Disease Control and Prevention (CDC) projects that the number of older individuals with diabetes will double or even triple by 2050, affecting one in three adults older than 65.2 In addition, more Medicare dollars are spent on beneficiaries with diabetes.3 The good news is type 2 diabetes can be prevented or delayed with appropriate lifestyle changes.

This article discusses the prevalence of diabetes and prediabetes in older adults, associated diabetes complications, the Diabetes Prevention Program (DPP) and Medicare DPP (MDPP), and strategies for nutrition professionals counseling older adults on diabetes prevention.

Diabetes Prevalence
According to CDC projections, even if diabetes rates level off, the aging population will change the face of diabetes, and the incidence of diabetes will continue to grow. In fact, it's projected to double in the next 20 years.4

Diabetes is a costly disease—personally and economically. Older adults with diabetes experience diabetes complications such as lower-extremity amputation, myocardial infarction, visual impairment, and end-stage renal disease at rates higher than any age group.4 Those aged 75 and older are twice as likely to visit an emergency department for hypoglycemia than the general population with diabetes, and deaths from hyperglycemic crises are also significantly higher.4

One out of every three Medicare dollars is spent on diabetes.5 The Centers for Medicare & Medicaid Services (CMS) estimates that Medicare spent $42 billion more on fee-for-service in 2016 for beneficiaries older than 65 with diabetes than it would have spent if those beneficiaries didn't have the disease.3

Prediabetes
Just as troublesome as the diabetes epidemic in terms of personal impact and costs is the alarming prevalence of prediabetes in the older US population.

"According to CDC estimates, 86 million Americans have prediabetes, and approximately nine out of 10 Americans don't even know they have prediabetes," says Angela Ginn-Meadow, RD, LDN, CDE, senior diabetes education coordinator at the University of Maryland Center for Diabetes and Endocrinology in Baltimore. "Prediabetes is a growing concern for the American workforce—many of whom are 65 years of age and older—in which billions of dollars are lost in productivity and medical expenses," Ginn-Meadow adds.

In a study published in the December 2014 issue of Diabetes Care, researchers found that over a five-year period (2007–2012), the cost of prediabetes increased 74% to $44 billion, while the cost of undiagnosed diabetes rose a staggering 82% to $33 billion.6 These astounding statistics demonstrate the personal and economic burden of diabetes. Moreover, they draw attention to the need for continued strategies for prevention.

The risk of progression to type 2 diabetes in an individual with prediabetes is around 5% to 10% per year, or as much as 20 times higher than in individuals with normal blood glucose.7,8 Development of diabetes from normal glucose tolerance to prediabetes is a continuous process. During the prediabetes stage, blood glucose levels are higher than normal but not high enough for a diabetes diagnosis.9 The American Diabetes Association defines prediabetes as impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). IFG is defined as a fasting blood glucose of 100 mg/dL to 125 mg/dL, and IGT is defined as a glucose level from 140 mg/dL to 199 mg/dL two hours after consuming a glucose-rich drink. A1c levels (glycated hemoglobin) of 5.7% to 6.4% also are used to identify individuals with prediabetes.10

The risk factors for prediabetes are the same as for diabetes: overweight or obesity; 45 years or older; physical inactivity; having a parent, brother, or sister with diabetes; race and ethnicity, particularly African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native Hawaiian, or Pacific Islander; history of gestational diabetes; blood pressure 140/90 mm Hg or higher or being treated for high blood pressure; HDL cholesterol less than or equal to 40 mg/dL or triglycerides above 250 mg/dL; polycystic ovary syndrome, depression, IFG, or IGT; acanthosis nigricans; and history of cardiovascular disease.11

Diabetes Prevention
The evidence showing that type 2 diabetes can be prevented or delayed by lifestyle interventions including improved nutrition, increased physical activity, and weight loss of 5% to 7% is robust. However, most of the evidence from clinical trials enrolled primarily middle-aged participants. The exception is the DPP—the largest clinical trial to date. In the DPP, approximately 20% of the participants were aged 60 years or older at enrollment.4 These seniors experienced a 71% risk reduction for type 2 diabetes compared with a 58% risk reduction in younger participants.12

Follow-up of the DPP participants for 10 years showed the seniors continued to benefit most. Those aged 60 and older had a 49% risk reduction compared with a 34% reduction for all participants.4 Additional benefits of the lifestyle intervention that might impact older adults, such as reduction in urinary incontinence, improvement in several quality-of-life domains, and improvements in cardiovascular risk factors, also were observed.4

Further research translating the DPP clinical trial to a community setting led Congress to authorize the CDC to establish the National DPP.5 The National DPP is a partnership of public and private organizations, such as the YMCA, working to reduce the incidence of prediabetes and type 2 diabetes by providing evidence-based, cost-effective interventions in communities across the United States.

