Dietary advice for the older person with diabetes

Dietary advice for the older person with diabetes Virginia Griffith Diabetes Specialist Dietitian Airedale NHS Foundation Trust

I aim to discuss Nutritional recommendations for diabetes in older people. How nutritional guidelines differ for a person with diabetes who is malnourished, overweight or obese. Dietary considerations for different diabetes treatments. MUST assessment.

Nutritional recommendations for diabetes Food and nutrition alongside medication and activity are the cornerstone to diabetes management. Eating a balanced diet, managing weight (both over and underweight), and following a healthy lifestyle, together with taking any prescribed medications and monitoring where appropriate will all help keep people with diabetes well.

Diet is important for. . . • • • General health Helping control blood glucose Keeping a healthy weight Helping control blood pressure Preventing/treating hypos Enjoyment

Recommended Daily Amounts Starchy foods 5 -14 portions Fruit and Vegetables 5 -9 portions Dairy foods 2 -3 portions Meat, Fish, Eggs and Pulses 2 -3 portions • Foods high in Fat and Sugar 0 -4 portions • •

Practical dietary guidelines • Plan for three meals a day. Try to help residents to avoid skipping meals and space breakfast, lunch and evening meal over the day. This will not only help control appetite but also help in managing blood glucose levels. Snacks depend on an individual’s diabetic treatment, weight and personal preferences.

• At each meal include a moderate portion of starchy carbohydrate foods such as bread, chapattis, potatoes, rice, pasta, noodles and cereals. The amount of carbohydrate eaten is important to control blood glucose levels. All varieties are fine but those that are more slowly absorbed ( lower glycaemic index ) will not affect blood glucose levels as much.

Better choices include pasta, basmati rice, grainy and seeded breads, new potatoes and porridge oats, all bran and natural muesli. The high fibre varieties of starchy foods will also help to maintain good bowel health and prevent constipation.

• Cutting down on fat especially saturated fats. All fats contain calories. Fat is the greatest source of calories ( 9 kcals per g ) so eating less fat and fatty foods will help with weight management. Monounsaturated fat should be consumed in preference to saturated or polyunsaturated fat because it reduces bad cholesterol so good for heart health.

• Include more fruit and vegetables. Aim for at least five portions a day to provide residents with vitamins , minerals and fibre as well as to help the balance of the overall diet. A portion is 1 piece of fresh fruit eg a pear 1 handful of grapes 1 small glass of pure fruit juice 1 tablespoon of dried fruit 3 tablespoons of vegetables

• Include more beans and lentils. These include kidney beans, butter beans, chickpeas, red and green lentils. They are a good source of non-meat protein and can help control blood glucose and blood cholesterol levels.

• Aim to provide two portions of oily fish a week. Examples include mackerel, sardines, salmon and pilchards and can be tinned, frozen or fresh. Oily fish contains a type of polyunsaturated fat called omega 3 which helps to protect against heart disease.

Limit sugar and sugary foods. This does not mean that residents need to eat a sugar- free diet. Sugar can be used in foods and in baking as part of a healthy diet. Using sugarfree, no added sugar or diet squashes/fizzy drinks instead of sugary versions can be an easy way to reduce sugar in the diet.

• Limit the amount of processed foods provided. These foods can contain high levels of salt

• Alcohol should be taken in moderation only. 2 - 3 units for women 3 - 4 units for men 1 unit is a single measure ( 25 ml ) spirits ½ pint ordinary beer, lager or cider 100 ml wine 50 ml sherry

• Don’t use diabetic foods or drinks. They offer no benefit. They can still affect blood glucose levels, contain just as much fat and calories as the ordinary versions, can have a laxative effect and are expensive.

Important note These recommendations are for well older people with diabetes. Older people in care homes may be more likely to be underweight rather than overweight and the prevalence of malnutrition and under nutrition is high. It may therefore not be appropriate to reduce the fat, sugar and salt in the diet for every older person with diabetes !

Weight management Weight is a significant factor in the development and management of Type 2 diabetes. For residents who are overweight or obese a weight reduction of between 5 and 10 % may be beneficial. Specific goals should be identified and negotiated as part of the care planning process. Less fat and sugar and reduced portion sizes are all helpful, as well as more activity if possible.

