Article Archive

March/April 2009

Diabetes Prevention — The Best Medicine
By Sharon Palmer, RD
Aging Well
Vol. 2 No. 2 P. 22

The evidence is clear—older adults' lifestyle choices dramatically influence the risk for developing type 2 diabetes. With such compelling information, promoting preventive lifestyle strategies should be part of routine healthcare for older adults.

It’s never too late—at least when it comes to type 2 diabetes. Contrary to popular belief, type 2 diabetes doesn’t have to be a rite of passage as we age. For older adults, the evidence increasingly reveals that there are two distinct paths: a sedentary, overweight lifestyle that leads straight to the burden of type 2 diabetes, or an active, leaner lifestyle that can delay or even prevent diabetes’ onset. Equipped with a few important strategies, older adults can beat the odds of acquiring this condition.

Diabetes is such a monstrous disease that the battle is definitely worth tackling. It afflicts an estimated 8% of our population, a rate that has increased by 13.5% from 2005 to 2007. According to a 2007 article in the American Journal of Nursing, more than 10 million older adults aged 60 and older have been diagnosed with diabetes in the United States, a prevalence of almost 21% in this age group compared with a prevalence of almost 10% in younger adults.

Diabetes carries with it an economic cost to the tune of $174 billion per year. Diabetes-related medical expenditures totaled $116 billion in 2007, including $27 billion for diabetes care, $58 billion for chronic diabetes-related complications, and $31 billion for additional general medical costs.

The costs of diabetes extend beyond the financial. The disease carries a catastrophic potential for debilitating and life-threatening complications, making it the seventh leading cause of death listed on U.S. death certificates in 2006, a statistic that is probably underreported. In fact, older adults with diabetes experience about twice the risk of death compared with those without diabetes at a similar age. Among elders with diabetes, the risk for stroke and heart disease death rates are both two to four times higher compared with adults without diabetes. Diabetes is also the leading cause of blindness and kidney failure among those aged 20 to 74. Between 60% and 70% of people with diabetes have mild to severe forms of nervous system damage.

More than 60% of nontraumatic lower limb amputations occur in older adults with diabetes. Periodontal disease is also more common. And uncontrolled diabetes often leads to biochemical imbalances that can prompt acute life-threatening events, such as diabetic ketoacidosis and hyperosmolar coma. Older adults with diabetes are also more susceptible to many other illnesses, and their prognoses are often worse when they acquire these illnesses. Older adults aged 60 and older who have diabetes are two to three times more likely to report an inability to walk one quarter of a mile, climb stairs, do housework, or use a mobility aid compared with older adults without diabetes in the same age group.

“Older adults with diabetes take more medications and have higher cost issues. Preventing the disease makes good sense for financial and personal savings,” says Linda Haas, PhC, RN, CDE, an endocrinology clinical nurse specialist at the VA Puget Sound Health Care System, Seattle Division, and chair of the National Diabetes Education Program’s Older Adult Work Group.

The Diabetes Prevention Program
The importance of lifestyle approaches for type 2 diabetes prevention gained credence thanks to a landmark study, the Diabetes Prevention Program (DPP), sponsored by the National Institutes of Health (NIH) and published in The New England Journal of Medicine in 2002. The DPP was a 27-center, randomized clinical trial that studied more than 3,200 adults aged 25 and older who were at increased risk of developing type 2 diabetes. The DPP evaluated the effectiveness of intensive lifestyle modification (healthy diet and moderate physical activity of 30 minutes per day for five days per week), standard care plus the drug metformin, and standard care plus placebo for delaying or preventing type 2 diabetes.

The study found that people with an increased risk of developing type 2 diabetes could prevent or delay the disease’s onset by losing 5% to 7% of their body weight through increased physical activity along with a reduced fat and lower calorie diet. These lifestyle interventions worked particularly well in older adults aged 60 and older, reducing the development of diabetes by 71%.

The Finnish Diabetes Prevention Study, published in Diabetes Care in 2003, examined the effect of short- and long-term changes in diet and exercise behavior among 522 middle-aged, overweight subjects with impaired glucose tolerance on glucose and lipid metabolism. Individuals were randomized to either a usual care control group or an intensive lifestyle intervention group. The control group received general dietary and exercise advice at baseline and had an annual physician’s examination. The intervention group received additional individualized dietary counseling with a nutritionist and were offered circuit-type resistance training sessions and were advised to increase overall physical activity.

At one and three years, weight reductions were 4.5 and 3.5 kilograms in the intervention group and 1 and 0.9 kilograms in the control group, respectively. The intervention group experienced more improved measures of glycemia and lipemia. Researchers concluded that intensive lifestyle intervention produced long-term beneficial changes in diet, physical activity, and clinical and biochemical parameters and reduced diabetes risk, making this type of intervention a feasible option to prevent type 2 diabetes within the primary healthcare system.