The National DPP consists of 16 intensive "core" sessions of a CDC-approved curriculum in a group-based setting that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthful lifestyle. After the 16 core sessions, monthly maintenance sessions help to ensure that the participants maintain healthful behaviors. The primary goal of the intervention is to reduce the incidence of type 2 diabetes by achieving at least a 5% average weight loss among participants.13

DPP Expansion
As a result of the dramatic success seniors achieved in the DPP clinical trial and the National DPP, the YMCA's DPP was identified as a promising approach to lower Medicare expenditures. In 2013, the YMCA was awarded a grant from the Center for Medicare & Medicaid Innovation to test the efficacy of the DPP with Medicare seniors. Since 2013, local YMCAs have delivered evidence-based behavioral counseling to nearly 8,000 Medicare beneficiaries. Federal officials report that as a result of the YMCA's DPP grant, Medicare saved $2,650 over 15 months for every beneficiary enrolled in the program. The YMCA's DPP also demonstrated the ability to improve the quality of patient care without limiting Medicare coverage or benefits.14

Because of the positive outcomes of the YMCA's DPP, CMS proposed to expand the DPP to Medicare beneficiaries. Thus, the DPP will be the first ever preventive service model certified for expansion from the CMS Innovation Center.13 The expanded DPP program, MDPP, will go into effect January 1, 2018.

This expansion represents a major shift in how the nation's largest health care system treats diabetes. Rather than only treating diabetes, the focus will be on prevention and quality of life for older adults. "The MDPP expansion will cut health care costs, improve quality of life, and prevent a large population of the United States from developing type 2 diabetes," Ginn-Meadow says. "Obtaining insurance coverage is a driver to scaling and sustaining programs around the country for years to come," she adds.

Lifestyle Intervention
Strategies to help prevent seniors with prediabetes from developing full-blown type 2 diabetes also have been put into place. Prediabetes is associated with abdominal obesity, high triglycerides and/or low HDL cholesterol, and hypertension; therefore, individualized MNT should target these comorbidities.8 The American Diabetes Association 2017 Standards of Medical Care in Diabetes recommend all patients with prediabetes be referred to an intensive behavioral lifestyle intervention program modeled after the DPP to achieve and maintain a 7% loss of initial body weight and increase moderate intensity physical activity, such as brisk walking, to at least 150 minutes per week.8

In the DPP clinical trial, weight loss was achieved with a low-calorie, low-fat diet containing no more than 25% of calories from fat. However, recent evidence suggests that the quality of fat consumed in the diet is more important than the total quantity of dietary fat.8 An example of this type of eating pattern is the Mediterranean diet, which is relatively high in monounsaturated fats, yet evidence suggests it may help prevent type 2 diabetes.8

Evidence also suggests that seniors with prediabetes may benefit from particular foods. Studies suggest that whole grains may help prevent type 2 diabetes and higher intakes of nuts, berries, yogurt, coffee, and tea are associated with reduced diabetes risk. There's also evidence that red meats and sugar-sweetened beverages are associated with an increased risk of type 2 diabetes.8

Putting It Into Practice
Taking into account the results of the DPP clinical trial, the National DPP, and the MDPP, the following best practices may assist dietitians' diabetes prevention efforts when working with older adults:

• Make a nutrition assessment. As in all matters of MNT, dietitians must make a full assessment of individual nutrition needs including personal and cultural preferences, willingness and ability to make behavioral changes, and barriers to change. "It's also important to have a good understanding of an elderly patient's meal pattern, eating environment, and access to food," says Caroline Meehan, RDN, LDN, nutritionist at the University of Maryland Medical Center in Baltimore.

• Remember, one size does not fit all. Individualization of care is critical since all seniors are not the same functionally or cognitively. An active, relatively healthy 65-year-old patient with prediabetes is going to require very different intervention strategies than a 95-year-old with cognitive decline. "Many of our clients may be up in age, but remain young at heart," says Angel Planells, MS, RDN, CD, a Seattle-based dietitian. "Regardless of age, it's important that we provide nutritional care with empathy, dignity, and grace," adds Planells, who's also a spokesperson for the Academy of Nutrition and Dietetics.

At the end of her counseling sessions, Meehan uses the teach-back method to confirm the patient's understanding of the information she provided. The teach-back method enables patients to describe in their own words what they need to know. Before ending the session, Meehan and her patients decide on one to two goals that they will work on over the next three to six months. "It's important to provide support and guidance as patients begin to incorporate new dietary changes into their lifestyle," Meehan says.

• Forget the all-or-nothing philosophy. Acknowledging that it can be difficult to educate the senior population on healthful eating, Amy Klassman, RD, LDN, a dietitian at The Clare, a continuing care retirement community in Chicago, says, "Many individuals are very set in their ways regarding eating. As such, RDs need to meet residents where they are within their eating habits and suggest small steps to improvement. For example, if someone eats dessert for lunch and dinner on a daily basis with their spouse, I would recommend that they split dessert with their spouse at each meal or reduce dessert consumption to once per day."

• Focus on small, gradual changes. Planells says slow and steady wins the day when it comes to behavior change. "I set up small, gradual goals and long-term goals, building up confidence, and adjusting goals as we go along. Many great successes have come with this approach: weight loss, improved lab values, improved health status, quality of life, and, most importantly, a very enthusiastic client who's taking care of his health and wellness," Planells says.