Underweight and malnutrition Residents with diabetes may have numerous underlying risk factors for poor nutritional status including multiple medications affecting GI function and appetite, medical co-morbidities, disabilities affecting the ability to eat and drink safely, low mood and poor cognition.

A high energy, high protein diet may be appropriate. A food first care plan should be agreed to improve nutritional intake. This is achieved via extra snacks, nourishing drinks and fortifying foods. If this is not enough supplement drinks or nasogastric feeding may be necessary. If high blood glucose levels are noted it may be necessary to adjust diabetes medication to achieve better blood glucose levels.

Vitamin D Risk factors for Vitamin D deficiency Ø Insufficient exposure to the sun Ø Age over 65 years Ø Diet that restricts the major food sources of vitamin D Ø Malabsorption syndrome Ø Low bone density

Dietary sources of vitamin D It is only found in a few foods and not in sufficient quantities for a balanced diet to meet Vitamin D requirements Foods include Herring Fresh tuna Sardines Mackerel Salmon Egg yolks, evaporated milk, some powdered milks, margarine and some breakfast cereals

Maintenance Therapy OTC supplements are recommended Vitamin D (Colecalciferol ) 1000 units ( 25 micrograms ) per day as maintenance therapy Costs less than £ 20 per year

Hypoglycaemia Quantity and timings of carbohydrate containing foods and drinks. The potential need for snacks. Timings of meals in relation to medication timing. • Effects of alcohol. • •

Oral health It is estimated that people with diabetes can be up to approximately three times more likely to develop gum disease than people without diabetes. Nutritional status may be compromised as a result of poor food and drink intake. Residents with diabetes and gum disease should be identified and dietary adjustment made according to specific need.

Dehydration It is widely accepted that the older person with diabetes is at greater risk of dehydration for a number of reasons. A resident with diabetes and uncontrolled diabetes may be at additional greater risk of becoming dehydrated as a result of polyuria. Particular attention should be made to the monitoring and provision of fluid for this resident and treatment modified accordingly so as to limit symptoms of hyperglycaemia. 8 -10 cups of fluid per day should be encouraged.

Dietary considerations for different diabetes treatments

Medication: short acting tablets • Help body’s insulin work better, stops liver releasing too much glucose • Take with meals • No hypo risk on its own • Doesn’t cause weight gain • Glucophage MR is slow release, take once or twice a day • Metformin, also called Glucophage

…longer acting tablets • • Gliclazide or Diamicron Glimepiride or Amaryl one a day Glipizide or Minodiab Take before food Help body make more insulin May cause hypos May increase weight a little Glibenclamide not usually given to elderly – hypo risk

…glitazones • • • Rosiglitazone or Avandia Pioglitazone or Actos Take with food May gain weight Avandamet is metformin + rosi Competact is metformin + pio

New therapies • Exenatide or liraglutide injections • Sitagliptin or vildagliptin tablets • Don’t cause weight gain • Dapagliflozin • Can cause weight loss

Insulin • Long acting • Short (fast) acting • Mixes Very important to get timing right! Ask DSN or GP if not sure

…long acting • • Lantus (glargine) Levemir (detemir) Usually once a day Take at same time each day • Insulatard, Humulin I and Insuman Basal, greater hypo risk, may need snack between meals, need supper

…super short acting Novorapid (aspart) Humalog (lispro) Glulisine (apidra) Take immediately before, with or just after meals • Lower hypo risk • Do not take if missing a meal • •

…other short acting • • • Actrapid, Humulin S and Insuman Rapid Take 20 -30 mins before meal Do not take if missing a meal Not often used Hypo risk, may need snack between meals

… mixes to take just before meals Novomix 30 Humalog mix 25 Humalog mix 50 Usually twice a day, just before breakfast and evening meal • Can be prescribed for 3 times a day • •

…mixes to take 30 mins before food • Humulin M 3 • Insuman Comb 15 (or 25 or 50) • May need a snack between meals and supper to prevent hypos

What is malnutrition? ‘the nutrition intake does not meet the individuals needs’

Consequences of malnutrition • Poor healing and wound breakdown • More likely to get infections • Muscle wasting • Increased complications • Lack of energy/Depression • Dehydration • Vitamin and mineral deficiencies

