Diabetes in the United States presents a serious and growing public health concern. Approximately half of all diabetes cases occur in people older than 60 …

Live Well, Live Long: Steps to Better Health
Health Promotion and Disease Prevention for Older Adults

Diabetes Prevention and Management: Small Steps With Big Rewards

Introduction

Diabetes in the United States presents a serious and growing public health
concern In the last decade, the number of people with diabetes has grown
dramatically Approximately half of all diabetes cases occur in people
older than 60 years of age In 2002, diabetes was the fourth leading cause
of death for elders ages 55 to 64, and the fifth leading cause for elders
ages 65 to 84 In addition, diabetes affects people of color, especially
elders, more severely than non-Hispanic whites

The good news is that changes in eating habits, physical activity, and
diabetes self-care are often within the individuals power to control The
challenge is that in order to become permanent these changes require
support from family, partners, friends, healthcare, public health, and
aging-services professionals, health insurance administrators, and
policymakers in the community

The Diabetes Prevention and Management module provides aging-services
professionals with the tools to create a supportive
community environment
that allows older adults to take small steps toward preventing and better
managing type 2 diabetes
Highlights of the module:

An overview and definition of type 2 diabetes and prediabetes
Current national guidelines for diabetes management, weight loss,
and nutrition and physical activity for people with diabetes
Information on how to tailor your programs to special populations,
such as communities of color
Strategies for empowering individuals to make healthful choices and
communicate better with their healthcare providers
Suggestions for creating organizational and community-wide
partnerships for improving care of elders with diabetes
Consumer education curricula and handouts
Strategies for creating an evidence-based health promotion program,
including developing clear goals and objectives, drafting logic
models, and developing an evaluation plan

This module was developed by Sandra Maldague, MPH, American Society on
Aging, and Carolyn Leontos, MS, RD, CDE, University of Nevada The module
was independently reviewed for cultural competency The authors wish
to
thank the National Diabetes Education Program older adults workgroup for
their technical support in the development of this module Materials
published in September 2005
Live Well, Live Long: Steps to Better Health
Health Promotion and Disease Prevention for Older Adults

Diabetes Prevention and Management: Small Steps With Big Rewards

Chapter 1 Introduction to Diabetes in Older Adults

Table of Contents

Introduction
The Definition of Diabetes and Prediabetes
How Do Insulin Resistance and Diabetes Affect the Body?
How Can Diabetes Be Prevented?
Many People Are at Risk for Diabetes but Do Not Know It
Overweight Increases the Risk of Diabetes in Older Adults
Achieving a Healthy Weight
What Is Body Mass Index
How Can Diabetes Be Controlled?
Controlling the ABCs of Diabetes
Controlling A1C: Preventing High Blood Glucose Levels
Controlling Blood Pressure
Controlling Cholesterol: Preventing High LDL Levels
What Are Long-Term Diabetes-Related Problems? Are They Preventable?
How Is
Diabetes Different for Older Adults Than Younger Adults?
Treatment of Diabetes in Older Adults
American Geriatrics Society Guidelines for Improving the
Care of
the Older Person With Diabetes Mellitus
The ABCDEFGs of Diabetes in Older Adults
Myths About Diabetes in Older Adults
How Does Diabetes Affect Special Populations?
African Americans
American Indians and Alaska Natives
Asian/Pacific Islander Americans
Hispanic/Latino Americans
Common Myths About Diabetes
Resources
References
Glossary

Introduction

Diabetes in older adults is a serious problem — one out of five people
183 percent ages 60 and older have diabetes[1] and two out of five
people 401 percent ages 40 to 74 have prediabetes[2], a condition that
can lead to diabetes Current thinking in diabetes research is that being
overweight significantly contributes to the high rates of diabetes in the
United States Among older adults, one out of five people nearly 40
percent over age 50 is severely overweight obese, and nearly one out of
four people about
23-24 percent ages 51 and older are overweight[3] –
the numbers are very similar to the rates of diabetes and prediabetes for
roughly the same age group

National experts at the Centers for Disease Control and Prevention and the
National Institutes of Health do not believe that this is a coincidence -
they recommend that all overweight people ages 45 and older get tested for
diabetes[4] Older people who are overweight are also less likely to be
physically active and more likely to suffer from other conditions,
including high blood pressure, high cholesterol, heart problems, and joint
problems Communities of color in particular experience higher rates of
diabetes, and often higher rates of overweight than whites on average

This chapter outlines the key concepts needed to understand how diabetes
affects older adults: its effect on the body, special concerns related to
older adults and diabetes, and diabetes and specific groups of older
adults The chapter also presents information on prediabetes, a condition
that can be treated relatively easily, and how to prevent or delay diabetes
among people who have prediabetes

The Definition of Diabetes and Prediabetes

The term
diabetes commonly refers to the condition of diabetes mellitus
Described simply, diabetes is the inability to control your blood glucose
sugar without making a conscious effort Characteristics of diabetes
mellitus include excessive blood glucose levels, which result from the
bodys inability to use blood glucose for energy[5]

Adults ages 45 and older who are overweight should be checked for
prediabetes every three years if their blood glucose levels are in the
normal range[6] People with prediabetes should be checked for type 2
diabetes every 1-2 years after diagnosis[7] Note that type 2 diabetes is
different from type 1 diabetes see glossary for definition This
publication was developed for professionals who work with older adults who
have or are at risk for type 2 diabetes

Individuals can get checked for type 2 diabetes by asking their doctor or
primary care provider for the following tests The two tests described in
Table 1 below are reliable and require fasting nothing to eat or drink
except water the night before

Prediabetes can be treated, and it is possible to prevent or delay the
onset of diabetes in people who have prediabetes To learn more, see How
Can Diabetes Be
Prevented?

Described simply, diabetes is the inability to control your blood glucose
sugar without making a conscious effort Characteristics of diabetes
mellitus include excessive blood glucose levels, which result from the
bodys inability to use blood glucose for energy[9]
This inability to use blood glucose can stem from resistance to insulin
The hormone insulin tells other cells when to use glucose for energy It
sparks the process of converting glucose into fuel for the body

The pancreas, an organ located behind the lower
part of the stomach, produces not only insulin but
other chemicals used in digesting food[10]

If insulin fails to shuttle the glucose into the
cells, the glucose remains in the bloodstream and
cells do not receive the fuel they need The
glucose
in the bloodstream then rises to
inappropriate highs, accumulating in blood vessels
and affecting organs and nerves In an effort to
flush the excess glucose out, the
kidneys pull more water out of the bloodstream — occasionally causing the
need to urinate and drink more frequently

As one ages, cells can become resistant to insulin Diabetes can also stem
from problems with function of the pancreas and its production of insulin
However, sometimes this process occurs so slowly that there are no
symptoms, which causes long delays in diagnosis As blood glucose levels
increase, the pancreas becomes less efficient at producing insulin and
eventually stops producing it

Insulin resistance — the bodys inability to respond to and use the
insulin it produces — is also linked to being overweight, having high
blood pressure, and having high levels of cholesterol in the blood[11]

How Can Diabetes Be Prevented?

Only recently have researchers been able to identify effective ways to
prevent or delay the onset of diabetes among people who are at risk In
2001, a large-scale national study called the Diabetes Prevention
Program
DPP showed — for the first time ever — that type 2 diabetes could be
prevented or delayed through changes in eating habits and physical
activity[12], [13]
What we have learned from the DPP study shows that diabetes can be
prevented or delayed by taking a few small steps:

Losing a moderate amount of weight
For people who weigh more than 200 pounds, losing 10 to 15 pounds
5 - 7 percent of body weight

Increasing physical activity wwwasagingorg/cdc/module6/homecfm

Walking or riding a bike for 30 minutes most days or other
comparable
activity

Consuming healthful foods in appropriate portion sizes

The study also showed that older adults respond better than younger age
groups to increased physical activity and weight loss achieved through low-
fat food choices In the same study, although medications were effective
to some degree, physical activity and weight loss were significantly more
effective in older adults[14]

Many People Are at Risk for Diabetes but Do Not Know It

According to recent estimates, 30 percent of people who have diabetes do
not know that they have the disease[15] — in other words, 52
million
people are unaware of their condition and the threat that diabetes poses to
their future quality of life Additionally, many older adults who do not
have diabetes are at high risk of developing diabetes Among US adults
ages 40-74, nearly 41 million are estimated to have prediabetes[16]
Studies show that many people with prediabetes will go on to develop
diabetes within 10 years[17]

With the prevalence of diabetes and prediabetes on the rise, public health,
aging-services and health-services providers face a challenge: informing
elders who are at risk for the disease and those who already have diabetes
but do not know it Furthermore, they must help elders who have been
diagnosed with diabetes learn to take care of themselves and prevent long
term diabetes-related problems from developing Providers face additional
challenges with reaching, informing, and assisting members of special
populations A later section describes ways to address these challenges

Overweight Increases the Risk of Diabetes in Older Adults

For adults, overweight and obesity ranges are determined by using weight
and height to calculate a number called the body mass index BMI BMI is
used because, for
most people, it corresponds with their amount of body
fat

An adult who has a BMI between 25 kg/m2 and 299 kg/m2 is
considered overweight for Asian Americans, adults with a BMI of
23 or higher are considered overweight; for Pacific Islanders,
adults with a BMI equal to or higher than 26 are considered
overweight
An adult who has a BMI of 30 kg/m2 or higher is considered
obese[18]

The National Heart, Lung and Blood Institute Obesity Education Initiative
has developed an online calculator to help people determine their BMI see
glossary For example, an adult who is 56 and weighs between 155 and
185 pounds is overweight and one who weighs more than 185 pounds is obese
The Weight-control Information Network WIN has developed a printable BMI
chart to share with consumers

To use the chart: Find your weight on the bottom of the chart Go straight
up from that point until you come to the line that matches your height
Then look to find your weight group Healthy Weight, Overweight or
Obese

National experts at the Centers for Disease Control and Prevention and the
National Institutes of Health recommend that all overweight people ages
45
and older get tested for diabetes[19] Older people who are overweight are
also less likely to be physically active and more likely to suffer from
other conditions, including high blood pressure, high cholesterol, heart
problems, and joint problems Also, while obesity in people ages 70 and
older does not necessarily shorten their life expectancy, it increases the
chances that they will experience some kind of disability[20]

Elders of color in particular experience higher rates of diabetes and
overweight than whites on average[21] Adults ages 51 to 69 experience
higher rates of obesity than people 70 and older Older adults with lower
incomes and those with less education also have greater rates of obesity -
27 percent for those who did not graduate from high school, compared to 22
percent for those with a high school degree or more Older men and women
have similar rates of obesity[22]

Achieving a Healthy Weight

Being a larger size in itself does not have to be a problem, as long
as the individual feels comfortable with their body and the community
does not make them feel bad for being larger The problem is that,
with larger size, people can
experience increasing complications with
their health that can affect their quality of life For larger
people, losing weight to improve health does not mean becoming a size
2 for women, or achieving perfectly flat and hard abs for men Losing
a moderate amount of weight 5-7 percent is just one step to feel
better daily, and to add more good years to your life

Like many aspects of your health, there is no right or wrong way to be
- we are all on a continuum There are some things we can improve
for example, regardless of our weight, at least 8 out 10 of us can
improve our eating habits, according to the national Continuing Survey
of Food Intake Information administered by the US Department of
Agriculture, and there are things that are out of our immediate
control eg unwalkable communities - if our communities are not
walking-friendly Those of us with one or more disabilities may face
additional challenges in being physically active and able to get
healthful foods If we value our health, it is important to improve
our relationship to eating, working, reflecting, and playing, and to

ask others around us including professionals, elected
representatives to be supportive
Body-Mass Index BMI

For many people, numbers relating to weight are a turn-off - the
number of pounds you weigh, the number of calories eaten, and body-
mass index But for some people, this may be an effective way to keep
track of body weight Body-mass index is a better measure of the
relationship between your health and your weight than just looking at
the number of pounds This is because it accounts for your height,
lean body mass, and body fat Also, the definitions of overweight
using BMI see glossary are related to potential problems with your
health due to high levels of body fat, not your image The Weight-
control Information Network WIN, a project of the National Heart
Lung and Blood Institute, has developed a series of helpful brochures
For more information, see the list of publications on the WIN
website: http://winniddknihgov/publications/indexhtm

How Can Diabetes Be Controlled?

