Diabetes Care for Older People: Is It Different?

October 16, 2014 at 1:43 pm | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

The Americans Diabetes Association has addressed the care of the older person living with diabetes  in their 2014 Clinical Practice Recommendations Standards of Medical Care. These recommendations do not define “older” by any specific numerical reference but instead are based on a person’s medical conditions. Quite honestly, this makes it easier for me to interpret these recommendations when I am caring for patients because I do not know what is considered “older” anymore. I think age is just a number that I personally hope keeps getting higher and higher, especially those decade celebrations because those silly cards are my all-time favorites.

The average lifespan of Americans is approximately 76 years for men and 81 years for women. This expectation has been slightly increasing over the years and everyone has an opinion as to why this is. I believe people are living longer due to a combination of better medical care, use of technology, and (quite frankly) attitude. I have been practicing for 30 years and I see people both living longer and living younger. I’d like to discuss this recommendation and offer some suggestions to help you and your family better understand and manage diabetes across your lifespan. I also want to remind you that these practice recommendations are just that: recommendations. Each person’s care should be individualized with their health care provider.

The Standards of Medical Care from the American Diabetes Association was developed because older adults with diabetes have a greater chance of premature death, cognitive impairment, and coexisting illness such as hypertension and heart disease. However, there are not many long-term studies available about the benefits of intensive control of blood sugar and blood pressure in the older population. The ADA has determined that people with few coexisting illnesses and intact cognitive and functional abilities should have similar goals for treatment as the general population. Those with multiple coexisting illnesses and some impairment (cognitively and /or functionally), end stage chronic illnesses, and/or severe cognitive impairment should have less stringent goals for treatment per the same recommendations. Health care providers need to consider that the goals for blood sugar management need to be directed to be sure that the acute complications of hyperglycemia, such as poor wound healing, dehydration, and coma, are avoided. It’s also important for health care providers to remember to screen for complications across the lifespan and individualize this screening to be most aware of complications such as visual and lower extremity injury that can develop quickly and seriously impact functional status.

Now, how can we break this down so people living with diabetes can use this information to stay well? As we age, we may be faced with challenges such as multiple medical conditions, decreased memory ability, decreased agility and mobility, and financial challenges. People with many medical conditions have to manage multiple medications and medical appointments. It’s helpful to bring a friend or family member to appointments to be sure all important information is provided to the health care provider, and make sure that the provider’s suggestions are understood. A visiting nurse home evaluation may be in order to help with medication safety.

People who are struggling with memory issues may forget when their appointments are. They may also forget if they took their medications which could have life threatening implications, including hypo or hyper –glycemia. Family members may be able to set up simple reminders like Post- it® notes on the bathroom mirror or the kitchen counter. A simple large calendar may help with the appointment reminders.

People with mobility issues may not be able to exercise as they once did, so glucose control may be hindered. They may also be at greater risk of injury from falling. A safety assessment of the living space may be needed to avoid falls. Osteoarthritis can make checking blood sugars, administering insulin, and food preparation difficult or even unsafe. They may actually not be able to do frequent glucometer checks, meaning medication dose(s) may need to be adjusted to ensure safety.

Financial needs are very important to identify and address as costs of medications, testing supplies, and food can definitely impede people’s health. Health care providers need to inquire about these issues as people may be too embarrassed to bring it up themselves. Referral to social services for assistance is an important piece to try to work on a solution to this problem.

These are complicating factors on their own, but people with diabetes may also have severe visual impairment as the chance of developing retinopathy increases across the life span. This factor alone can be a huge negative impact on a person’s health status. Diabetes is difficult to manage at times. It takes time and dedication for the person living with diabetes, their family, and their providers. Aging is another unavoidable bump in the road of management. Adjustments in your diabetes care plan are sometimes needed because of this unavoidable fact, but the goal of these changes is to continue your good health. I think that the best approach is not to get caught up in the A1C values, but rather continuing to do all you can to stay healthy and keep collecting those silly birthday cards!