Recognising Malnutrition • Mobility: weakness, impaired movement • Mood: apathy, lethargy, poor concentration • Current intake: reduced appetite, changes in meal pattern and food choice • Physical appearance: loose clothing, rings or dentures, sunken eyes, dry mouth, emaciation, pale complexion, hair loss • Screening tools: e. g. MUST

Screening Tools MUST – Malnutrition Universal Screening Tool �Assesses BMI: �BMI 20 -25 kg/m 2 = Healthy �BMI 18. 5 -20 kg/m 2 = Borderline �Below 18. 5 kg/m 2 = Malnourished �Assesses weight loss in last 3 -6 months: � 5 -10% = Borderline �>10% = Malnourished �Assesses current nutritional intake

Step 1 – BMI Estimate height from Ulna Length

Step 1 BMI Estimate weight from mid upper arm circumference If less than 23. 5 cm, BMI is likely to be less than 20 kg/m 2 If more than 32. 0 cm, BMI is likely to be more than 30 kg/m 2

Step 1 BMI • • BMI kg/m 2 Score >20 (>30 Obese) = 0 18. 5 -20 = 1 <18. 5 = 2

Step 2 – Percentage weight loss score Example: Was 68 kg, now 64 kg • • • Find original weight in the left hand column e. g. 68 kg. Move across the row until you find the amount of weight the resident has lost in the last 3 -6 months e. g. 4 kg is in the yellow column. Look at the top of the column for the percent weight loss and score. In this case, Score=1 (5 -10% weight loss) <5% Score =0 >10% Score =2

Step 3 – Acute disease Effect Score • Most likely to apply to patients in hospital. • E. g. the critically ill, those with swallowing difficulties (e. g. NBM after stroke), or those undergoing major gastrointestinal surgery. • Can only score a 0 or 2

MUST score and overall risk

Step 5 Nutrition care planning NUTRITION FLOW CHART FOR MANAGING ADULTS AT RISK OF UNDERNUTRITION IN CARE HOMES Medium Risk (1) Low Risk (0) 1. No Action 2. Repeat monthly 1. 2. 3. Assess factors which affect intake and take appropriate action (see boxes) Consider a fortified diet including snacks and high energy drinks Appendix 1 and 2 Screen weekly 1. 2. 3. 4. 5. 6. Factors that can affect nutritional intake Poor appetite Symptoms e. g. nausea, constipation, Difficulty with eating, chewing or swallowing (including poor dentition) Motor ability (interactions between muscles and nerves) Long term poor health (mental /physical) Smoking/drinking/substance misuse 7. 8. High risk (2 and over) Referral to GP to investigate any underlying cause. Assess factors which affect intake and take appropriate action (see box) Record food and drink in detail for 5 days Provide a fortified diet Provide a snack mid am and pm Provide 2 homemade or non prescription drinks Screen weekly Refer to dietitian via GP, Matron or District Nurse (Appendix 3) Action Consider referral to appropriate service e. g. speech and language therapist, occupational therapist, physiotherapist, dentist, psychiatrist Treat underlying symptoms check medication side effects

What to do If you feel a resident is at risk of malnutrition: Inform a staff nurse Monitor food and fluids on food charts Monitor weight weekly Encourage oral intake – additional snacks, food fortification • If no improvement consider referral to a dietitian • •

Regulation 14: Meeting nutritional and hydration needs • The intention of this regulation is to make sure that people who use services have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment. • To meet this regulation, where it is part of their role, providers must make sure that people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. • People must have their nutritional needs assessed and food must be provided to meet those needs. This includes where people are prescribed nutritional supplements and/or parenteral nutrition. People's preferences, religious and cultural backgrounds must be taken into account when providing food and drink. • CQC can prosecute for a breach of this regulation or a breach of part of the regulation if a failure to meet the regulation results in avoidable harm to a person using the service or a person using the service is exposed to significant risk of harm. In these instances, CQC can move directly to prosecution without first serving a warning notice. Additionally, CQC may also take any other regulatory action. See the offences section for more detail. • CQC must refuse registration if providers cannot satisfy us that they can and will continue to comply with this regulation. • The regulation

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