Hermes Florez

Diabetes in Older Adults

More than 25% of the U.S. population aged ≥65 years has diabetes (1), and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization (2). Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets—for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged ≥65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions: 1. What is the epidemiology and pathogenesis of diabetes in older adults? 2. What is the evidence for preventing and treating diabetes and its common comorbidities in older adults? 3. What current guidelines exist for treating diabetes in older adults? 4. What issues need to be considered in individualizing treatment recommendations for older adults? 5. What are consensus recommendations for treating older adults with or at risk for diabetes? 6. How can gaps in the evidence best be filled? According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥65 years varies from 22 to 33%, depending on the diagnostic criteria …

Diabetes in Older Adults: A Consensus Report

More than 25% of the U.S. population aged 65 years has diabetes mellitus (hereafter referred to as diabetes), 1 and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization. 2 Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets— for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged 65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions:

Outdoor exercise reduces the risk of hypovitaminosis D in the obese

Obesity is associated with lower levels of serum 25-hydroxyvitamin D (25(OH)D). Obese individuals might need higher doses of vitamin D supplementation than the general population. In this cross-sectional study, associations between 25(OH)D serum levels, body mass index (BMI), and outdoor exercise were assessed in a population of 291 ambulatory patients attending the Osteoporosis Center at the University of Miami, mean age 62+/-13.48 years. Obesity was defined as BMI> or =30 kg/m(2) and hypovitaminosis D as 25(OH)D< or =30 ng/ml. Overall, prevalence of obesity was 14.1% and of hypovitaminosis D was 42.4%. Among Hispanics, there was a significantly higher prevalence of hypovitaminosis D in obese (63.2%) compared to non-obese individuals (35.8%). Outdoor exercise had a significant effect on the prevalence of hypovitaminosis D in Hispanics, with a lower prevalence in those performing outdoor exercise (24.1%) compared to those who did not (47.9%). After adjusting for age, gender, and ethnicity, those reporting outdoor exercise were 47% less likely to have hypovitaminosis D, while those with obesity had more than twice the risk. Since outdoor exercise may protect overweight individuals from hypovitaminosis D, prevention programs involving higher doses of vitamin D and/or outdoor exercise may result in additional metabolic and functional benefits in this population.

Impact of Metformin-Induced Gastrointestinal Symptoms on Quality of Life and Adherence in Patients with Type 2 Diabetes

Abstract Aims: Gastrointestinal (GI) symptoms are common in patients with type 2 diabetes mellitus (T2DM). This study assesses the impact of 1) metformin on GI symptoms and health-related quality of life (HRQoL) and 2) metformin-associated GI symptoms on medication adherence in patients with type 2 diabetes newly beginning therapy. Methods: Patients with T2DM aged ≥ 18 years starting metformin from January to June 2007 who filled their prescriptions for ≥ 3 months were identified from a health benefits company database. Via telephone, GI symptom impact was evaluated in a 360-patient sample using the validated Bowel Symptom Questionnaire and Medical Outcomes Study 36-Item Short-Form Health (SF-36) survey. Adherence was assessed using the medication possession ratio (MPR). Logistic regression adjusting for demographic and clinical covariates was used to assess the relationship between GI symptoms and MPR < 80%. Results: The most and least common GI symptoms reported were diarrhea (62.1%) and retching (21.1%), respectively. Most GI symptoms were associated with lower physical and mental HRQoL (P < 0.05). Most changes in specific HRQoL reached the minimum important difference of 3 points. Bloating, nausea, and abdominal pain were significantly associated with MPR < 80%. Adjustment for demographic, clinical, and HRQoL factors made these relationships less evident. Conclusions: Metformin-associated GI symptoms in patients with T2DM lead to lower physical and mental HRQoL, which may result in patient nonadherence or physician reluctance to optimally titrate the metformin dose.