On Insulin and Weight Gain

October 2, 2014 at 2:28 pm | Posted in Uncategorized | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

Does my insulin make me look fat? The answer to this question is …it might. That would make it the wrong answer because none of us want to take a medication that may cause weight gain, especially as maintaining a healthy weight is such a crucial aspect of good diabetes management. The purpose of this post is to discuss how insulin works and how it may affect your weight. I hope after reading this you’ll have fewer reservations about using insulin if it becomes necessary.

Maintaining a healthy weight is so important for general health and is particularly important for people with chronic diseases such as high blood pressure, high cholesterol, heart disease, arthritis, and diabetes. A healthy diet and weight may mean fewer daily medications or a lower dose of medications you still require. Many medications have the potential for side effects; diabetes medications are no different. Weight gain IS a possible side effect of insulin, but it may also happen with oral medications.

Let’s talk about insulin as a first step. It is, simply put, a lifesaving medication. Insulin was discovered in 1921 at the University of Toronto and has been extensively studied and improved upon since. The job of insulin is to move the glucose from the food we eat into our cells so they’re able to stay healthy and work well. It then takes the remaining glucose from the bloodstream and stores it so it can be used for energy later. People with Type 1 Diabetes are totally dependent upon this medication for survival as their pancreas does not produce insulin. People with Type 2 Diabetes can manage their disease many different ways: diet, exercise, oral medications, and insulin. Diabetes is a progressive and chronic disease that as yet does not have a cure. That is why so many people with Type 2 Diabetes will require insulin as part of their management over time.

Two common symptoms of poorly controlled diabetes are significant weight loss and excessive urination. The weight loss happens because stored fat gets broken down to provide enough fuel for bodily functions (heart and lungs, for example) to operate and maintain life. You may start to notice the numbers on the scale decrease, regardless of what you eat or drink. This is because calories consumed aren’t being properly metabolized but rather directly excreted with urination.

The treatment for extreme hyperglycemia is insulin therapy. The insulin corrects the high blood sugar, correcting the excessive weight loss in the process. The insulin is helping the body work correctly; it’s not causing new weight but rather replacing what was lost when the body was in crisis. It’s a sign the body is healing and starting to work more normally again. This is a good thing, but it can also be frustrating for people who struggle with their weight regardless of their level of glucose control. If your weight is still creeping up after your blood sugar is better controlled, there are probably other reasons for this and further investigation is needed.

Frequent episodes of hypoglycemia (low blood sugars) can cause added weight. I’ve discussed hypoglycemia in more detail in the past, but I want to review a couple of points now. Under eating, over exercising, and both oral medicines and insulin are potential causes of this frightening and potentially life threatening condition. Proper treatment is key, but it’s common for people to over treat low blood sugars because they feel so poorly and think more is faster and better. This is not the case, and the extra calories may cause added weight over time.  The strategy I encourage my patients to use is trying things like glucose tablets and gels for treatment more often than juices or regular soda because they are pre-packaged for the correct carbohydrate (15grams). It can be hard to measure out 4 oz of juice or regular soda when you are feeling so poorly and anxious during an episode of low blood sugar. I also strongly encourage all of my patients to see our RD CDE on a regular basis to review meal plans and make any adjustments as needed to assist with better weight control. It is also important to be as active as possible as any type of movement will decrease insulin resistance and improve weight and blood sugar numbers.

Insulin initiation is a daunting prospect for some. Many of my patients, especially those who are really struggling with their weight, have told me the fear of gaining weight is why they refuse insulin. I hope that my explanation helps to minimize this fear. So, this brings us back to where we started. Does my insulin make me look fat? I prefer to answer this way: It makes your body healthy so you look marvelous!!!

Caring for the Caregiver

September 25, 2014 at 11:15 am | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

Living with diabetes is a full time job for the patient, but what about their loved ones and family members? How do they cope with this disease and all of its implications? I would like to address the concerns of the caregivers today and how everyone can work together successfully.

Many people living with diabetes are perfectly able to care for all parts of their disease independently. However people who are visually impaired, have arthritis (particularly if their hands are involved), the elderly, and people with impaired mental functioning may require assistance in managing their diabetes. Their caregivers may include family members with whom they live or people who come to their homes as needed. The patient may work with just one person or there may be a team of caregivers available to assist.