• Emphasize portion control. "The plate method is a helpful tool when counseling elderly patients at risk for prediabetes and for teaching the basics of a heart healthy diet," Meehan says. "Emphasizing the importance of a balanced plate and enjoying treats in moderation is key." The plate method calls for filling one-half the plate with nonstarchy vegetables, one-quarter of the plate with lean protein, and the other one-quarter with grains and other starchy foods. The plate method is an easy way to control portions without measuring food.

• Decipher carbohydrates. Educating older adults on what foods contain carbohydrates is key to helping prevent type 2 diabetes. "The majority of individuals I've worked with in this population [seniors] believe that carbohydrates are only in sugar and desserts and believe that if they avoid desserts and sweets, they will not develop diabetes," Klassman says. "The potato-loving Midwestern individuals that I work with are always shocked to learn that they need to be mindful of their potato consumption."

Lauri Wright, PhD, RDN, LD/N, director of the doctorate in clinical nutrition program at the University of North Florida in Jacksonville, Florida, agrees that confusion over carbohydrate is a concern. Many believe they have to eliminate all carbohydrate. Instead, Wright suggests they "choose healthier carbohydrates such as fruit rather than candy, or whole grain bread rather than white; eat smaller amounts of carbohydrate-rich foods such as a 1/2 cup of juice rather than 16 oz; and spread out the carbohydrates—two to three servings each meal."

• Encourage physical activity. Planells suggests older adults choose activities they consider fun. "Reframe the concept of physical activity by stressing the benefits but also educating on the various ways to accomplish activity that doesn't involve [lifting] heavy amounts of weights at a gym," Planells says.

Wright agrees it should be fun: "It doesn't need to be a marathon. Walking has been found to be one of the most beneficial forms of activity." Wright encourages seniors to walk with a friend or with their dog to make it even more enjoyable.

Silver Lining
Diabetes in the elderly can be prevented or delayed with lifestyle interventions, including improved nutrition, increased physical activity, and weight loss. "It's estimated that as many as nine out of 10 cases of type 2 diabetes, the most common form of diabetes in older adults, can be avoided with small changes," Wright says. The MDPP, which will go into effect January 1, 2018, will have a profound impact on diabetes prevention in the elderly. "It [the MDPP] will allow states to engage providers, employers, and community organizations to increase awareness, screening, and billable lifestyle training for prevention of a costly disease," Ginn-Meadow says.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is a past national spokesperson for the Academy of Nutrition and Dietetics, specializing in African American nutrition, and author of The African American Guide to Living Well With Diabetes and Eating Soulfully and Healthfully With Diabetes.

References
1. Mather M. Fact sheet: aging in the United States. Population Reference Bureau website. http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstates-fact-sheet.aspx. Published January 2016. Accessed February 13, 2017.

2. Number of Americans with diabetes projected to double or triple by 2050. Centers for Disease Control and Prevention website. http://www.cdc.gov/media/pressrel/2010/r101022.html. Updated October 22, 2010. Accessed February 13, 2017.

3. Medicare Diabetes Prevention Program (MDPP) expanded model. Centers for Medicare & Medicaid Services website. https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/. Updated March 1, 2017.

4. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35(12):2650-2664.

5. Preventing diabetes in seniors. American Diabetes Association website. http://www.diabetes.org/advocacy/advocacy-priorities/prevention/preventing-diabetes-in.html. Updated May 29, 2015. Accessed February 11, 2017.

6. Economic burden of prediabetes up 74 percent over five years. American Diabetes Association website. http://www.diabetes.org/newsroom/press-releases/2014/economic-burden-of-prediabetes-up-74-percent-over-five-years.html#sthash.IdqEOqaF.dpuf. Published November 20, 2014. Accessed February 11, 2017.

7. Bansal N. Prediabetes diagnosis and treatment: a review. World J Diabetes. 2015;6(2):296-303.

8. American Diabetes Association. American Diabetes Association 2017 standards of medical care in diabetes — 2017. Diabetes Care. 2017;40(Suppl 1):S1-S135.

9. Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: a high-risk state for diabetes development. Lancet. 2012;379(9833):2279-2290.

10. History of diabetes. American Diabetes Association website. http://www.diabetes.org/research-and-practice/student-resources/history-of-diabetes.html. Updated May 9, 2014. Accessed February 13, 2017.

11. Risk factors for type 2 diabetes. National Institute of Diabetes and Digestive and Kidney Disease website. https://www.niddk.nih.gov/health-information/diabetes/overview/risk-factors-type-2-diabetes. Updated November 2016.

12. Diabetes Prevention Program (DPP). National Institute of Diabetes and Digestive and Kidney Disease website. https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Pages/default.aspx. Accessed February 13, 2017.

13. Medicare Diabetes Prevention Program expansion. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07.html. Published July 7, 2016. Accessed February 11, 2017.

14. The Y launches project to test cost effectiveness of the YMCA's Diabetes Prevention Program among qualifying Medicare enrollees. YMCA website. http://www.ymca.net/news-releases/y-launches-project-to-test-cost-effectiveness-of-ymcas-diabetes-prevention-program-among-qualifying-medicare-enrollees/. Published February 21, 2013. Accessed February 11, 2017.