Download 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...
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General health
Helping control blood glucose
Keeping a healthy weight
Helping control blood pressure
Preventing/treating hypos
Enjoyment
Recommended Daily Amounts
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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 ( 9kcals 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
100ml 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
Insufficient exposure to the sun
Age over 65 years
Diet that restricts the major food sources of
vitamin D
Malabsorption syndrome
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
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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
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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
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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
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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
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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
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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
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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 M3
• 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/m2 = Healthy
 BMI 18.5-20 kg/m2 = Borderline
 Below 18.5 kg/m2 = 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 than23.5 cm, BMI is likely to be less than 20 kg/m2
If more than 32.0 cm, BMI is likely to be more than 30 kg/m2
Step 1 BMI
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BMI kg/m2 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
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Find original weight in the left
hand column e.g. 68kg.
Move across the row until you find
the amount of weight the resident
has lost in the last 3-6 months e.g.
4kg 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
1. No Action
2. Repeat
monthly
High risk (2 and over)
Medium Risk (1)
Low Risk (0)
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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
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6.
Factors that can affect nutritional intake
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Poor appetite
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Symptoms e.g. nausea, constipation,
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Difficulty with eating, chewing or swallowing (including poor
dentition)
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Motor ability (interactions between muscles and nerves)
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Long term poor health (mental /physical)
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Smoking/drinking/substance misuse
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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
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Consider referral to appropriate service e.g.
speech and language therapist, occupational
therapist, physiotherapist, dentist, psychiatrist
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Treat underlying symptoms
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check medication side effects
What to do If you feel a resident is at
risk of malnutrition:
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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
The End
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