Hypovitaminosis D in the elderly: From bone to brain

ConclusionThere is a growing consensus that vitamin D recommended daily intakes for the elderly are far too low, and that all individuals should take as much vitamin D as needed to raise levels to between 32 to 40 ng/ml (80 to 100 nmol/L) (5, 108, 109). Supplementation will likely be necessary in most elderly, since according to current lifestyles, diet and sunlight alone are inadequate sources of vitamin D (17). We believe that to raise and maintain 25(OH) vitamin D levels at a minimum of 32 ng/ml (80 nmol/L), most elderly will require at least 2,000 IU of cholecalciferol per day.But many questions remain. Are other biological markers preferable to 25(OH) vitamin D to assess repletion? Do the current estimates of optimal serum levels provide health benefits for all conditions, or do optimal vitamin D levels differ depending on the target tissue? How much vitamin D, cholecalciferol, or ergocalciferol, should be given to maintain these levels? What are the molecular mechanisms by which vitamin D influences health and disease?Cross-sectional studies have suggested that low vitamin D levels not only predict nursing home admission but also are associated with increased mortality (1, 2). Further knowledge of the mechanisms of vitamin D action and prospective clinical trials designed to determine if supplementation resulting in vitamin D levels higher than those shown to reduce the risk of falls and fractures is also effective in reducing the burden of various medical conditions could help validate a cost-effective intervention that will provide greater quality of life and longevity and have a major public health impact.

Beyond the Obesity Paradox in Diabetes: Fitness, Fatness, and Mortality

THE PREVALENCE OF DIABETES IS RAPIDLY INCREASING in the United States and worldwide. Almost 26 million US adults have diabetes, 79 million Americans aged 20 years or older have prediabetes, and it is projected that by 2050 nearly 50 million Americans will have diabetes. More than one-third of US adults are obese, putting them at increased risk of diabetes and other chronic diseases. In response to these public health challenges, Healthy People 2020 goals include reduction of the obesity and diabetes burden in an effort to lower the incidence, complications, and mortality rates in the US population. Despite the role of obesity in the development of chronic comorbidities, once these conditions are manifested, being overweight may provide some “protective” benefits. This has been termed the obesity paradox, based on the observation that obese patients with cardiovascular disease survive longer than their normal-weight counterparts with cardiovascular disease. In this issue of JAMA, Carnethon and colleagues provide an analysis of an inception cohort of adults with recentonset diabetes, free of comorbid cardiovascular disease at baseline, pooled from 5 longitudinal studies. Based on data from 2625 persons with incident diabetes, the authors show that, compared with overweight and obese individuals, those who are normal weight at the time of diabetes incidence have higher mortality rates (152.1 per 10 000 person-years vs 284.8 personyears, respectively), even after adjusting for demographic factors and major cardiovascular risk factors. This study adds an important dimension to evidence supporting the obesity paradox in diabetes, as it is the first to measure body mass index (BMI) at the time of onset of diabetes, eliminating the potential confounding effects of diabetes duration. This report provides meaningful insights into the mortality risk for metabolically obese normal-weight (MONW) individuals who develop diabetes. Despite having a BMI within normal limits, these individuals have hyperinsulinemia, insulin resistance, and hypertriglyceridemia and are predisposed to type 2 diabetes and premature coronary heart disease. Individuals who are MONW are becoming more common, as reported in an analysis from the National Health and Nutrition Examination Survey (NHANES): 23.5% of normal-weight adults in the United States (8.1% of the overall population) were metabolically abnormal. Furthermore, individuals with normal BMI but high body fat content (MONW-like) have higher cardiovascular mortality, particularly among women. The results reported by Carnethon et al also are consistent across minority groups with MONW, including Asian American individuals. This has broad significance in view of the global effects of diabetes, with an accelerating epidemic in Asian populations. This increase in diabetes prevalence is in part related to the emergence of the MONW phenotype, with data from the Korean NHANES showing the MONW phenotype in 12.7% of normal-weight persons (8.7% of the overall population). Sarcopenic obesity is defined by high body fat in the presence of reduced lean body mass and is associated with a reduction in cardiorespiratory fitness and physical function, which in turn leads to mobility disability and premature death. The study by Carnethon et al also highlights a potential role for lower lean mass and increased waist circumference (ie, sarcopenic obesity) in the higher mortality eventually seen in normal-weight individuals at the time of diabetes development. In their analyses, larger waist circumference was associated with increased total mortality, yet normal BMI remained significantly associated with mortality after adjustment for waist circumference, supporting contributions from both high body fat and low lean body mass. In a systematic review, the risk for all-cause and cardiovascular mortality was lower among individuals with high BMI and good aerobic fitness than in individuals with normal BMI and poor fitness. This phenomenon has also been reported in a study of veterans with diabetes in which the obesity paradox was observed along with an independent association between poor exercise capacity and mortality within BMI categories. Improved knowledge of the effects of body composition, fat distribution, and physical function, beyond the measurement of BMI, will help the medical and scientific community better understand the relationships among obesity, morbidity, and mortality in adults with diabetes.

Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association

Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

Weight Management for Veterans: Examining Change in Weight Before and After MOVE!

In the year 2000, 31% of women and 40% of men receiving outpatient care at Veteran Affairs (VA) medical facilities were overweight (BMI ≥25 and <30 kg/m2); 37.4% of women and 32.9% of men were obese (BMI ≥30 kg/m2). The purpose of the present study was to assess treatment effects of MOVE! Weight Management Program for Veterans by comparing the trajectory of change in weight postintervention (3, 6, and 12 months postenrollment) to a preintervention period (1, 3, and 5 years before enrollment). The sample consisted of 862 veterans participating in MOVE! at the Miami VA. All veterans participated in a 2‐h Self‐Management Support (SMS) session, which involved completion of a self‐assessment questionnaire and a nutrition education group session. After completing SMS, veterans had the option of continuing with Supportive Group Sessions (SGS), which included 10‐weekly group sessions led by a multidisciplinary team. Veterans served as their own controls in the analyses. Veterans gained 2 kg/year before enrolling in MOVE!. There were similar increases in weight across sex, racial/ethnic groups, and treatment condition. Weight for participants in SMS stabilized after enrollment whereas participants in SGS had an average weight loss of 1.6 kg/year. The preintervention slope for weight was significantly different from the postintervention slope, suggesting treatment effect. Findings from this study support the need for a lifestyle modification program such as MOVE! in primary care settings to assist overweight and obese patients in managing their weight.

Prevalence of the Metabolic Syndrome Among U.S. Workers

OBJECTIVE Differences in the prevalence of cardiovascular disease (CVD) and its risk factors among occupational groups have been found in several studies. Certain types of workers (such as shift workers) may have a greater risk for metabolic syndrome, a precursor of CVD. The objective of this study was to assess the differences in prevalence and risk of metabolic syndrome among occupational groups using nationally representative data of U.S. workers. RESEARCH DESIGN AND METHODS Data from 8,457 employed participants (representing 131 million U.S. adults) of the 1999–2004 National Health and Nutrition Examination Survey were used. Unadjusted and age-adjusted prevalence and simple and multiple logistic regression analyses were conducted, adjusting for several potential confounders (BMI, alcohol drinking, smoking, physical activity, and sociodemographic characteristics) and survey design. RESULTS Of the workers, 20% met the criteria for the metabolic syndrome, with “miscellaneous food preparation and food service workers” and “farm operators, managers, and supervisors” having the greatest age-adjusted prevalence (29.6–31.1%) and “writers, artists, entertainers, and athletes,” and “engineers, architects, scientists” the lowest (8.5–9.2%). In logistic regression analyses “transportation/material moving” workers had significantly greater odds of meeting the criteria for metabolic syndrome relative to “executive, administrative, managerial” professionals (odds ratio 1.70 [95% CI 1.49–2.52]). CONCLUSIONS There is variability in the prevalence of metabolic syndrome by occupational status, with “transportation/material moving” workers at greatest risk for metabolic syndrome. Workplace health promotion programs addressing risk factors for metabolic syndrome that target workers in occupations with the greatest odds may be an efficient way to reach at-risk populations.

Prevalence and Associations of Binge Eating Disorder in a Multiethnic Population With Type 2 Diabetes

Binge eating disorder (BED) is a syndrome characterized by recurrent uncontrollable overeating (1,2), with prevalence rates of ∼3% in the general population and 10- to 20-fold higher in patients seeking treatment for obesity (1,3). There are limited reports of BED in subjects with type 2 diabetes, particularly in minorities (4,5). We conducted a pilot study to assess BED and its association with obesity, metabolic control, and depression in a tri-ethnic (37% Hispanic, 40% non-Hispanic white, and …