As November is Diabetes Awareness Month, it is important to understand how technological advancements in diabetes care offer important help for older adults. In adults ages 65 and older, nearly 50% have prediabetes and approximately 25% have a diabetes diagnosis. Diabetes may be complicated in older adults due to its duration, comorbidities, and functional status. Older adults also may be managing cognitive and/or functional impairment, frailty, unintentional weight loss and polypharmacy. When it comes to supporting blood glucose management, lifestyle modification (including diet and nutrition) should be the foundation for all therapy, which can be further supported via continuous glucose monitors (CGMs).
Recommendations for CGM Use
CGMs are a technological tool that can be used by patients, caregivers and healthcare practitioners to aid in managing diabetes. CGMs include a small sensor worn on the body with a thin filament inserted under the skin to continuously measure glucose. Glucose readings are visible on a smartphone or specific CGM reader. The American Diabetes Association (ADA) and the American Association of Clinical Endocrinology (AACE) guidelines provide recommendations for use of CGMs in people living with diabetes, which include offering a CGM to all adults with diabetes who need multiple daily injections (MDI), insulin pumps or basal insulin. The AACE guidelines further recommend use of CGMs in people with Type 2 diabetes (T2D) with a high risk for hypoglycemia or hypoglycemia unawareness.
Older adults can use CGMs to make small changes to their diet and activity as each 5% improvement in time in range is considered clinically significant.
CGMs may benefit older adults to support medication and nutrition management. CGMs (via smartphone or reader) provide current glucose values, trending arrows, and alerts to the patient and caregivers through mobile apps. These functionalities alert patients and caregivers of hypo- or hyperglycemic events that may require action.
Understanding the Numbers from CGMs
While many individuals and healthcare practitioners are likely familiar with goal fasting blood glucose and 2-hour post prandial glucose levels recommended for individuals living with diabetes, these measures are often adjusted as an individual ages and/or develops comorbidities. Individuals using a CGM will notice that their smartphone/reader provides a glucose value accompanied by an arrow (appearance, type, and total number of arrows vary by manufacturer). The combination of a glucose value and arrow empowers individuals or their caregivers to understand how the glucose is changing (see Figure 1, below). They can collaborate with their healthcare team to develop a plan for their medication and nutrition management.
Figure 1: Examples of glucose values and symbols provided by a CGM
|
↑ Rising |
→ Steady |
↓ Falling |
Healthcare practitioners also have access to reports to help interpret the CGM data. The International Consensus on Time in Range resulted in a standardization of the ambulatory glucose profile (AGP) report, which includes mean glucose, time in range (TIR), glucose variability, and other data. One important aspect of the TIR is that the range for individuals with diabetes (not during pregnancy) is the same target range of 70–180mg/dL (see Figure 2, below), but the percent of time recommended to be in that range differs based upon age and comorbidities.
Older adults can use CGMs to make small changes to their diet and activity as each 5% improvement in TIR is considered clinically significant. By collaborating with their healthcare team through medication and nutrition management, a 10% increase in TIR is associated with a decrease in retinopathy, microalbuminuria, major adverse cardiovascular event and hypoglycemia.
Figure 2: Examples of targeted percentages for time in range (TIR) glucose based on hemoglobin A1c goals
|
Goal A1c |
% TIR (70-180mg/dL) |
% TBR (<70mg/dL) |
|
<7% |
>70% |
<4% |
|
<8% |
>50% |
<1% |
TIR = time in range; TBR = time below range
In addition to the TIR information, the ambulatory glucose profile includes a summary graph of the glucose values over the 14-day report period. A greater difference between the top and bottom of the graph may indicate greater variability or “swings” in glucose levels. Using this graph is beneficial in identifying times of day that may need adjustments to medication, nutrition and activity to optimize glucose control.
Personalized Nutrition Interventions When Using CGMs
There is no one eating plan that is ideal for a person with diabetes, according to a consensus report from the American Diabetes Association. However, older adults with diabetes may be at risk for shifting food choices due to changes in appetite, taste and smell, as well as emotional well-being. This can result in favoring high-glycemic carbohydrates and under-consuming nutrients such as protein and fiber, which can impact glucose management. Medical nutrition therapy (MNT) used in combination with CGM data can be an effective strategy to provide an individualized and dynamic approach for older adults with diabetes. MNT can include lifestyle modifications through diet education and diabetes-specific oral nutrition supplements (ONS) to promote adherence and support improvements in healthful eating patterns and glycemia.
See below for examples of nutrition interventions to support optimal TIR and to minimize hypoglycemia:
- Suggest keeping a food log to evaluate how choices impact glucose.
- Ask patients if they are willing to make changes to their food or beverage choices.
- Encourage the plate method, by filling ½ of the plate with non-starchy vegetables, ¼ protein, ¼ carbohydrate foods, and pairing with water or a low-calorie drink.
- Evaluate whether hyperglycemia peak occurs before or after eating.
- Meal/snack-time hyperglycemia: balance plate with non-starchy vegetables, whole grains and lean proteins, consider reducing portion sizes, replace a meal or snack with diabetes-specific oral nutrition supplements, and/or increase activity after meals.
- Daytime variability: review day-to-day activity levels, reinforce adherence to medication timing, encourage patients to focus on foods at mealtimes that keep glucose between 70–180 mg/dL.
- Hypoglycemia: Use the 15/15 rule of 15 grams fast-acting carbohydrates and rechecking after 15 minutes to manage low glucose.
For individualized meal planning, older adults with diabetes using CGM should work with a registered dietitian (RDN) and/or certified diabetes care and education specialist (CDCES) to prioritize the right amounts of carbohydrates, fats and proteins in their diet to support healthy aging and glucose control.
Resources:
- The ADA’s Nutrition Conversation Starter answers nutrition-related questions and provides tips based on the AGP.
- This Nutrition and Diabetes Toolkit provides nutrition and meal planning tips for people with diabetes.
- The ADA’s Continuous Glucose Monitoring (CGM) Infographic: Helping you make lifestyle choices for improved glucose management.
Cindy King, PharmD, BCACP, CDCES, is a Medical Science liaison for the Diabetes Care division of Abbott, in Alameda, Calif. Carley Rusch, PhD, RDN, LDN, is a Medical Science liaison for the Nutrition division of Abbott, in Columbus, Ohio.
Photo credit: Sea Wave