People with diabetes can take action to lower their chances of developing
heart disease, stroke, and other
diabetes-related problems by:

Controlling the ABCs of diabetes
Following an individualized meal plan
Engaging in physical activity
wwwasagingorg/cdc/module6/phase2/phase2_4cfm
Using self-management techniques, such as foot checks and self-
monitoring of blood glucose, as instructed by healthcare providers
Reporting any new symptoms, such as vision problems or falls, to
their healthcare provider in a timely manner
Avoiding tobacco use
Taking medications as prescribed

A multidisciplinary team approach is critical to success in diabetes care
and prevention All health care providers can help by discussing how self-
management and diabetes control relate to preventing complications

Controlling the ABCs of Diabetes

About 2 out of 3 65 percent people with diabetes die of some form of
heart or blood vessel disease eg, heart attack or stroke[23] People
who have diabetes often have high blood pressure and high cholesterol as
well To address this, a healthcare provider who encounters a person with
diabetes will develop individual goals for blood glucose, blood pressure,
and cholesterol

Healthcare providers use the
A1C blood test to measure average blood
glucose levels over a two to three month period Healthcare providers also
use blood pressure and cholesterol to check the health of someone who has
diabetes These are referred to as the ABCs of diabetes For more
information, see Comprehensive Treatment of Diabetes

The ABCs of Diabetes A1C, Blood Pressure, and Cholesterol
Using the A1C, good blood glucose levels are less than 7 percent
Good blood pressure levels are less than 130/80
Good cholesterol levels LDL are less than 100 mg/dl

The figures above are considered target values for the general
population, and are meant to be tailored to individual needs by a
healthcare provider Among frail older adults, in particular, these rules
do not always apply See glossary for definition of frail To find out
more, see How Is Diabetes Different for Older Adults Than Younger Adults?

Many people with diabetes, including older adults, are not aware of the
link between cardiovascular disease eg, heart disease and stroke and
diabetes

In one survey, nearly 7 in 10 68 percent people with diabetes
reported that they do not consider cardiovascular disease to be a

serious complication of diabetes
In the same survey, 3 in 5 60 percent people with diabetes
reported that they do not feel at risk for either high blood
pressure or cholesterol problems

Healthcare providers also need to be educated in this area A survey of
healthcare providers worldwide called the AUDIT Study showed that the
targets that diabetes specialists set for their patients are frequently not
as low as their professional organizations recommend Specifically, many
diabetes specialists still do not recognize that diabetes is a coronary
equivalent The term coronary equivalent refers to the fact that people
with diabetes are at high risk for suffering a cardiovascular event, such
as a stroke or heart attack, and should be considered in the same category
as others who are at high risk for suffering a cardiovascular event

Table 2 demonstrates some of the types of services used by providers and
people with diabetes to control the disease Table 2 also shows the
percentage of people who receive services, in comparison with the
objectives set by the US Department of Health and Human Services for 2010
called Healthy People 2010, wwwhealthypeoplegov/

Table 2:
Use of Healthcare Services for Diabetes Care[24]

Controlling A1C: Preventing High Blood Glucose Levels

High
blood glucose levels are a major problem for most people with
diabetes, even once treatment has begun According to the US Third
National Health and Nutrition Examination Survey NHANES III, a
national survey conducted between 1988-1994 by the National Center for
Health Statistics NCHS, Centers for Disease Control and Prevention
CDC, only 43 percent of Americans diagnosed with diabetes are
achieving and maintaining optimal blood glucose control A1C less than
7 percent, according to the American Diabetes Association A1C is a
measure of blood glucose over a two- to three-month period That means
more than half nearly 6 million people of those diagnosed with
diabetes are at risk for serious complications associated with
uncontrolled diabetes

Among those who are uncontrolled:
57 percent have an A1C7
41 percent have an A1C8
15 percent have an A1C10[25]
The Diabetes Control and Complications Trial DCCT showed that tight
blood glucose control reduced the risk of nerve damage and eye and
kidney disease in persons with type 1 diabetes

The United Kingdom
Prospective Diabetes Study UKPDS showed that,
among people with type 2 diabetes, improved control of blood glucose
and blood pressure had many long-term benefits For every 1 percent
lowering of the A1C toward normal blood glucose levels, there is a
lower risk of:
percent in parenthesis refers to the percent decrease in risk:

Amputation or dying of peripheral vascular disease 43
percent[26]
Diabetes-related nerve damage and eye and kidney disease
together, these conditions are referred to as microvascular
disease 37 percent[27]
Diabetes-related kidney problems as measured by the presence
of a protein called albumin in the urine 33 percent[28]
Cataracts requiring surgery 24 percent[29]
Diabetes-related damage to the retina called retinopathy
21 percent [30]
Dying of diabetes 21 percent[31]
Heart failure 16 percent[32]
Heart attack or myocardial infarction 14 percent[33] - 16
percent[34]
Stroke 12 percent[35]

Controlling Blood Pressure

Controlling blood pressure is another challenge that many people with
diabetes and their healthcare providers face In national surveys,
about 73 percent of adults with diabetes have high blood pressure
defined as having a blood pressure greater than or equal to 130/80 mm
Hg or using prescription medications for high blood pressure[36]
High blood pressure is easily detectable and usually controllable with
lifestyle modifications such as increasing physical activity or
lowering salt intake, with or without medications[37]

Some statistics on blood pressure in the general population:

About 1 in 3 American adults have high blood pressure High
blood pressure affects:
o About 2 in 5 40 percent African Americans[38]
o About 1 in 4 27 percent non-Hispanic whites[39]
o About 1 in 5 20 percent Hispanics and Native
Americans[40]
o About 1 in 6 17 percent Asians[41]

On average, men tend to have slightly higher rates than women
and have lower rates of controlled blood pressure People of

lower income levels have worse control and higher blood
pressure rates than people of higher income levels on
average[42]

People living in the South, Northeast, and the Industrial
Midwest regions tend to have the highest rates of high blood
pressure[43]

The United Kingdom Prospective Diabetes Study UKPDS showed that,
among people with type 2 diabetes, improved control of blood glucose
and blood pressure had many long-term benefits Improved blood
pressure control[44] over 8 years led to a lower chance of developing
percent in parenthesis refers to the percent decrease in risk:

Diabetes-related damage to the retina of the eye 34 percent
Blindness 47 percent
Diabetes-related nerve damage and eye and kidney disease
together, these conditions are referred to as microvascular
disease 37 percent
Heart failure 56 percent
Stroke 44 percent[45]

Controlling Cholesterol: Preventing High LDL Levels

Recently, two large health maintenance organizations HMOs studied
patients with
diabetes and found that only about 1 in 3 37 percent
adults achieved LDL cholesterol levels of less than 100 mg/dL, the
recommended goal set by the American Diabetes Association[46]

Some statistics on cholesterol in the general population:

People in the Southwest, Northwest except for the state of
Washington, and some Southern and Midwestern states are
least likely to have had their blood cholesterol checked
within the past five years[47]

High cholesterol affects:
o About 1 in 5 19 percent blacks/African Americans
o About 1 in 5 21 percent non-Hispanic whites
o About 1 in 5 18 percent Mexican Americans
o Slightly more women than men 22 vs 19 percent[48]

On average, people with lower income and a high school
education or less are more likely to have high cholesterol
than people with higher income and more education[49]
Multiple studies have shown that lowering LDL cholesterol lowers the
risk of developing heart disease or stroke The first of these
landmark
studies was the Coronary Primary Prevention Trial CPPT
This study gave the first conclusive evidence that lowering LDL
cholesterol and total blood cholesterol can lower the risk of heart
disease and heart attacks in men at high risk because of high amounts
of blood cholesterol Men who took a cholesterol-lowering drug on
average experienced a 19 percent lower chance of dying from heart
disease Subsequent studies confirmed these results and showed that
lowering cholesterol could lower the chances of dying of heart disease
by as much as 47 percent the Oslo Study Diet and Antismoking
Trial[50] Later studies also showed that people with average
cholesterol levels could also reduce their risk for developing heart
disease by lowering cholesterol[51]

What Are Long-Term Diabetes-Related Problems? Are They Preventable?

Over time, if blood glucose is not kept under good control, or if someone
has had diabetes for a long time about ten years, the following diabetes-
related problems may surface:

Loss of feeling in the feet and hands
Damage to blood vessels
Slow healing cuts and scrapes
Chronic
wounds on hands and feet
Blindness
Hyper- or hypoglycemia high or low blood sugar
Kidney disease
Heart disease
Stroke
Complications related to influenza
Complications related to pneumonia
Depression

Medications can be prescribed or adjusted to better control blood glucose
sugar Higher levels of blood glucose encourage bacteria to grow Poor
circulation prevents the white blood cells that fight off bacteria and
viruses from reaching the wound as efficiently The combined effect of
diabetes on blood vessels, nerves, and the immune system the bodys
ability to heal can lead to a chronic infection in the feet or other
extremities

Diabetes is also the leading cause of blindness in the United States for
people ages 20-74[52], [53] Almost everyone with diabetes will have some
damage to their eye called diabetic retinopathy because the blood vessels
in the eye become damaged, but severe eye problems, including blindness,
can be prevented and treated if caught early Some people also assume that
amputation of a foot or a leg is to be expected with the onset of diabetes
This is not true — going regularly to medical visits, taking
adequate
steps for self-care, and controlling blood glucose can prevent blindness
and amputation Treatments exist for all long term diabetes-related
problems[54]

See the following table to determine which long-term diabetes-related
problems are preventable or controllable

For more information on preventing diabetes-related problems, see
Identifying and Treating Long-Term Diabetes Problems in Chapter 2,
Guidelines for Diabetes Care: When to Get Checkups and What to Expect

How Is Diabetes Different for Older Adults than Younger Adults?