In a 2008 study published in the American Journal of Preventive Medicine, researchers set out to determine whether a group-based DPP lifestyle intervention in a community setting in partnership with the YMCA would yield similar results. The DEPLOY Pilot Study was a pilot cluster-randomized trial designed to compare group-based DPP lifestyle intervention delivery by the YMCA to a brief, counseling-alone control in adults. Ninety-two subjects, who had a body mass index (BMI) of 24 kilograms per meter squared or more, at least two diabetes risk factors, and a random capillary blood glucose of 110 to 199 milligrams per deciliter, attended a diabetes risk-screening event at one of two semiurban YMCA facilities. After six months, body weight decreased by 6% in intervention participants and by 2% in controls. Intervention participants also showed greater changes in total cholesterol. These differences were sustained after 12 months. Researchers concluded that the YMCA may be a promising channel for the wide-scale dissemination of a low-cost approach to lifestyle diabetes prevention.

Such results indicated that lifestyle holds enormous potential for reducing the risk of elders developing type 2 diabetes. “In the Diabetes Prevention Program, the subjects 60 and older had a decreased risk of developing diabetes by 71%. That’s huge. They lost 5% to 7% of their weight and were physically active at least 30 minutes per day. Parts of this study were replicated in a YMCA study with the same results. Lifestyle changes were the most effective in preventing type 2 diabetes, especially in older adults. This is a doable thing; it’s not drastic, it’s not climbing mountains,” says Haas.

In recent years, many organizations have campaigned to educate healthcare professionals about targeting type 2 diabetes prevention through lifestyle intervention. The National Diabetes Education Program (NDEP) created the “Small Steps. Big Rewards. Prevent Type 2 Diabetes” campaign, providing messages and materials for people at risk for type 2 diabetes, as well as promoting diabetes prevention to healthcare providers by giving them tools and information to help patients take lifestyle steps toward diabetes prevention. The Centers for Disease Control and Prevention (CDC) supports 50 state and territorial diabetes prevention and control programs that focus on community interventions, health communications, and health system changes to prevent diabetes complications and improve the health and quality of life for all people with diabetes.

The American Diabetes Association supports a prevention campaign by encouraging people to take small steps in lifestyle modification to prevent type 2 diabetes and its complications. The American Society on Aging asserts that small changes in daily habits can prevent or manage type 2 diabetes. The International Diabetes Federation created a plan for the prevention of type 2 diabetes based on controlling modifiable risk factors.

Risk Factors
It’s important to target older adults at risk for developing diabetes. According to the National Institute of Diabetes and Digestive and Kidney Diseases, the risk factors for developing type 2 diabetes include the following:

• aged 45 or older;

• being overweight, defined as a BMI of 25 or more (23 or more for Asian Americans and 26 or more for Pacific Islanders);

• family history (parent or sibling) with diabetes;

• ethnic background of Alaska Native, American Indian, African American, Hispanic/Latino, Asian American, or Pacific Islander;

• history of gestational diabetes or giving birth to at least one baby weighing more than 9 pounds;

• blood pressure of 140/90 or higher;

• abnormal lipid levels (high-density lipoprotein cholesterol below 35 or triglyceride level above 250);

• physical inactivity (exercising fewer than three times per week);

• impaired glucose tolerance or fasting glucose;

• insulin resistance; and

• history of cardiovascular disease.

Haas urges healthcare professionals to recognize risk factors that increase the likelihood for developing diabetes and to pay more attention to screening for prediabetes through glucose testing. “Many people relate type 2 diabetes risk to family history, not to being overweight. They think that their family history is the most significant risk rather than lifestyle,” adds Haas. According to the NDEP, screening for diabetes and prediabetes is strongly recommended for those aged 45 and older and who are overweight. For individuals aged 45 and older without any other risk factors, healthcare providers should consider the risks and discuss them with patients before testing.

Of particular concern are the estimated 57 million older adults in the United States who have prediabetes, which the American Diabetes Association defines as 100 to less than 126 fasting plasma glucose or 140 to less than 200 oral glucose tolerance test. Not only do these individuals experience a higher risk for developing type 2 diabetes, but recent research also indicates that some long-term damage to the heart and circulatory system may already occur with prediabetes. By seriously stepping up lifestyle intervention during prediabetes, the onset of type 2 diabetes can be delayed or prevented.

Top Three to Be Diabetes Free
The DPP notes three important lifestyle strategies to delay or prevent type 2 diabetes: modest weight loss of 5% to 7%; a lower fat and lower calorie diet; and moderate physical activity of 30 minute per day five days per week.