Allow yourself to think for a minute about all that goes into daily self-care for a person living with diabetes. There are glucometer checks, medications and possibly self-titrating of insulin, meal adjustments, and the chance of unforeseen complications like hypoglycemia or an illness. Now think how stressful and difficult these responsibilities may be for a caregiver, especially for someone requiring a high level of assistance. Just as the person with diabetes can get overwhelmed and fatigued by their daily care, so too can the caregiver. That is when the caregiver needs the care.

Hopefully, if there is a team of people pitching in, no one will feel overburdened. However, many times there is just one person closely involved with the patient and it may be more difficult to realize the caregiver is suffering. It’s important that all involved in the patient’s care, including the health care team, check in with each other to see how things are going. Try to pick up on subtle clues such as off handed comments by the caregiver(s) like “I don’t always have time to get everything done, there is so much to do” or “I’m so tired all the time.” Also try to be aware of any changes in demeanor such as being impatient or more withdrawn, possible signs of fatigue or depression.

Schedules are important as well, not just for the patient but for the caregiver. It helps to still do the things that are important in their daily life so that their health and well-being are maintained. It’s important for caregivers to know that it‘s perfectly fine to ask for help. It doesn’t mean that they’re doing a bad job or can’t handle the tasks — just the opposite. Providing the best care possible really does begin with a mentally and emotionally healthy caretaker. Having responsibility in someone else’s care is a difficult and stressful job. It’s important for all involved to realize this. Caretakers should feel able to discuss their feelings with the health care team. Referral to social services may be in order to assist with identifying what other community services may be available. Support groups in the area may also be a good outlet to help to cope with the situation.

Everybody needs a little help sometime. A clear channel of communication between all the parties involved will hopefully ensure a caring environment is in place for all.

2014 – 2015 MGH Central Flu Clinic Schedule

September 18, 2014 at 11:16 am | Posted in Announcements | Leave a comment
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The 2014-2015 flu season is quickly approaching. Getting a flu shot is the best way to protect you and others from getting or spreading the flu.  We encourage all of our patients to consider getting a flu shot, especially those that are at high risk for getting the flu.  People who are high risk are:

  • People with medical conditions, like asthma and diabetes
  • Pregnant women
  • Children aged 6 months to 5 years
  • People older than  65 years of age
  • People who live with or care for others considered to be high-risk

Flu shots will be available on the MGH Main Campus on the following dates:

MGH Centralized Flu Shot Program
Wang Ambulatory Center Main Lobby
October 6th through November 21st
Monday-Friday:  8:00am-6:00pm
9:00am-3:00pm on Monday, October 13th (Columbus Day)

 

For more information, please call our flu hotline at 877-733-3737.  You can also visit www.massgeneral.org/flu or www.facebook.com/massgeneral for more details.

Cranberry Gorgonzola Spinach Salad

September 5, 2014 at 10:32 am | Posted in recipes | Leave a comment
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This salad utilizes flavorful, seasonal ingredients without derailing your healthy diet and takes minimal effort to prepare. Add grilled chicken, salmon or flank steak to make it into a meal.

Ingredients:
1 cup pecan halves
12 cups baby spinach
½ cup dried cranberries
1 cup gorgonzola (or other blue cheese), crumbled (about 4-5 ounces)
3 tbsp olive oil
1 tbsp balsamic vinegar
1 tsp grated orange peel (optional)
Salt and pepper

Instructions:
Preheat oven to 350 degrees. Bake pecans on an ungreased cookie sheet for 8-10 minutes or until golden. In a large bowl, combine spinach, cranberries and gorgonzola. Pour balsamic vinegar into a small bowl, whisk in olive oil and orange peel (if using). Pour over salad mixture and toss to combine.  Add pecans, season with salt and pepper to taste.