With increasing age

The body is less able to absorb glucose sugar from the
bloodstream into the cells
Typical symptoms of diabetes, including dizziness and frequent
urination, are often absent
Some symptoms of diabetes, such as mental confusion, weight loss,
and incontinence, often go unnoticed because they are thought to be
related to medications or the aging process
Diabetes often
goes unrecognized and undiagnosed until a person is
hospitalized for a diabetes-related long-term problem, such as a
heart attack or stroke In nursing home residents, diabetes may not
be diagnosed until someone is hospitalized for coma resulting from
too high blood glucose
Depression and cognitive impairment are more likely to be a problem
for elders with diabetes compared to other elders
Older adults using insulin for diabetes are more likely to
experience problems with low blood glucose[55], [56], [57], [58]

In addition, the National Diabetes Education Program states that anyone
ages 45 and above who is overweight is at risk for diabetes
Numbers and Statistics: The Impact of Diabetes on Older Adults

The diabetes epidemic among older Americans is evidenced by the following:

Nearly half of all people who have diabetes are age 65 or older
The majority of older adults with diabetes have type 2 diabetes
Of Americans ages 60 and older, nearly one in five have diabetes 86
million people[59]
Of Americans ages 40-74, two in five have prediabetes 41 million
people[60]
In 2002, nearly half
a million people ages 60 and above were diagnosed
with diabetes for the first time[61]
o In 2002, diabetes was the fourth leading cause of death for
elders ages 55 to 64, and the fifth leading cause for elders
ages 65 to 74, and ages 75 to 84[62]
o For elders who are 85 and older, diabetes is ranked as the
seventh leading cause of death Heart disease, stroke, influenza
and pneumonia are other important causes of death among people
ages 65 and older[63] About 2 out of 3 65 percent people with
diabetes die of some form of heart or blood vessel disease
eg, heart attack or stroke[64] People with diabetes are 2
to 3 times more likely than those without diabetes to have
pneumonia and influenza as an underlying or contributing cause
of death[65]

In addition, diabetes affects people of color, especially elders, more
severely than non-Hispanic whites In 2002,

Diabetes was the third leading cause of death among American Indian
and Alaska Native men and women ages 65 or older[66]
Diabetes was the fourth leading cause of death among:

o Older Hispanic men and women[67]
o Asian and Pacific Islander women ages 65 or older [68]
o Black women ages 65 or older[69]
The fifth leading cause of death among black men ages 65 or older
was diabetes[70]
Diabetes ranked sixth among older white men and older Asian and
Pacific Islander men[71]
Diabetes ranked seventh among older white women ages 65 or
older[72]

Compared to non-Hispanic whites, people of color are more likely to suffer
and die of diabetes-related problems However, efforts to prevent diabetes
are just as effective in elders of color as they are in non-Hispanic
whites

In the next 25 years, people ages 65 and older will make up most of the
diabetic population in the United States[73]

Chart 1: Number of Americans With Diabetes by Age Group[74]

Treatment of Diabetes in Older Adults

Treating diabetes in older adults in theory is no different than treating
diabetes in middle-aged adults The recommendations are essentially the
same - the main difference being that older adults are more likely to
experience physical or mental health issues or social problems that makes
treating the
diabetes more challenging Despite the magnitude of the
problem of diabetes in older adults, and the potential for prevention and
control of complications, diabetes in older adults is often unrecognized
and undertreated Additionally, elders with diabetes may require more
frequent visits than younger age groups to monitor the effects of
medications on their blood glucose, blood pressure and cholesterol

One concern is that older adults with diabetes are not receiving adequate
care for heart disease and stroke prevention For example, in the
Cardiovascular Health Study CHS, a study of heart health in adults ages
65 and older, researchers examined the medical care of older adults who
have diabetes compared to those who do not The study found that:

Only 12 percent of older people with diabetes achieved blood
glucose levels within the range recommended by the American
Diabetes Association ADA

Only 50 percent of older people with diabetes and known heart
disease used aspirin as recommended by current guidelines Only 33
percent of people with diabetes but no known heart disease used
aspirin as recommended

Approximately 50
percent of older people with diabetes and known
problems with high blood pressure ie, a diagnosis of
hypertension had uncontrolled high blood pressure greater than
140/90 mmHg Interestingly, more people with diabetes were being
treated with medications for high blood pressure

Older people living with both diabetes and high cholesterol
received significantly worse care for their cholesterol problems
than people without diabetes Only 8 percent of older people with
diabetes had low-density lipoprotein LDL, or bad cholesterol
levels below the current treatment goal of 100 mg/dL Fifty-four
percent of older people who do not have diabetes but are treated
for high cholesterol have LDL levels below the recommended
treatment goal[75]

The Cardiovascular Health Study results support the need for improved
control of A1C, blood pressure and cholesterol among older adults with
diabetes Other studies suggest that more research is needed to determine
the effects of tight blood glucose control in older people[76] In most
cases, controlling the ABCs for adults ages 50 and older with diabetes
can
significantly lower their chances of developing heart disease, stroke,
and other diabetes-related problems, and improve overall well-being and
quality of life The American Geriatrics Society Guidelines for Improving
the Care of the Older Person outline the circumstances in which tight
control of the ABCs may not be a priority, such as when a persons life
expectancy is less than 5 years

Darin Olson, MD, PhD, an instructor at the Division of Endocrinology and
Metabolism, Emory University School of Medicine, and Staff Physician at the
Atlanta Veterans Affairs Medical Center, summarized the guidelines from the
California Healthcare Foundation/American Geriatrics Society Panel on
Improving Care for Elders with Diabetes[77] These guidelines were
developed in response to the less-than-ideal diabetes care experienced by
many older adults

1 American Geriatrics Society AGS Guidelines for Improving the Care
of the Older Person With Diabetes Mellitus[78] Offer individualized
therapy that considers:
Life expectancy
Cognitive impairment
Patient preferences
Functional status
Social support

2 Keep
therapy as simple and inexpensive as possible Prescribe low-
cost generic drugs whenever possible

3 Encourage diabetes education of the patient and primary caregivers,
with the reminder that such education is covered by Medicare
Medicare covers diabetes self-management training and, as of
January 1, 2006, diabetes supplies

4 Treat high blood pressure and high cholesterol LDL, the bad
cholesterol to lower the risk of heart disease

5 Consider that treating high blood pressure is likely to require
more than one medication, and medications should be titrated
slowly In other words, with high blood pressure medication, most
people need to have the dosage and strength of the medication
increased until the end of life no way to go but up Because
these medications can cause some damage to the kidneys, however,
healthcare providers should make changes as slowly as possible

6 The goal, in most cases, for glycemic control should usually
include the standard A1C target of less than 7 percent For older
adults, target hemoglobin A1C should be more individualized than
in
younger age groups Consider a higher goal, if appropriate, based
on the following factors:

Patient preference
Diabetes severity
Life expectancy
Functional status

A reasonable goal for A1C in relatively healthy adults with good
functional status is 7 percent or lower For frail older adults
see glossary for definition of frail, persons with life
expectancy of less than five years, and others in whom the risks of
intensive glycemic control appear to outweigh the benefits, a less
stringent target such as 8 percent is appropriate

7 Refer patients for a dilated eye exam at least every 2 years, and
yearly when diabetes-related eye problems or other eye problems
exist, or if risk factors are present such as high blood pressure
and poor control of blood glucose

8 Screen for depression and offer psychological or medication therapy
promptly if the patient is depressed

9 Maintain an updated medication list and monitor regularly for
medication-related problems

10 Screen annually for cognitive impairment and
other geriatric
syndromes eg, urinary incontinence, pain, or falls

The ABCDEFGs of Diabetes in Older Adults

Fredrick Sherman, MD, MSc, medical director for senior services at Mt
Sinai NYU Health and medical editor of the publication Geriatrics,
developed the mnemonic of the ABCDEFGs of diabetes for older adults[79] In
general, his memorizing tool is consistent with the AGS guidelines for
diabetes care in older adults This memorizing tool builds on the widely
known concept of the ABCs of diabetes A1C, Blood pressure, Cholesterol

Aspirin: Recommend that patients take 81 mg per day
Aim for an A1C of less than 8 aim for 7 if the person is not frail

Blood pressure should be less than 130/80 mm Hg

Cholesterol LDL should be less than 100
Cognitive impairment: Conduct a Mini-Mental State Examination with the
patient

Depression: Ask the patient the following questions: Do you often
feel sad or depressed? During the past month, have you been bothered
by feeling down, depressed, or hopeless? During the past month, have
you been bothered by little interest or pleasure in doing things?

Eyes:
Recommend that patient be examined by an eye specialist every
one or two years
Electrolytes: Test for diabetes-related kidney problems such as
microalbuminuria
Exercise: Encourage exercise and physical activity

Feet: Examine skin and pedal pulses, and conduct a monofilament test
for diabetes-related nerve problems
Falls: Ask about falls and test balance tandem gait, tandem stance
Flu vaccine: Recommend a yearly flu vaccine, and ask about pneumonia
vaccine

Geriatric Giants: Assess patient for multiple medication use,
medication-related problems from improperly prescribed drugs,
cognitive impairment, urinary incontinence, and pain

Stop Smoking: Remind older adults it is never too late to stop smoking

Myths About Diabetes in Older Adults

Overall, management strategies for diabetes, such as making changes in
eating habits and physical activity and using diabetes medications, are no
different for older people than for younger groups However, older adults
are diverse in terms of their physical and cognitive abilities, health,
life expectancy, and desire to remain healthy As a result, there are
a
number of prevalent myths about diabetes in older adults

Myth: All older adults with diabetes are frail

Reality: While frail elders, such as those residing in nursing homes,
need highly individualized care to determine appropriate blood glucose
levels, taking into account whether they are underweight and what
their life expectancy is,[80] most older adults with diabetes live in
the community and would not be considered frail Frail implies that
the person does not have long to live and should be made comfortable
Because the percentage of older adults who meet the definition of
frail is relatively small,[81] we should question whether we would
make more of an effort to help this person improve their health if
they were 10 or 20 years younger See glossary for definition of
frail

Myth: The high prevalence of diabetes in older adults is inevitable

Reality: Despite the high rate of diabetes and prediabetes among older
adults, the Diabetes Prevention Program study showed that diabetes can
be prevented or delayed through changes in eating habits and physical
activity In fact, older adults
in the study who made changes in these
habits had better health than younger groups[82]

Myth: High blood glucose in the older adult population is usually a
benign condition

Reality: While frail older adults such as most nursing home
residents tend to have higher blood glucose levels than younger or
healthier groups, high blood glucose levels can be prevented through
medication, physical activity, and eating better Many older adults
are hospitalized each year and go into a coma because they have high
blood glucose and undiagnosed diabetes This underlines the importance
of older adults getting screened to see if they have diabetes see
next section

Myth: Reduced life expectancy makes the consequences of ongoing high
blood glucose irrelevant They dont have long to live so why treat
them?

Reality: Ongoing high blood glucose can result in many severe
complications, such as foot wounds leading to amputation and eye
problems leading to blindness, that can be prevented by proper
diabetes care People with high blood glucose levels are also more
likely to suffer from heart disease and stroke
And they are more
likely to suffer from memory loss These complications are painful and
costly They are also needless — in most cases, such complications
can be prevented or even reversed if treated appropriately

Also, life expectancy for persons at every age group also has
increased during the past century Based on todays age-specific death
rates, individuals aged 65 years can be expected to live an average of
18 more years, for a total of 83 years Those aged 75 years can be
expected to live an average of 11 more years, for a total of 86
years[83]

Medications can be adjusted to prevent high blood glucose levels The
use of specific medications can maximize blood glucose control and
minimize the risk of low blood glucose in older adults[84] Treatments
exist for all diabetes-related complications[85] Studies have shown
that people who are treated appropriately for ongoing high blood
glucose live longer, too So people may have more good years left in
them than some might think

Myth: The majority of older adults with type 2 diabetes are obese and
need to lose weight

Reality: While 2 in 5 older adults are overweight, only 1 in 5 are
obese While many overweight adults are at risk for prediabetes and
can benefit from losing weight, those who are medically overweight
will benefit the most Also, many people do not know if they are a
little overweight or obese, and should check with their doctor to see
if they are at risk for prediabetes Frail elders with diabetes
typically need to gain weight, not lose it

Myth: Older adults are less capable of self-monitoring of their blood
glucose than younger adults

Reality: While older adults may experience some changes in learning
ability and memory retention, once a change in routine becomes a
habit, many older adults are better at maintaining the change than
younger groups Studies have shown that older adults may need extra
training in the beginning to learn to monitor blood glucose, but that
they are just as capable as anyone else of learning to do so[86]

How Does Diabetes Affect Special Populations?