1. Weight loss: The NDEP recommends that healthcare professionals set realistic, long-term weight loss goals to reduce diabetes risk. “An important way to prevent diabetes risk is through weight loss by eating a low-calorie diet or through eating enough calories for weight maintenance for those who are not overweight. A small amount of weight loss, 5% to 7%, can actually offset the risk of developing diabetes,” says Constance Brown-Riggs, MSEd, RD, CDE, CDN, a national spokesperson for the American Dietetic Association and the author of Eating Soulfully and Healthfully With Diabetes.

2. Healthful eating: The DPP found that by reducing calories and fat, weight loss and diabetes risk reduction occurred. “Fat is a very important goal; people should reduce their fat intake to below 30% of total calories. Saturated fat goes along with that,” says Brown-Riggs. “In addition, people should increase their fiber intake. The general guideline for fiber is 15 grams per 1,000 calories. Focus on healthier carbs” such as whole grains, fruits, vegetables, and legumes.

3. Physical activity: DPP findings point out that moderate exercise can help reduce type 2 diabetes risk. “As people age, they become more sedentary. Exercise has the single greatest impact on health,” says Peggy Buchanan, MA, director of fitness, aquatics, and physical therapy at Vista del Monte Retirement Community in Santa Barbara, CA, and a spokesperson for the older adult fitness program for the IDEA Health & Fitness Association. Buchanan suggests that in recommending a fitness program to elders who have been sedentary for some time, it’s important to consider barriers such as cardiac issues, medications, and joint health. Once those considerations have been identified, “The best exercise is the one that people will do,” says Buchanan, whether it’s walking, a gym membership with supervision, or group exercise classes. She suggests that an effective exercise program should include elements of strengthening, cardiovascular, flexibility, and balance, adding, “Older adults should exercise at least 30 minutes most of the days out of the week.”

Putting It Into Practice
Evidence suggests that preventive strategies can be implemented in routine clinical settings. Yet the widespread application of such strategies has been elusive, primarily due to financial considerations. “Healthcare professionals need to spend more time with their patients in order to prevent type 2 diabetes, but our healthcare system reimburses for procedures, not counseling. We need to help people facilitate these lifestyle strategies like weight loss, changing their diet, and increasing their activity level. Seniors need help with where they can go for more physical activity. We need to help people deal with all the information that is available. Not every healthcare provider has access to a registered dietitian or physical therapist. You need to develop resources in the medical office that are quick and painless,” says Haas.

To promote prevention, it’s important to create practical tips for clients that promote healthful eating, weight control, and exercise. “Particularly in older adults, healthcare professionals need to take into consideration how motivated the individual is toward change. Small, gradual change works the best. You can’t overwhelm the individual to make a 360-degree turn in their life,” says Brown-Riggs, who suggests that the low-calorie plate method is a simple tool. This method promotes that one half of the plate should be filled with nonstarchy vegetables, one fourth with lean protein, and one fourth with starch. She recommends that physicians partner with registered dietitians who can not only provide individual counseling or group classes for older adults but who will also be aware of insurance reimbursement and may accept discount rates for partnerships. “It requires more than 15 minutes or one hour or one visit to make and maintain change,” adds Brown-Riggs.

“A low-cost exercise plan can be a pair of walking poles that can incorporate upper body into the walking workout. Buying a pedometer and putting it on a belt can make people self-accountable and let them track what they are doing. You can also advise people to look into adult education opportunities in their communities that don’t cost much,” suggests Buchanan.

Haas urges healthcare professionals to take advantage of the resources available from the NDEP, including through its Web site at Haas says, “There are lots of resources in local areas via aging programs and senior centers. Be aware of what they offer. Socialization helps folks get these lifestyle approaches. Support is very important. The CDC’s state diabetes prevention and control programs work with communities to develop and sustain programs for healthy eating and increased activity. Put together a file with resources in the community, hang a poster in the office, offer flyers about diabetes prevention. The doctor, nurse, and medical assistant can all talk to patients about diabetes prevention.”

— Sharon Palmer, RD, is a freelance food and nutrition writer in southern California.


Reducing the Risk
If you’re in search of an easy method of integrating prevention into your practice with older adults, check out the National Diabetes Education Program’s clinical tools and patient education materials, available free of charge at Some of the handy resources available include:

• Informational video series: What Is Type 2 Diabetes?

• Diabetes presentations slide sets

• Healthcare provider tool kit: Small Steps. Big Rewards. Your GAME PLAN to Prevent Type 2 Diabetes

• Web site: Making Systems Change for Better Diabetes Care (

Guiding Principles for Diabetes Care

• Poster: Working Together to Manage Diabetes

• Clinical images: Working Together

• Reference card: Diabetes Numbers at-a-Glance

• Diabetes prevention patient education materials
— SP