Yield: 6 servings

Nutrition Information per Serving (chicken, salmon or steak not included):
CALORIES: 300 • PROTEIN: 6g • SODIUM: 360mg • CARBOHYDRATE: 14g • FIBER: 3.5g •
FAT: 25g • Sat Fat: 6g

Diabetes and Sleep Apnea

August 28, 2014 at 10:39 am | Posted in Health | Leave a comment
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By Matt T. Bianchi, MD, PhD
Chief, Division of Sleep Medicine

In an era when advanced technologies, imaging, genetics, and personalized medicine is making heroic steps towards improving healthcare it may come as a surprise that a common and serious disorder with multiple available treatments remains largely undiagnosed. Yet such is the case for sleep apnea, which affects about 10% of adults but is diagnosed in fewer than half of these.  Sleep apnea is defined as repeated obstructions in breathing during sleep, each lasting typically 20-30 seconds.  These events can range from complete obstruction (apnea) to partial obstruction (hypopnea) and are often accompanied by drops in oxygen.

Sleep apnea is more common in people with diabetes, especially if other risks like obesity are present. Undiagnosed sleep apnea can increase risk of heart attack and stroke – which are already increased in those with diabetes. Sleep disturbances such as sleep apnea can also make it harder to keep blood sugars under control. Other risk factors include male sex, older age, smoking, and alcohol use. Those who have already had a heart attack or stroke, or who have poorly controlled blood pressure, are also at increased risk.

Diagnostic testing, performed in the laboratory or sometimes even at home, involves monitoring breathing and oxygen levels. Pauses in breathing (obstructions) occurring at 5 or more times per hour indicate sleep apnea is present. Increased pause rate means increased severity of the problem (15-30 is moderate; >30 is severe). This disorder often comes with snoring, sleepiness and being overweight – but not in every case.

There are many treatment options for those with sleep apnea. Wearing a mask known as continuous positive airway pressure (CPAP) while sleeping is the standard treatment. Although some initially find the prospect of this treatment daunting, there are dozens of different kinds of masks to help accommodate each person’s needs and comfort. Alternatives come in two categories: surgical and non-surgical. Surgeries include soft palate surgery and jaw advancement surgery, as well as a new stimulator device that acts like a pacemaker to prevent obstructions in sleep. Dental appliances can be made that pull the bottom jaw forward in sleep – these are made by specially trained dentists.

For some people, the sleep apnea is present mainly when they sleep on their back.  In these cases avoiding that position can be helpful. This can be accomplished with a shirt/vest that has a bumper on the back that makes back-sleeping uncomfortable. (The challenge is that some people end up sleeping on their back for some or all their sleep regardless.) Finally, weight loss can be helpful for those patients who are overweight. Whichever treatment pathways are chosen, alone or in combination, it is best to speak with your doctor about your choices and how to monitor your progress.

Shared Decision Making Chat

August 21, 2014 at 11:21 am | Posted in Announcements | Leave a comment
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We’re honored to have had Leigh Simmons, MD and Karen Sepucha, PhD from the Health Decisions Sciences Center chat with us on Twitter earlier this week about using shared decision making to set healthcare goals and build stronger relationships with providers.

Click below to read the transcript.

Power Granola

August 13, 2014 at 11:15 am | Posted in recipes | Leave a comment
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Sprinkle this granola on top of yogurt or fresh fruit for a healthy dessert or portion it into Ziplock bags for an on-the-go snack. The flaxseeds and walnuts provide a healthy dose of omega-3 fats, while the dried fruit adds a touch of natural sweetness.

Ingredients:
2 cups oats
1/3 cup flaxseed (whole or ground*)
¼ cup walnuts pieces
¼ cup slivered almonds
2 tsp cinnamon
1/3 cup orange juice
1/3 cup honey
¼ cup brown sugar, packed
1 tbsp canola oil
1 tsp vanilla extract
1/3 cup dried cranberries
¼ cup dried apricots, chopped
¼ tsp salt
Cooking spray or additional canola oil

Instructions:
Preheat oven to 315 degrees. In a large bowl, mix oats, flaxseed, nuts and cinnamon. Combine orange juice, honey and sugar in a small saucepan and cook on medium heat until sugar dissolves; remove from heat and stir in oil and vanilla. Pour orange juice mixture over oat mixture and toss to combine. Spray cookie sheet with cooking spray (or grease lightly with additional canola oil) so that granola will not stick to pan. Spread oat mixture on cookie sheet.
Bake for 10 minutes; stir mixture and bake for an other 10-15 minutes or until golden brown. Stir in dried fruit and let cool completely.