Diabetes is now the sixth leading cause of death in the United States –
and for American Indians, African Americans,
Asian/Pacific Islander
Americans, and Hispanics/Latinos, diabetes is in the top five[87] Many
elders in the United States are more at risk for diabetes due to their race
or ethnicity Women, people with lower incomes or assets, people who did
not complete high school, and people living in rural or central urban areas
are also more likely to have diabetes Genetics and health status are not
the only reasons for this These issues are also discussed in chapter 3,
with examples of programs that have been successful in addressing some
aspect of these barriers

Some studies have shown a difference in the health status of people of
color and other groups compared to white men with higher income and
education who live in the suburbs that could not be explained by income or
education For example, black men with the same income and education as
white men, living in the same area, experience higher rates of disease[88]
Further research has shown that people of color and women of color in
particular do not receive equal treatment for health conditions[89]

In the United States, all people of color have a higher chance of
developing diabetes than white people Recent research suggests that
people
with diabetes are less likely to exercise and more likely to be overweight,
or at least have an increased percentage of abdominal fat[90] Older
adults in general are more likely to develop diabetes than younger adults,
and elders of color are among the most likely of the US population to
develop diabetes Note also that many people of color, especially women,
develop diabetes in their 30s and 40s and sometimes their 20s, long before
they are considered elders

Why do some groups appear to suffer more from diabetes than others?

Genetic risk factors
The common finding that diabetes runs in families indicates that
there is a strong genetic component to type 1 and type 2 diabetes
Many scientists are now conducting research to determine the genes
that cause diabetes For type 2 diabetes, there seem to be genes
that determine insulin secretion and insulin resistance

Medical risk factors
Prediabetes, gestational diabetes diabetes that some women develop
during pregnancy, insulin resistance, and overweight are medical
conditions that predispose people to develop diabetes

Physical activity and
nutrition
Studies have shown that people from Latino and Asian/Pacific
Islander communities in the US eat more and engage in less
physical activity than people from their countries of origin
Regular physical activity is a protective factor against type 2
diabetes, and, conversely, lack of physical activity is a risk
factor for developing diabetes Researchers suspect that a lack of
physical activity is one factor contributing to the high rates of
diabetes in people of color compared to whites

However, the underlying reasons for the health status of many groups at
high-risk for diabetes involve the lack of conditions necessary to be
healthy:

Legal, economic, education and historical discrimination
Due to segregation and other discriminatory laws, policies, and
employment practices, certain groups have historically been forced
to live in specific areas, limiting options for work, education,
career preparation, and healthcare While segregation no longer is
legal, it persists in various forms, and actions to ensure equal
economic access and equal access to healthcare
services, health
insurance, grocery stores, fresh produce, and safe parks and
recreational facilities have not been uniform across the country
Note: In one study of more than 3,700 women of color, participants
who had a regular doctor were at least twice as likely as those who
did not to receive preventive care for diabetes and other
conditions[91]

Interpersonal discrimination
Healthcare providers, other professionals, and support staff
sometimes make false assumptions about patients or clients,
consciously or unconsciously Sometimes, discriminatory healthcare
practices sanctioned by local, state, and federal government
agencies remain in the memory of elders from a particular group,
such as the Tuskegee Syphilis study among African American men[92]
and the treatment of tuberculosis in Filipinos and Latinos in Los
Angeles County and other parts of California[93] Cultural
competence training and use of healthcare providers representative
of the community being served has been shown to help healthcare
providers provide more sensitive care to
their patients[94]

Internalized discrimination
With life experience and history lessons taught by parents and
grandparents, many people of color learn to expect to be treated
differently based on their appearance This can result in
depression, anger, and limiting ones options for job training or
career pursuits Researchers have found people of color also have
higher stress levels called allostatic load not explained by
income, education, or other characteristics

Cultural characteristics relating to food and physical activity
Physical activity and eating customs vary widely from culture to
culture, and within each race and ethnic group, people may be from
different countries of origin, different tribes, and different
parts of the country or state[95] It is well-documented that:
Women generally are less active than men at all ages, people
with lower incomes and less education are typically not as
physically active as those with higher incomes and education
African Americans and Hispanics are generally less physically

active than whites
Adults in northeastern and southern States tend to be less
active than adults in North-Central and Western States
People with disabilities are less physically active than
people without disabilities
And, by age 75, one in three men and one in two women engage
in no regular physical activity[96]

Nearly every group has healthful foods — preferred vegetables,
fruits, grains, and legumes — rooted in its cultural traditions
Over time, many cultures have eschewed traditional healthful foods
for more readily obtained high-calorie, high-fat, high-salt, or
high-sugar foods Recommendations to increase dairy consumption go
against the cultural dietary habits and the lactose intolerance
of most people of color — 90 percent of the worlds population, in
fact[97] According to an article published in the American Academy
of Family Physicians, 60 to 80 percent of Blacks, 50 to 80 percent
of Hispanics, 95 to 100 percent of Asians, and 80 to 100 percent of
American Indians are lactose intolerant and may
suffer stomach
cramps, diarrhea, and other painful or distressing gastrointestinal
symptoms Lactose intolerance occurs in 6 to 22 percent of American
whites[98]

Low health literacy
Older adults from all racial and ethnic groups are likely to
become confused by medical information; elders of color even more
so, especially if English is a second language Hospital signage,
directions for obtaining appointments or performing tests,
instructions for taking medications, and explanations relating to
the causes of a disease often are given using confusing
terminology Such confusion can lead to medication-related
problems, missed appointments, poor follow-up care, and worse
overall health Studies have shown that low health literacy leads
to worse health outcomes for people with diabetes in
particular[99], [100]

Immigration status
Research has shown that immigrants to the United States have
better diets higher in fruits and vegetables and lower in fat
than their children or grandchildren who are born in the United
States
However, they have worse diets with respect to diabetes
than the people in their countries of origin

Language
In a study of the health of older Californians, while about 4 in
5 older non-Latino whites reported having private supplemental
health insurance, only 37 percent of limited-English speakers
reported having that insurance In the same study, older Latinos
and older Californians with limited-English were more likely than
the total state average to report diabetes, fair/poor health,
emotional difficulties, use of preventive services Note that in
the population studied, about 40 percent of Latinos were limited-
English, and about 45 percent of the older limited-English group is
Latino[101] Elders who are not proficient in English may shy away
from educational and health services not available in their
language Outreach, dissemination of health information, and
advertising of services should be done via culturally appropriate,
in-language media channels, such as Chinese language newspapers and
Latin American telenovelas on local Spanish
television

To address these challenges, Dr Sandra Black, an associate professor at
the University of Maryland School of Medicines Division of Gerontology
proposes the following actions:

1 Diabetes must be acknowledged as a public health problem Community
interventions, including early screening and lifestyle change, are
paramount and must be culturally appropriate

2 Effective treatment and prevention programs must become standard
clinical practice Intensive diabetes management and improved
glycemic control will minimize the impact of diabetes and lead to
fewer medical costs, lower rates of complications, and greatly
reduced mortality as a result of the disease[102]

3 Screening and interventions in the prediabetic years must become
the norm We need to increase screening among high-risk groups and
institute culturally appropriate interventions that will enhance
change in the prediabetic years

4 Those groups at highest risk must be empowered to take control of
their own health Control of diabetes is a highly demanding
endeavor, requiring substantial vigilance, lifestyle
change,
medication adherence, and motivation Those who suffer from the
disease are often those least prepared to deal with it All people
at risk for diabetes must be helped to develop the skills necessary
to prevent or manage the disease[103]

The sections on the next page discuss how diabetes affects specific groups
of elders The recent results of the Diabetes Prevention Program study
provide encouraging news for all people at risk for diabetes, including
elders of color People at high risk for type 2 diabetes can prevent or
delay diabetes with regular physical activity, healthy eating changes, and
modest weight loss Much can be done to prevent and manage long-term
diabetes-related problems as well

For specific strategies on addressing cultural competence and health
disparities among older adults, see Creating Culturally Sensitive and
Effective Health Promotion Materials and Strategies for Promoting
Physical Activity in Culturally Diverse Communities Additional resources
on health disparities and cultural competence are listed in a resource list
developed by the American Society on Agings Healthcare and Aging Network
in partnership with Network
of Multicultural Aging

African Americans

Some facts and figures on diabetes and related conditions among African
Americans in the United States:

Heart disease death rates are more than 40 percent higher for
African Americans than for whites[104]

Nearly 3 27 million non-Hispanic blacks ages 20 or older have
diabetes 114 percent of all non-Hispanic blacks aged twenty
years or older have diabetes[105]

On average, non-Hispanic blacks are 16 times as likely to have
diabetes than non-Hispanic whites of similar age[106]

Among African Americans ages 65-74, about 1 in 4 25 percent have
diabetes[107]

On average, non-Hispanic blacks are about twice 16 times as
likely to have diabetes as non-Hispanic whites of similar age[108]

Overweight is a major medical risk factor for diabetes in African
Americans, especially for women Some diabetes may be prevented
with weight control through regular exercise and healthy
eating[109]

African Americans have higher incidence of diabetes complications
such as kidney failure, visual impairment, and amputations,
and
these complications result in greater disability for African
Americans[110]
African Americans in California have hospitalization rates for
diabetes that are up to 10 times higher for diabetes than other
ethnicities The same study showed that hospitalization rates for
hypertension were about 7 times higher for hypertension[111]

Death rates for people with diabetes are more than 25 percent
greater for African Americans compared to white people[112]

Programs that have successfully addressed diabetes, nutrition, or physical
activity in African American communities:

American Diabetes Association
Body and Soul
Examples of Innovative Physical Activity Programs for Older Adults
in Culturally Diverse Communities

To find culturally appropriate materials for African Americans in your
community, contact the National Diabetes Information Clearinghouse or the
American Diabetes Association The National Diabetes Education Program also
has an African American Workgroup of diabetes experts dedicated to
promoting diabetes awareness and prevention in African American
communities Contact the National
Diabetes Education Program for more
information about the workgroup

American Indians and Alaska Natives

Medical and lifestyle factors are thought to contribute to the high rates
of diabetes in American Indians and Alaska Natives Increasing rates of
obesity have been measured in many American Indian and Alaska Native
communities In Pima Indians, 95 percent of those with diabetes are
overweight A thrifty gene is also thought to cause a genetic
predisposition to obesity, although this gene has not been identified
Changes in diet and physical activity have also changed in the past several
decades and are linked to the rise in diabetes For example, Pima Indians
living in Mexico who consumed a more traditional diet less animal fat and
more complex carbohydrates had a lower rate of type 2 diabetes than Pima
Indians living in Arizona Pima Indians in Mexico also spent more calories
through physical activity High rates of prediabetes and insulin
resistance are also thought to contribute to diabetes in American Indians
and Alaska Natives[113]

Some facts and figures on diabetes among American Indians and Alaska
Natives in the United States:

American Indians and Alaska Natives
are about 2 22 times as
likely to have diabetes as non-Hispanic whites[114]

In a 1995 study in 13 American Indian tribes in Oklahoma, Arizona
and North and South Dakota, 33 to 70 percent of American Indian
adults age 45 to 74 were found to have diabetes compared to 183
percent of people ages 60 and older in the general US
population Those in Arizona had the highest rates of diabetes;
South and North Dakota had the lowest American Indian women
experienced higher rates of diabetes than men in all geographic
areas[115]

Rates of diabetes vary widely among American Indian tribes, bands,
pueblos, and villages At the regional level, diabetes is least
common among Alaska Natives fewer than 1 in 10, or 82 percent
and most common among American Indians in the southeastern United
States about 1 in 4 people, or 278 percent and southern Arizona
about 1 in 4 people, or 278 percent[116] As a group, however,
American Indians and Alaska Natives served by the Indian Health
Service experience a much higher rate of diabetes than non-Hispanic
whites Diabetes
rates among 45 - 64 year olds are about 4 times as
high in American Indians/Alaska Natives 199 vs 52 percent
American Indians and Alaska Natives 65 and older experience rates
of diabetes that are about twice as high compared to non-Hispanic
whites 226 vs 114 percent[117]

Available data may underestimate the true prevalence of diabetes
among American Indians For example, data from the Navajo Health
and Nutrition Survey, published in 1997, showed that about 23
229 percent of Navajo adults had diabetes, one third of whom had
not yet been diagnosed[118]

Among the Pima Indians of Arizona, about 1 in 2 people 50 percent
ages 30-64 have diabetes[119]