Store in an airtight container at room temperature for up to 2 weeks or in the refrigerator for up to several months.

*Ground flaxseed will provide more omega-3 fats

Yield: About 4½ cups (serving size: ¼ cup)

Nutrition Information per Serving:
CALORIES: 125 • PROTEIN: 3g • SODIUM: 35mg • CARBOHYDRATE: 20g •  FIBER: 2.5g • FAT: 4.5g • Sat Fat: 0.5g

(Recipe adapted from Cooking Light)

In a Nutshell

July 31, 2014 at 11:08 am | Posted in Nutrition, Secret Ingredient | Leave a comment
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By Leslie Wall
Dietetic Intern

Why are dietitians so crazy about nuts and seeds?! Nuts and seeds are morsels of heart healthy fats that can be added to meals and snacks or eaten alone. They pack a nutrient-dense punch of vitamins, minerals, and heart healthy fats that can lower cholesterol and reduce inflammation. They are also an excellent source of protein and fiber that help us feel full and satisfied, and add texture and flavor to many dishes.

Nuts and seeds vary in shape and size, and can be prepared in a variety of ways including toasted, roasted, raw, blanched, and salted. Aim to add a variety of nuts and seeds in their most natural form to your diet—raw or dry roasted are great choices. A serving of nuts is 1 ounce (about a palm full). Try mixing it up, as each variety of nuts and seeds contain different vitamins and minerals.

The MVPs of Nuts and Seeds – Here is a list of our favorites.

1. Almonds: Available year round, these nuts are rich in calcium, vitamin E, manganese, magnesium, copper, vitamin B2 (riboflavin), and phosphorus.

2. Cashews: High in antioxidants. Has a buttery taste when pureed, and often used to replace cheese sauces in vegan dishes. Chop and sprinkle on pizza for a meaty, flavorful texture.

3. Pecans: Buttery and slightly bittersweet, they’re typically used in pies, quick breads, cakes, cookies, candies and ice cream.

4. Pine Nuts: The edible seeds of pine trees, pine nuts are the key ingredient in fresh pesto and are out of this world sprinkled over salads, pasta, and pizza.

5. Flax Seeds: The richest plant source of omega-3 fatty acids. Add to breads, cookies, pancake mix, yogurt, and smoothies or sprinkle on cereal and salads.

6. Pumpkin Seeds (a.k.a. Pepitas): A great source of potassium, zinc and vitamin K. Roasted pumpkin seeds can be eaten alone as a snack, or and in salads and breads.

7. Sunflower Seeds: Sunflowers belong to the daisy family and are native to North America. The seeds are high in selenium, vitamin E and magnesium. Shelled seeds are delicious eaten raw or toasted, added to cakes and breads or sprinkled on salads or cereals.

Tips for Toasting: While nuts and seeds are certainly delicious eaten raw, toasting them on the stove or in the oven enhances their flavor.

  • On the stove: Place nuts in a skillet and toast for 5 to 10 minutes over medium heat. Shake and stir nuts until they’re golden brown and fragrant, then remove from the pan immediately and allow to cool.
  • In the oven: Arrange a single layer of nuts or seeds in a shallow baking pan and toast in a 350°F oven for 5 to 10 minutes, stirring occasionally.

Summer Recipe

Homemade Granola Bars ~ FitDay
Perfect for hiking, camping, and snacking.

(Post content reviewed by MGH Department of Nutrition and Food Services)

 

 

 

 

Grilling/BBQ Chat Recap

July 25, 2014 at 10:50 am | Posted in Announcements | Leave a comment
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Summer is prime season for grilling, BBQs and outdoor parties.  Erika Chan, a dietetic intern with the MGH Department of Nutrition and Food Services, led a discussion about healthy, flavorful ideas for your next cookout.

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