The death rate for diabetes in American Indians is estimated to be
more than 4 times the rate in non-Hispanic white people[120]

Diabetes contributes to several of the leading causes of death in
American Indians: heart disease, cerebrovascular disease,
pneumonia, and influenza

American Indians and Alaska Natives with diabetes have a high
incidence of long-term diabetes-related problems, such as
eye and
kidney disease, cardiovascular disease, and lower-extremity
amputations[121] The incidence of periodontal disease is nearly
three times higher in Pima Indians with diabetes than in those who
do not have it[122]Cardiovascular disease was the leading cause of
death in American Indians, and diabetes is a high contributing risk
factor for cardiovascular disease[123]

Programs that have successfully addressed diabetes, nutrition, or physical
activity in American Indian and Alaska Native communities include:
A garden project in rural Oklahoma
A diabetes education exhibit at a pow-wow and rodeo in South Dakota
A traditional foods program to reduce blood glucose
Community health representatives
Examples of Innovative Physical Activity Programs for Older Adults
in Culturally Diverse Communities

To find culturally appropriate materials for American Indians and Alaska
Natives in your community, contact the Indian Health Service The National
Diabetes Education Program also has an American Indian and Alaska Native
Workgroup, diabetes experts dedicated to promoting diabetes awareness
and
prevention in American Indian and Alaska Native communities The AIAN
Workgroup has developed an online and print community partnership guide
The National Diabetes Information Clearinghouse, and the American Diabetes
Association also have materials for American Indian and Alaska Native
communities

Asian/Pacific Islander Americans

Some facts and figures on diabetes among Asian/Pacific Islander Americans
APIAs in the United States:

Prevalence data for diabetes among Asian/Pacific Islander Americans
are limited Some groups within this population are at increased
risk for diabetes[124] For APIAs ages 45-64, diabetes ranked as
the fifth-highest cause of death in non-Hispanic whites, diabetes
is the seventh leading cause[125]

In 2002, Native Hawaiians, and Japanese and Filipino residents of
Hawaii ages 20 and older were approximately 2 times as likely to
have diagnosed diabetes as white residents of Hawaii of similar
age[126]

The food choices of some Asian Americans and Pacific Islanders have
changed due to modern times and their migration to the United
States Instead of traditional
plant- and fish-based diets, they
are choosing foods with more animal protein, animal fats, and
processed carbohydrates[127]

Rates of blindness from diabetes for people of color are double
those for non-Hispanic whites However, no data on Asian/Pacific
Islander Americans are available[128]

Asian and Pacific Islander Americans have the lowest prevalence of
end-stage renal disease of all communities of color People of
color have better survival rates after treatment with dialysis than
do non-Hispanic whites[129]

Programs that have successfully addressed diabetes, nutrition, or physical
activity in APIA communities include:

A Filipino American retirees organization in San Diego, California

Community health workers in a Chinese American community in
Oakland, California
A project that adapted cultural recipes for Chinese and Filipino
American elders with diabetes
Examples of Innovative Physical Activity Programs for Older Adults
in Culturally Diverse Communities see the Community Health and
Nutrition Demonstration Project

To find culturally
appropriate materials for Asian/Pacific Islander
Americans in your community, contact the National Diabetes Information
Clearinghouse, or the American Diabetes Association, The National Diabetes
Education Program also has an APIA Workgroup of diabetes experts dedicated
to promoting diabetes awareness and prevention in APIA communities Contact
the organization for more information about the workgroup

Hispanic/Latino Americans

Being familiar with the following values and ways of thinking can
facilitate communicating with Hispanic/Latino Americans about health

Fatalismo
Translated as fatalism, this way of thinking is captured in the
expression Ojala - if God wills it In terms of health, it
implies that humans have no control over their health or sickness -
only God has the power to decide

Familismo
Messages about self-care are received better if the concept of the
family is included For example, women may respond better to
messages to take care of themselves if they are tied to family
eg do it for your grandchildren Family members are often the
primary caregivers and children or grandchildren
may accompany
elders to medical visits

Respeto
The value of respect, or giving deference to respected
professionals, implies that a patient may be more willing to trust
the opinion of a doctor, nurse or other healthcare providers over
the opinion of family members

Personalismo
This concept relates to building trust and getting to know the
person In spite of the limited time available in todays
healthcare settings, Hispanic/Latino American healthcare providers
can play an important role in establishing trust and developing
relationships with patients of the same culture
Some facts and figures on diabetes among Hispanic/Latino Americans in the
United States:

About 1 in 10 82 percent Hispanic/Latino Americans ages 20 and
older have diabetes On average, Hispanic/Latino Americans are
almost 2 15 times more likely to have diabetes than non-Hispanic
whites[130]

Diabetes is particularly common among middle-aged and older
Hispanic Americans For those ages 50 or older, about 1 in 4 25 to
30 percent have either diagnosed or undiagnosed
diabetes[131]

The following factors are thought to contribute to the high rates
of diabetes among Hispanic/Latino Americans Hispanic/Latino
Americans are generally less physically active than non-Hispanic
whites[132] Hispanic/Latino Americans are also more likely than
non-Hispanic whites to be overweight[133]

Diabetes in Hispanic/Latino Americans is a serious health challenge
because of the increased prevalence of diabetes in this population,
the greater number of risk factors for diabetes in Hispanic/Latino
Americans, the greater incidence of several diabetes complications,
and the growing number of people of Hispanic/Latino American
ethnicity in the United States[134]

Hispanic/Latino Americans with diabetes have a higher incidence of
diabetes complications such as eye and kidney disease than non-
Hispanic whites However, they may have lower rates of heart
disease[135]

Programs that have successfully addressed diabetes, nutrition, or physical
activity in Latino American communities include:

Community health workers in Latino and Asian Communities

Puerto Rican and Latino diabetes and health literacy projects
Examples of Innovative Physical Activity Programs for Older Adults in
Culturally Diverse Communities

To find culturally appropriate materials for Latino Americans in your
community, contact the National Diabetes Information Clearinghouse or the
American Diabetes Association The National Diabetes Education Program also
has a Latino/Hispanic Workgroup of diabetes experts dedicated to promoting
diabetes awareness and prevention in Latino American communities Contact
the program for more information about the workgroup

Common Myths About Diabetes

Many myths related to diabetes persist among people across all levels of
education, cultures, and income levels

Myth: Diabetes can be cured

Fact: Diabetes has no cure Diabetes results from changes in the
bodys ability to absorb glucose sugar Once these changes happen,
the body never fully regains its ability to process glucose

However, people with diabetes can improve their glucose absorption
through careful monitoring of what they eat and blood glucose levels
Physical activity may also benefit people with diabetes by
increasing
glucose absorption and reducing their weight and percentage of body
fat People with diabetes can develop a better sense of how food and
activity affect them by regularly monitoring their glucose over time
Through these strategies, you can slow the progression of the disease
and lower the risk of developing long-term diabetes-related problems
So while diabetes cannot be cured, it is a very manageable and livable
chronic disease

Myth: I have a touch of sugar

There is no such thing as a touch of sugar You cannot have a
touch of diabetes any more than you can be a touch pregnant Having
sugar means having diabetes Treat it seriously so that it does not
become serious

Myth: Only people who inject insulin have diabetes I am only borderline

Fact: There is no such thing as borderline with diabetes To a lot
of people, borderline means they dont have to make healthful
changes to control diabetes because they dont believe they have it
yet

Fact: Type 2 diabetes does not worsen or turn into type 1 diabetes
when a person begins to use insulin Many people are hesitant about

beginning insulin treatment because they feel it means their diabetes
is worse or terminal

People with consistently high blood glucose levels may postpone a
visit to the doctor, afraid their doctor will prescribe them insulin
They may become depressed if their doctor prescribes insulin
injections instead of oral medications to control their diabetes
Beginning insulin use may trigger loss of hope and belief that all
diet and physical activity efforts have failed — which may affect
their adherence to the treatment regimen

In reality, a diagnosis of diabetes is based on a bodys ability to
process glucose, not on the treatment As with most conditions,
treatment varies depending on the individual Common colds, stress,
and chronic diseases, as well as diet and physical activity, affect
the bodys tolerance for glucose A switch to insulin is not
necessarily permanent

Myth: Diabetes is caused by eating too many sweets or too much sugar –
thats why its called sugar diabetes

Fact: Diabetes is the inability to control a type of sugar: glucose
Glucose is found in many foods — not
just sweets Pasta, rice,
fruits, milk, and breads all contain carbohydrates, which are broken
down into glucose during digestion Not all carbohydrates are created
equal Fruits and vegetables are sources of carbohydrate, calories and
other nutrients such as vitamins, minerals, and fiber Hard candy, on
the other hand, is also a source of carbohydrate and calories;
however, it does not contain additional nutrients If someone is at
risk for diabetes because of his or her eating habits, it is more
likely due to general habits of overeating that result in weight gain

Myth: If diabetes runs in my family, there is nothing I can do to prevent
it

Fact: African Americans, Native Americans, Latinos, Asian Americans,
and Pacific Islanders experience higher rates of diabetes than whites
in the United States, and may be more likely to assume there is
nothing they can do to prevent diabetes But losing weight by changing
eating habits and exercising effectively prevents or delays the onset
of diabetes — no matter which race or ethnicity someone belongs to
Healthy eating habits and 30 minutes of
physical activity on five or
more days per week[136] benefit almost anyone at risk for diabetes,
regardless of whether or not the disease runs in their family or is
common among people in their racial or ethnic group

Environmental factors can influence the formation and maintenance of
healthy eating and exercise habits Many low-income communities do not
have grocery stores, and fresh produce can be hard to find Rural
roads can make traveling to stores difficult, and the selection of
foods available at stores may be limited

Myth: If I have diabetes, I will never be able to eat the things I like
again

Fact: Diabetes educators and nutritionists can help develop eating
plans that still incorporate enjoyable foods The American Diabetes
Association offers many recipes and nutrition tips on its website and
in publications such as 101 Nutrition Tips for People With Diabetes

For example, in Northern California, Daly City Senior Services helped
Filipino elders with diabetes to write a cookbook containing
traditional recipes The elders provided the recipes, which were then
given to a
nutritionist with understanding of Filipino food
traditions The nutritionist reviewed the recipes and developed
similar but healthier versions Now the elders meet at their senior
center on a regular basis and hold potlucks using the modified
recipes

Myth: By drinking water, I can wash away the extra sugar in my blood and
cure diabetes

Although you can wash away spilled sugar from a table, the bodys own
sugar, glucose, cannot be washed away by drinking water However, you
can control your diabetes by eating a healthy diet, staying physically
active, losing weight if you are overweight, seeing your healthcare
provider regularly, taking any medications as prescribed, and
monitoring your blood glucose levels regularly

Myth: Insulin is a cure for diabetes

Insulin is not a cure for diabetes At this point, there is no cure
for diabetes, only medicine and behaviors that help to control it
Insulin helps to control diabetes by keeping glucose, the bodys
sugar, from building up in the bloodstream

Resources

Use the following online and print resources to determine the
following:

Finding a Diabetes Expert in Your Community

American Diabetes Association
800 DIABETES 342-2383
Website: wwwdiabetesorg

The American Diabetes Association offers resources for professionals,
including
PowerPoint slides for presentations, brochures for the public, and a
free e-newsletter Professional members receive peer-reviewed
publications and resources for networking such as member directories
and participation in professional councils Find links to these
resources on the Health Professionals and Researchers Homepage

Other useful tools and programs offered by the American Diabetes
Association:

The Advocacy and Legal Resources Homepage contains insurance
and discrimination information for people of all ages that
have difficulty obtaining health insurance because of their
diabetes

Information for congregations on how to organize a Diabetes
Day, a faith-based program in African American and Latino
communities During a designated service, the pastor or
another individual briefly
discusses the seriousness of
diabetes Support groups for people with diabetes, healthy
cooking classes, and exercise workshops follow

The ADAs Diabetes and Cardiovascular Disease Toolkit
contains informational flyers on nutrition, physical
activity, blood pressure, glucose monitoring, and other
health issues for people with diabetes

ClubPed is an online tool to track steps and find local
walking groups

State-Based Diabetes Prevention and Control Programs
Centers for Disease Control and Prevention
Division of Diabetes Translation
877 232-3422
Website: wwwcdcgov/diabetes/states/indexhtmlist

Every state has a diabetes prevention and control program located
within the state health department State diabetes program staff can
provide your community with expert information and guidance on
preventing and controlling diabetes They can also provide your
community with information on NDEP wwwndepnihgov/ campaign
products and help link your community to available resources for
people with diabetes and their
families

Indian Health Service
The Reyes Building
801 Thompson Avenue, Ste 400
Rockville, MD 20852-1627
Website: wwwihsgov/MedicalPrograms/Diabetes/indexasp

The Indian Health Service IHS, an agency within the US Department
of Health and Human Services, is responsible for providing federal
health services to American Indians and Alaska Natives The provision
of health services to members of federally recognized tribes grew out
of the special government-to-government relationship between the
federal government and Indian tribes The IHS is the principal federal
healthcare provider and health advocate for Indian people, providing
healthcare services to approximately 15 million American Indians and
Alaska Natives who belong to more than 557 federally recognized tribes
in 35 states The IHS has a Division of Diabetes Treatment and
Prevention that has developed an integrated diabetes education
recognition program As part of the program, the IHS identifies
preapproved curricula
wwwihsgov/MedicalPrograms/Diabetes/recognition/iderp_curriculapdf
and model diabetes
programs
wwwihsgov/MedicalPrograms/Diabetes/recognition/iderp_pdpdf

American Association of Diabetes Educators AADE
800 338-3633, or call 800 TEAMUP4 to find a local diabetes
educator
Website: wwwaadenetorg

The AADE is made up of a wide variety of health professionals who are
involved in educating people about diabetes The AADE has a number of
state and regional chapters that sponsor educational conferences for
health professionals and is a great source, via the Diabetes Educator
Access Line, for referrals to nurse educators and physicians in your
area who specialize in diabetes

American Dietetic Association ADA
800 877-1600
Website: wwweatrightorg

The American Dietetic Association serves the public by promoting
optimal nutrition, health, and well-being The 4,700 members of the
associations Diabetes Care and Education Practice Group DCE are
registered dietitians, dietetic technicians, and other members with an
interest in diabetes The DCE promotes high-quality nutrition care and
education to people with diabetes and their families, the DCE

membership, other professional organizations, and industry by
advocating a proactive position on nutrition and diabetes issues and
by responding to the needs of diabetes organizations The American
Dietetic Association also provides daily nutrition tips, healthy
lifestyle tips, and information for professionals

State Cooperative Extension Offices
Cooperative State Research, Education, and Extension Service CSREES
Waterfront Centre
800 9th St SW, Washington, DC 20024
202 720-3029
Website: wwwcsreesusdagov

Alternately, you can contact your local county extension office
listed under local government in the telephone directory or local
land-grant university

The CSREES responds to predominant quality-of-life problems through
strategic planning and the development of research and education
programs in cooperation with its partners Extension specialists and
agents are often registered dietitians with extensive experience in
providing guidance on healthy eating for people with diabetes and
their families Many organize Dining with Diabetes programs to
provide
support to people with diabetes and their families in learning
to prepare diabetes-friendly meals

Lions Clubs
Lions Clubs International Headquarters
630 571-5466
Website: wwwlionsclubsorg

With 14 million members in 43,000 clubs, the Lions Club sponsor
humanitarian projects in communities throughout the world The clubs
are actively involved in programs related to the prevention and
treatment of diabetic eye disease, including public and community
education programs and provision of assistance to diabetic patients
with eye disorders Lions Clubs have a variety of materials on
diabetes and diabetic eye disease that may be useful for your
community They also may be able to provide your group with support
for your community diabetes activities The Lions Clubs is a great
organization to contact if you are planning an activity in January -
National Eye Health Month - because of the link between diabetes and
sight

Sources of Diabetes Consumer Education Information

A Diabetes Community Partnership Guide
Developed by the National Diabetes Education Program NDEP

Order online at http://ndepnihgov/materials/pubs/community-
guide/community-guidehtm

This guide is widely used by US Department of Agriculture Extension
Service dietitians and other healthcare and aging-services
professionals to develop activities for community audiences in places
where people live, work, play, and reflect The guide provides plain-
language definitions of diabetes, prevention and control messages for
community audiences, and suggestions for integrating diabetes
activities and messages into any community Program examples,
suggested activities, and culturally appropriate consumer education
tools reflect the diversity of communities affected by diabetes
Bilingual Spanish-English materials are included More materials in a
variety of languages are available on the NDEP website

The National Diabetes Education Program
Website: http://ndepnih/gov

The National Diabetes Education Program NDEP is a partnership
between the National Institute of Diabetes and Digestive and Kidney
Diseases of the National Institutes of Health and the Centers for
Disease Control
and Prevention The purpose of the NDEP is to improve
the treatment and outcome for people with diabetes, promote early
diagnosis, and ultimately prevent the onset of this disease

The current NDEP diabetes prevention campaign, Small Steps, Big
Rewards, is focused on small, realistic steps that individuals can
take to prevent or delay the onset of diabetes As with all NDEP
campaigns, materials contain culturally appropriate ideas and
information on losing weight by eating healthier and getting more
physical activity A few sample materials:

Tip Sheet
Its Not Too Late to Prevent Diabetes: Take Your First Step
Today
Target: older audience
Website: wwwndepnihgov/diabetes/pubs/nottoolate_tipspdf

Tip Sheet
More Than 50 Ways to Prevent Diabetes
Target: African American audience
Website: wwwndepnihgov/diabetes/pubs/50Ways_tipspdf

National Diabetes Information Clearinghouse
National Institute of Diabetes and Digestive and Kidney Diseases
1 Information Way
Bethesda, MD 20892-3560
800 860-8747
Website:
http://diabetesniddknihgov/

The National Diabetes Information Clearinghouse provides information
about diabetes to people with diabetes and their families, health care
professionals, and the public Through the clearinghouse, communities
can order an array of brochures, pamphlets, how-to kits, and other
materials on controlling diabetes

How Widespread Is the Problem of Diabetes in Your Community?

For more information on the problem of diabetes in your community, contact
the following national organizations to find the members who are active in
or responsible for tracking diabetes in your state, county, or region
These organizations may also make good partners for forming coalitions to
address diabetes in your area

Centers for Disease Control and Prevention State-based Diabetes
Prevention and Control Programs DPCPs
Website: wwwcdcgov/diabetes/states/indexhtmlist

American Diabetes Association ADA
Website: wwwdiabetesorg

The American Diabetes Association has local chapters for most, if not
all, regions of the United States
National Association of Community Health Centers NACHC
7200 Wisconsin
Ave, Suite 210
Bethesda, MD 20814
Tel: 301 347-0400
Website: wwwnachcorg

Community health centers are local, non-profit, community-owned
healthcare providers serving low-income and medically underserved
communities For nearly 40 years, the national network of health
centers has provided high-quality, affordable primary care and
preventive services, and often provide on-site dental, pharmaceutical,
and mental health and substance abuse services Also known as
Federally-Qualified Health Centers FQHCs, these centers are located
in areas where care is needed but scarce Currently, more than 1,000
community, migrant, and homeless health centers serve 3,600 urban and
rural communities in every state and territory Many community health
centers have established diabetes registries to track the care of
their patients

Americas Health Insurance Plans AHIP

601 Pennsylvania Avenue, NW
South Building
Suite 500
Washington, DC 20004
Tel: 202 778-3200
Website: http://wwwahiporg/

Americas Health Insurance Plans is the national association
representing
nearly 1,300 member companies providing health insurance
coverage to more than 200 million Americans Member companies offer
medical expense insurance, long-term care insurance, disability income
insurance, dental insurance, supplemental insurance, stop-loss
insurance and reinsurance to consumers, employers, and public
purchasers

Association of Schools of Public Health ASPH

1101 15th St NW, Suite 910
Washington, DC 20005
Tel: 202 296-1099
Website: wwwasphorg

Schools of public health are a resource for training and support to
identify and address community health problems They also are
resources for collecting and analyzing health data, educating the
public on health issues, shaping local and state health policy, and
planning programs School of public health libraries will often have
statistics on local and state health issues

Sources for National and State Data on Diabetes Morbidity and Mortality

Centers for Disease Control and Prevention

Division of Diabetes Translation
877 CDC-DIAB 232-3422
Website: wwwcdcgov/diabetes

The CDCs Division of
Diabetes Translation is the national agency
responsible for collecting data on diabetes in the United States

The CDC has also published a report that contains comprehensive
information on morbidity and mortality:

CDC Task Force on Community Preventive Services 2001
Strategies for Reducing Morbidity and Mortality From Diabetes
Through Health-Care System Interventions and Diabetes Self-
Management Education in Community Settings: A Report on
Recommendations of the Task Force on Community Preventive
Services Morbidity and Mortality Weekly Report Recommendations
and Reports, September 28, 2001 / 50RR16; 1-15 Available
online at wwwcdcgov/mmwr

In addition, the CDC maintains an online list of state-based diabetes
prevention and control programs at
wwwcdcgov/diabetes/states/indexhtmlist

American Diabetes Association

Website: wwwdiabetesorg

The American Diabetes Association has local chapters for most, if not
all, regions of the United States, and each chapter will have
information on the burden of diabetes for the area

National Center for Health Statistics
wwwcdcgov/nchs/
The National Center for Health Statistics has published a number of
reports on diabetes:

1999 Summary of Progress on the Healthy People 2000 objectives
for diabetes
wwwcdcgov/nchs/data/hp2000/diabetes/diabtsprpdf

FASTATS on diabetes
wwwcdcgov/nchs/fastats/diabeteshtm

Medicare Quality Improvement Organizations QIOs
http://cmshhsgov/qio/2asp

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Glossary - Chapter 1

A1C
The A1C also called HbA1C, Hemoglobin A1C, or glycosylated
hemoglobin is a test that measures the amount of glucose attached to
the hemoglobin molecule in your blood cells The A1C test is a simple
lab test that reflects your average blood glucose levels over the past
3 months It is the best way to know how well your blood glucose is
controlled overall It does not measure how your blood glucose changes

over the course of the day This test used to be called hemoglobin
pronounced he-mo-glo-bin A-1-C or H-b-A-1-C You should have this
test at least twice a year The goal for most people with diabetes is
below 7

BMI or Body-Mass Index
Body-mass index is a measure of the relationship between health and
weight that accounts for a persons height, lean body mass, and body
fat

Frail
The term frail has often been used to describe people who were weak
or had balance problems Researchers have developed a new definition
that classifies someone as frail if he or she has three or more of
the following: muscle weakness, slow walking speed, exhaustion, low
physical activity levels, or unintentional weight loss
From July 2005 report on Frailty: Emergence and Consequences in
Women Aged 65 and Older in the Womens Health Initiative Observational
Study Journal of the American Geriatrics Society 538:1321-1330
The report is authored by Nancy Fugate Woods et al Visit
wwwblackwell-synergycom/doi/abs/101111/j1532-5415200553405x to
view the report

Overweight:
For adults,
overweight and obesity ranges are determined by using
weight and height to calculate a number called the body mass index
BMI BMI is used because, for most people, it corresponds with their
amount of body fat

An adult who has a BMI between 25 kg/m2 and 299 kg/m2 is
considered overweight for Asian Americans, adults with a
BMI of 23 or higher are considered overweight; for Pacific
Islanders, adults with a BMI equal to or higher than 26 are
considered overweight
An adult who has a BMI of 30 kg/m2 or higher is considered
obese[137]

Retina
The retina is a part of the eye responsible for transmitting visual
information from the eye to the brain Extensive damage to the retina
by high levels of glucose in the blood can lead to blindness
Type 1 diabetes
Also referred to as Insulin-dependent diabetes mellitus and
Juvenile onset diabetes In type 1 diabetes, the beta cells of the
pancreas produce little or no insulin, the hormone that allows glucose
to enter body cells Without adequate insulin, glucose builds up in
the
bloodstream instead of going into the cells Within 5 to 10 years
after diagnosis, the insulin-producing beta cells of the pancreas are
completely destroyed, and no more insulin is produced Type 1 diabetes
can occur at any age, but it usually starts in people younger than 30
Symptoms are usually severe and occur rapidly

———————–
[1] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[2] Ibid
[3] Center on an Aging Society, Georgetown University July 2003 Obesity
Among Older Americans Data profile: No10 Monograph Available at
Georgetown University on the World Wide Web:
ihcrpgeorgetownedu/agingsociety/pubhtml/obesity2/obesity2html
[4] National Diabetes Education Program April 2004 Guiding Principles
for Diabetes Care: For Health Care Providers NIH Publication No 99-4343
[5] National Institute of Diabetes and Digestive and Kidney Diseases
[NIDDK] 2002 The Diabetes Dictionary NIH Publication No 02-3016
Available at NIDDK on
the World Wide Web:
wwwniddknihgov/health/diabetes/pubs/dmdict/dmdicthtm
[6] American Diabetes Association 2004 Frequently Asked Questions About
Pre-Diabetes Available at ADA on the World Wide Web: wwwdiabetesorg/pre-
diabetes/faqjsp
[7] Ibid
[8] American Diabetes Association 2005 Clinical Practice
Recommendations: Diagnosis and Classification Diabetes Care 28S1:S41
[9] National Institute of Diabetes and Digestive and Kidney Diseases
[NIDDK] 2002 The Diabetes Dictionary NIH Publication No 02-3016
Available at NIDDK on the World Wide Web:
wwwniddknihgov/health/diabetes/pubs/dmdict/dmdicthtm
[10] Ibid
[11] Ibid
[12] Diabetes Prevention Program Research Group 2002 Reduction in the
Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin New
England Journal of Medicine 3466:393-403
[13] American Diabetes Association and NIDDK April 2002 Position
Statement: The Prevention or Delay of Type 2 Diabetes Diabetes Care
254:742-49
[14] Kelly, JM, et al 2004 Diabetes Prevention: A GAMEPLAN for
Success Geriatrics 597:28
[15] American Diabetes Association October 24, 2003 Expert Committee
Redefines Impaired Fasting Glucose Press release Available at American
Diabetes Association on
the World Wide Web: wwwdiabetesorg/for-
media/diabetes-care/10-24-03jsp
[16] Errata-June 2005 CDC 2004 National Diabetes Statistics Fact
Sheet: General Information and National Estimates on Diabetes in the United
States, 2003, rev ed Atlanta, GA: US Department of Health and Human
Services Available online at wwwcdcgov/diabetes/pubs/factsheetshtm For
the latest diabetes statistics, visit the CDC website for diabetes
statistics at wwwcdcgov/diabetes/statistics/indexhtm
[17] American Diabetes Association October 24, 2003 Expert Committee
Redefines Impaired Fasting Glucose Press release Available at American
Diabetes Association on the World Wide Web: wwwdiabetesorg/for-
media/diabetes-care/10-24-03jsp
[18] Centers for Disease Control and Prevention 2005 Overweight and
Obesity: Defining Overweight and Obesity Available at CDC on the World
Wide Web: wwwcdcgov/nccdphp/dnpa/obesity/defininghtm
[19] National Diabetes Education Program April 2004 Guiding Principles
for Diabetes Care: For Health Care Providers NIH Publication No 99-4343
[20] Reynolds, SL, Saito, Y, and Crimmins, EM 2005 The Impact of
Obesity on Active Life Expectancy in Older American Men and Women
Gerontologist 45:
438-444
[21] Center on an Aging Society, Georgetown University July 2003
Obesity Among Older Americans Data profile: No10 Monograph Available
at Georgetown University on the World Wide Web:
http://ihcrpgeorgetownedu/agingsociety/pubhtml/obesity2/obesity2html
[22] Center on an Aging Society, Georgetown University July 2003 Obesity
Among Older Americans Data profile: No10 Monograph Available at
Georgetown University on the World Wide Web:
http://ihcrpgeorgetownedu/agingsociety/pubhtml/obesity2/obesity2html
[23] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[24] Table 1 in Task Force on Community Preventive Services 2001
Strategies for Reducing Morbidity and Mortality from Diabetes Through
Health-Care System Interventions and Diabetes Self-Management Education in
Community Settings: A Report on Recommendations of the Task Force on
Community Preventive Services MMWR Recommendations and Reports 50RR16:1-
15
[25] Aim, Believe, Achieve - The Diabetes A1C InitiativeTM
Facts About
Uncontrolled Diabetes Available at Diabetes Watch on the World Wide Web:
wwwdiabeteswatchcom/a1c/diabetes_facts_and_figures/diabetes_factsasp
[26] Stratton, IM, Adler, AI, Andrew, H, Neil, W, et al 2000
Association of glycaemia with macrovascular and microvascular
complications of type 2 diabetes UKPDS 35: prospective observational
study British Medical Journal 321:405-412
[27] Ibid
[28] United Kingdom Prospective Diabetes Study UKPDS 1998 Intensive
Blood Glucose Control with Patients with Type 2 Diabetes Lancet 352:837-
853
[29] Ibid
[30] Ibid
[31] Stratton, IM, Adler, AI, Andrew, H, Neil, W, et al 2000
Association of glycaemia with macrovascular and microvascular
complications of type 2 diabetes UKPDS 35: prospective observational
study British Medical Journal 321:405-412
[32] Ibid
[33] Ibid
[34] United Kingdom Prospective Diabetes Study UKPDS 1998 Intensive
Blood Glucose Control with Patients with Type 2 Diabetes Lancet 352:837-
853
[35] Stratton, IM, Adler, AI, Andrew, H, Neil, W, et al 2000
Association of glycaemia with macrovascular and microvascular
complications of type 2 diabetes UKPDS 35: prospective observational
study British Medical Journal 321:405-412
[36]
CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[37] CDC 2005 Facts on High Blood Pressure Fact Sheet Available at
CDC on the World Wide Web: wwwcdcgov/cvh/library/fs_bloodpressurehtm
[38] Ibid
[39] US Department of Health and Human Services November 2000 Healthy
People 2010: Understanding and Improving Health, 2nd ed Objective 12-9
Washington, DC: US Government Printing Office
[40] CDC 2005 Facts on High Blood Pressure Fact Sheet Available at
CDC on the World Wide Web: wwwcdcgov/cvh/library/fs_bloodpressurehtm
[41] Ibid
[42] US Department of Health and Human Services November 2000 Healthy
People 2010: Understanding and Improving Health, 2nd ed Objective 12-9
and 12-10 Washington, DC: US Government Printing Office
[43] CDC 2005 Facts on High Blood Pressure Fact Sheet Available at
CDC on the World Wide Web: wwwcdcgov/cvh/library/fs_bloodpressurehtm
[44] In the form of a decrease from an average blood pressure of 154/87
mmHg in the control group to 144/82 mmHg in the
treatment group
[45] United Kingdom Prospective Diabetes Study UKPDS 1998 Intensive
Blood Glucose Control with Patients with Type 2 Diabetes Lancet 352:837-
853
[46] American Diabetes Association June 5, 2004 Cholesterol and Blood
Pressure Uncontrolled in Most People with Diabetes Press release
Available at American Diabetes Association on the World Wide Web:
wwwdiabetesorg/for-media/2004-press-releases/uncontrolledjsp
[47] CDC 2005 Facts on High Blood Pressure Fact sheet Available at
CDC on the World Wide Web: wwwcdcgov/cvh/library/fs_bloodpressurehtm
[48] US Department of Health and Human Services November 2000 Healthy
People 2010: Understanding and Improving Health, 2nd ed Objective 12-14
Washington, DC: US Government Printing Office
[49] Ibid
[50] American Heart Association 2005 Cholesterol-Lowering Studies
Available at AHA on the World Wide Web:
wwwamericanheartorg/presenterjhtml?identifier4524
[51] CDC June 2005 Facts on Cholesterol Fact sheet Available at CDC
on the World Wide Web: wwwcdcgov/cvh/library/fs_cholesterolhtm
[52] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta,
GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
For the latest diabetes statistics, visit the CDC website for diabetes
statistics at wwwcdcgov/diabetes/statistics/indexhtm
[53] Lighthouse International Causes of Vision Impairment Available on
the Lighthouse International on the World Wide Web:
wwwlighthouseorg/vision_impairment_causeshtm
[54] National Diabetes Education Program April 2004 Guiding Principles
for Diabetes Care: For Health Care Providers NIH Publication No 99-4343
p 7
[55] Gregg, EW, and Narayan, V 2002 Complications of diabetes in
elderly people British Medical Journal 325:916-917
[56] Strachan, MMJ 2002 Cognitive Decline and the Older Patient with
Diabetes Clinical Geriatrics 106:29-35
[57] Meneilly, GS, and Tessier, D 2001 Diabetes in Elderly Adults
Journal of Gerontology: Medical Sciences 56A1:M5-M13
[58] Morley, JE 2000 Diabetes Mellitus: A Major Disease of Older
Persons Journal of Gerontology: Medical Sciences 55A5:M255-M256
[59] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US
Department of Health and Human Services
Available at CDC on the World Wide Web:
wwwcdcgov/diabetes/pubs/factsheetshtm
[60] Mooradian, AD, et al 1999 Diabetes Care for Older Adults
Diabetes Spectrum 122:70-77
[61] NIDDK 2002 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2000
Bethesda, MD: US Department of Health and Human Services, National
Institutes of Health Available at NIDDK on the World Wide Web:
wwwcdcgov/diabetes/pubs/estimateshtmfig3
[62] CDC March 7, 2005 Table 1 Deaths, percentage of total deaths, and
death rates for the 10 leading causes of death in selected age groups, by
race and sex: United States, 2002 National Vital Statistics Reports
5317:13 Available at CDC on the World Wide Web:
wwwcdcgov/nchs/fastats/pdf/nvsr53_17t1pdf
[63] Ibid
[64] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available at CDC on the World Wide Web:
wwwcdcgov/diabetes/pubs/factsheetshtm
[65] Geiss, LS, Thompson, TJ 1995 Are persons with diabetes more
likely to die from
pneumonia and influenza? [abstract] Diabetes Care
44suppl 1:124A
[66] CDC March 7, 2005 Table 1 Deaths, percentage of total deaths, and
death rates for the 10 leading causes of death in selected age groups, by
race and sex: United States, 2002 National Vital Statistics Reports
5317:13 Available at CDC on the World Wide Web:
wwwcdcgov/nchs/fastats/pdf/nvsr53_17t1pdf
[67] CDC March 7, 2005 Table 2 Deaths, percentage of total deaths, and
death rates for the 10 leading causes of death in selected age groups, by
Hispanic origin, race for non-Hispanic population, and sex: United States,
2002 National Vital Statistics Reports 5317:50 Available at CDC on the
World Wide Web:
wwwcdcgov/nchs/fastats/pdf/Pages20from20nvsr53_17t2pdf
[68] CDC March 7, 2005 Table 1 Deaths, percentage of total deaths, and
death rates for the 10 leading causes of death in selected age groups, by
race and sex: United States, 2002 National Vital Statistics Reports
5317:13 Available at CDC on the World Wide Web:
wwwcdcgov/nchs/fastats/pdf/nvsr53_17t1pdf
[69] Ibid
[70] Ibid
[71] Ibid
[72] Ibid
[73] Gregg, EW, and Narayan, V 2002 Complications of Diabetes in
Elderly People: Underappreciated Problems Include Cognitive
Decline and
Physical Disability British Medical Journal 325:916-7
[74] Source: 1997-1999 National Health Interview Survey and 1988-1994
National Health and Nutrition Examination Survey estimates projected to the
year 2000 Published in CDC 2002 National Diabetes Fact Sheet
[75] Smith, NL, Savage, PJ, Heckbert, SR, et al 2002 Glucose,
Blood Pressure, and Lipid Control in Older People with and without Diabetes
Mellitus: The Cardiovascular Health Study Journal of the American
Geriatrics Society 50:3 416
[76] Abraira, C, Colwell, J, Nuttall, F, et al 1997 Cardiovascular
events and correlates in the veterans affairs diabetes feasibility trial
Veterans affairs cooperative study on glycemic control and complications in
Type II diabetes Archives of Internal Medicine 1572:181-8
[77] California Healthcare Foundation/American Geriatrics Society Panel on
Improving Care for Elders with Diabetes Mangione, CM, Brown, AF, et
al 2003 Guidelines for Improving the Care of the Older Person With
Diabetes Mellitus Journal of the American Geriatrics Society 51:S265-
S280
[78] Adapted from Table 2 in Olson, DE, and Norris, SL 2004 Diabetes
in Older Adults: Overview of AGS Guidelines for the Treatment of
Diabetes
Mellitus in Geriatric Populations Geriatrics 594:20
[79] Sherman, FT June 2004 The ADA Never Learned Its ABCs Geriatrics
596: 10-11 Reprinted with permission
[80] Life expectancy can determine how much healthcare providers want to
focus on keeping blood glucose low vs improving the overall quality of
life in the short remaining time left For example, a nursing home resident
may benefit more in the end of life from a liberalized diet than from being
given diabetic diet-type foods that do not appeal to them See the American
Dietetic Association position paper on nutrition issues across the
continuum of care for older adults and the position paper on liberalized
diets in nursing homes
[81] Less than 5 percent of adults ages 65 and older live in nursing homes,
although more frail elders may live in group homes or assisted living
settings or may be homebound Federal Interagency Forum on Aging Related
Statistics August 2000 Older Americans 2000: Key Indicators of Well-
Being, p 92
[82] Diabetes Prevention Program Research Group 2002 Reduction in the
Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin New
England Journal of Medicine 3466:393-403
[83] US
Department of Health and Human Services November 2000 Healthy
People 2010: Understanding and Improving Health, 2nd ed Washington, DC:
US Government Printing Office, p 8
[84] Figure 1 in Mooradian, AD, et al 1999 Diabetes Care for Older
Adults Diabetes Spectrum, 122:70-77
[85] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
[86] Mooradian, AD, et al 1999 Diabetes Care for Older Adults
Diabetes Spectrum 122:70-77
[87] Table E in Anderson, RN, and Smith, BL 2003 Deaths: Leading
Causes for 2001 National Vital Statistics Reports 529, p 9
Hyattsville, MD: National Center for Health Statistics
[88] Louisiana Health Department Black, SA 2002 Diabetes, diversity,
and disparity: What do we do with the evidence? American Journal of Public
Health 924:543-548
[89] Institute of Medicine 2002 Unequal Treatment: What Healthcare
Providers Need to Know about Racial and Ethnic Disparities in Healthcare
Washington, DC: National Academy Press
[90] Kissebah, AH, et al 1982 Relationship of Body Fat Distribution
to Metabolic Complications of Obesity Journal of Clinical Endocrinology
and Metabolism 54:254-260
[91]
Cornelius, LJ, et al 2002 What Factors Hinder Women of Color
From Obtaining Preventive Health Care? American Journal of Public Health
924:535-539
[92] University of Virginia, Health System Bad Blood: The Troubling
Legacy of the Tuskegee Syphilis Study Available on the World Wide Web:
http://wwwmedvirginiaedu/hs-library/historical/apology/
[93] Abel, EK 2004 Only the Best Class of Immigration: Public Health
Policy Toward Mexicans and Filipinos in Los Angeles, 1910-1940 American
Journal of Public Health 94: 932-939
[94] Fortier, JP and Bishop D 2004 Setting the Agenda for Research on
Cultural Competence in Health Care: Final Report Edited by C Brach
Rockville, MD: US Department of Health and Human Services Office of
Minority Health and Agency for Healthcare Research and Quality
[95] Cornelius, LJ, et al 2002 What factors hinder women of color
from obtaining preventive health care? American Journal of Public Health
924:535-539
[96] US Department of Health and Human Services 2000 Healthy People
2010: Understanding and Improving Health, 2nd ed Washington, DC: US
Government Printing Office
[97] Beyer, PL 2004 Focus on Lactose Tolerance: An Uncommon Anomaly?
In Chapter 30: Medical
Nutrition Therapy for Lower Gastrointestinal Tract
Disorders p 720, Mahan, LK, and Escott-Stump, S eds, Krauses
Food, Nutrition, and Diet Therapy Philadelphia, PA: Saunders
[98] Swagerty, DL, Walling, AD, and Klein, RM 2002 Lactose
Intolerance American Family Physician 659:1845-1850
[99] Schillinger, D, et al 2002 Association of Health Literacy with
Diabetes Outcomes Journal of the American Medical Association 2884:475-
482
[100] Rothman,RL, Malone, R, Bryant, B, Shintani, AK, et al March
2005 A randomized trial of a primary care-based disease management
program to improve cardiovascular risk factors and glycated hemoglobin
levels in patients with diabetes American Journal of Medicine 1183:276-
284
[101] Wallace, SP, et al 2003 Data from the 2001 California Health
Interview Survey and 2000 US Census: Health of Older Californians: County
Data Book The Regents of the University of California p 4
[102] Heart Outcome Prevention Evaluation Study Investigators 2000
Effects of Angiotensin-Converting-Enzyme Inhibitor, Ramipril, on
Cardiovascular Events in High Risk Patients New England Journal of
Medicine 342:145-153
[103] Black, SA 2002 Diabetes, Diversity, and Disparity: What Do We
Do
With the Evidence? American Journal of Public Health 924:543-548
[104] US Department of Health and Human Services 2000 Healthy People
2010: Understanding and Improving Health 2nd ed Washington, DC: US
Government Printing Office p 12
[105] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[106] Ibid
[107] Harris, MI, et al 1998 Prevalence of Diabetes, Impaired Fasting
Glucose, and Impaired Glucose Tolerance in US Adults: A Third National
Nutrition Examination Study, 1988-1994 Diabetes Care 21:518-524
[108] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[109] National Institutes of Health 2002 Diabetes in African Americans
NIH Publication No 02-3266 Available on the World Wide Web:
http://diabetesniddknihgov/dm/pubs/africanamerican/
[110] Ibid
[111]
Davis, SK, Liu, Y, Gibbons, GH 2003 Disparities in trends of
hospitalization for potentially preventable chronic conditions among
African Americans during the 1990s: Implications and benchmarks American
Journal of Public Health 933:447-455
[112] National Institutes of Health 2002 Diabetes in African Americans
NIH Publication No 02-3266 Available on the World Wide Web:
http://diabetesniddknihgov/dm/pubs/africanamerican/

[113] National Diabetes Information Clearinghouse 2002 Medical and
Lifestyle Risk Factors in Diabetes in American Indians and Alaska Natives
NIH publication no 02-4567
[114] Errata-June 2005 CDC 2004 National Diabetes Statistics Fact
Sheet: General Information and National Estimates on Diabetes in the United
States, 2003, rev ed Atlanta, GA: US Department of Health and Human
Services Available on the World Wide Web:
wwwcdcgov/diabetes/pubs/factsheetshtm
[115] Lee, ET, Howard, BV, Savage, PJ, et al 1995 Diabetes and
Impaired Glucose Tolerance in Three American Indian Populations Aged 45 -
74 Years The Strong Heart Study Diabetes Care 185:599-610
[116] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the
United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[117] Table 2 data from N Rios Burrows Data based on personal
communication Indian Health Service, Headquarters Diabetes Program, and
Centers for Disease Control and Prevention, Division of Diabetes
Translation July 26, 1999 cited in National Diabetes Information
Clearinghouse 2002 Diabetes in American Indians and Alaska Natives NIH
publication no 02-4567
[118] National Diabetes Information Clearinghouse 2002 Diabetes in
American Indians and Alaska Natives NIH publication no 02-4567
[119] Ibid
[120] National Diabetes Education Program May 1999 The Diabetes Epidemic
Among American Indians and Alaska Natives Fact sheet Available on the
World Wide Web: wwwndepnihgov/diabetes/pubs/FS_AmIndianpdf
[121] National Institutes of Health 2002 Diabetes in American Indians
and Alaska Natives NIH Publication No 02-4567 Available on the World
Wide Web: http://diabetesniddknihgov/dm/pubs/americanindian/indexhtm
[122] National Diabetes Education Program May 1999 The Diabetes Epidemic
Among American Indians and Alaska Natives Fact sheet
Available on the
World Wide Web: wwwndepnihgov/diabetes/pubs/FS_AmIndianpdf
[123] National Institutes of Health 2002 Diabetes in American Indians
and Alaska Natives NIH Publication No 02-4567 Available on the World
Wide Web: http://diabetesniddknihgov/dm/pubs/americanindian/indexhtm
[124] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[125] National Institutes of Health 2002 Diabetes in Asian and Pacific
Islander Americans NIH Publication No 02-4667 Available on the World
Wide Web: http://diabetesniddknihgov/dm/pubs/asianamerican/indexhtm
[126] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[127] National Institutes of Health 2002 Diabetes in Asian and Pacific
Islander Americans NIH Publication No 02-4667 Available online
at
http://diabetesniddknihgov/dm/pubs/asianamerican/indexhtm
[128] Ibid
[129] National Institutes of Health 2002 How Do Diabetes Complications
Affect Asian and Pacific Islander Americans? in Diabetes in Asian and
Pacific Islander Americans NIH Publication No 02-4667 Available on the
World Wide Web:
http://diabetesniddknihgov/dm/pubs/asianamerican/indexhtm
[130] CDC 2004 National Diabetes Statistics Fact Sheet: General
Information and National Estimates on Diabetes in the United States, 2003,
rev ed Atlanta, GA: US Department of Health and Human Services
Available on the World Wide Web: wwwcdcgov/diabetes/pubs/factsheetshtm
[131] National Institutes of Health 2002 Diabetes in Hispanic Americans
NIH Publication No 02-3265 Available online at
http://diabetesniddknihgov/dm/pubs/hispanicamerican/
[132] US Department of Health and Human Services 2000 Healthy People
2010: Understanding and Improving Health 2nd ed Washington, DC: US
Government Printing Office
[133] Center on an Aging Society, Georgetown University July 2003
Obesity Among Older Americans Data profile: No10 Monograph Available
at Georgetown University on the World Wide
Web:
http://ihcrpgeorgetownedu/agingsociety/pubhtml/obesity2/obesity2html
[134] National Institutes of Health 2002 Diabetes in Hispanic
Americans NIH Publication No 02-3265 Available online at
http://diabetesniddknihgov/dm/pubs/hispanicamerican/
[135] Ibid
[136] CDC 2005 Physical Activity for Everyone: Recommendations
Available at CDC on the World Wide Web:
wwwcdcgov/nccdphp/dnpa/physical/recommendations/indexhtm
[137] Centers for Disease Control and Prevention 2005 Overweight and
Obesity: Defining Overweight and Obesity Available at CDC on the World
Wide Web: wwwcdcgov/nccdphp/dnpa/obesity/defininghtm

———————–

Source:doh.state.fl.us

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