kelingwang/causation_strength_rating huggingface dataset:
PA accumulated in bouts of even <10 min is associated with favourable outcomes, including reduced mortality (110,111).
Exercise prescription is recommended to be adapted to T2DM-associated comorbidities, e.g. CAD, HF, AF, diabetic peripheral neuropathy, or retinopathy, as well as age and frailty (104,107,108).
Structured exercise intervention is also recommended in patients with T2DM with established CVD (e.g. CAD, AF, HFpEF; heart failure with mildly reduced ejection fraction [HFmrEF]; HFrEF) (102–104).
Interval endurance exercise training of more vigorous intensity (e.g. interval walking, alternating between moderate to vigorous intensities) has superior effects compared with moderate-intensity continuous walking regarding body weight, waist circumference, and glucose control (105).
Resistance exercise is recommended to be performed at least twice weekly (intensity of 60–80% of the individual�s one-repetition maximum).
For older or deconditioned adults, less volume and lower intensities are recommended, particularly during the initiation phase of 3–6 weeks (106).
Interventions shown to increase PA level or reduce sedentary behaviour include behaviour theory-based interventions, such as goal-setting, re-evaluation of goals, self-monitoring, and feedback (112,113).
Before starting a structured exercise programme in patients with T2DM and established CVD, performing a maximal exercise stress test to assess CV pathologies should be considered.
Moreover, assessment of aerobic and anaerobic thresholds by spiroergometry is particularly useful to provide an individualized endurance exercise prescription including exercise intensity (106–108).
Optimal intensity is determined based on an individual�s maximum (peak) effort during spiroergometry, e.g. percentage of cardiorespiratory fitness (% peak oxygen consumption), percentage of maximum (peak) heart rate (% HRmax), or perceived exertion rate according to the Borg scale (107–109).
Using a wearable activity tracker (e.g. smartphones) may help increase PA (114).
Most important is to encourage PA that people enjoy and/or can include in their daily routines, as such activities are more likely to be feasible and sustainable.
Smoking cessation is a key lifestyle intervention in patients with T2DM with or without CVD with evidence suggesting a 36% reduction in mortality in CVD patients (118–120).
If advice, encouragement, and motivation are insufficient, then drug therapies should be considered early, including nicotine replacement therapy (chewing gum, transdermal nicotine patches, nasal spray, inhaler, sublingual tablets) followed by bupropion (121).
In patients with ASCVD, varenicline, bupropion, telephone therapy, and individual counselling all increase success rates (122).
Electronic cigarettes (e-cigarettes) have been addressed as a potential smoking cessation aid to bridge transition from smoking to abstention, but�if used at all�should be limited for a short period of time.
A consensus regarding the efficacy and safety for this approach has yet to be reached (123,124).
Overall, smoking cessation programmes have low efficacy at 12 months; nonetheless, cessation measures should be repetitively addressed for smoking abstention to succeed (125).
People with type 2 diabetes often have lifestyles (eating and physical activity habits) which contribute to their problem.
It is essential they receive help soon after diagnosis to consider how they may modify lifestyle in ways which enable them to take control of their blood glucose, blood lipid and blood pressure, even if they also require pharmacotherapy (see Chapter 9: Glucose control therapy).
Evidence supports the effectiveness of nutrition therapy and physical activity in the prevention and management of type 2 diabetes [1–4].
This is reflected in the Canadian [5], UK NICE [6] and Australian guidelines [7] as well as the ADA standards of medical care [2,8,9].
Lifestyle modification can be difficult to achieve and maintain [6].
Most lifestyle intervention studies have been short-term, however this is being addressed by the Look AHEAD study [10].
Other considerations include a lack of knowledge about the ongoing contribution of lifestyle measures once medication has been introduced, or what kind of support is required on a continuing basis.
The UKPDS initial nutrition intervention was very effective in lowering blood glucose after diagnosis and some people were then able to maintain target glucose control for many years by nutrition modifications alone [11,12].
RCTs and outcomes studies of medical nutrition therapy (MNT) in the management of type 2 diabetes have reported improved glycaemic outcomes (HbA1c decreases of ~1.0–2.0%/11–22 mmol/mol; range: -0.5 to 2.6%/-6.5 to 29 mmol/mol, depending on the duration of diabetes) and level of glycaemic control [1].
MNT in these studies was provided by dietitians (nutritionists) as MNT only or as MNT in combination with diabetes self-management training.
Interventions included reduced energy intake and/or reduced carbohydrate/fat intake, carbohydrate counting, and basic nutrition and healthy food choices for improved glycaemic control.
Central to these interventions are multiple encounters to provide education initially and on a continued basis [5,9,13–19].
Cardioprotective nutrition therapy (saturated and trans fats less than 7% of daily energy, dietary cholesterol less than 200 mg daily, and a daily fat intake of 25–35%) can reduce total cholesterol by 7–21%, low density lipoprotein (LDL)-cholesterol by 7–22%, and triglycerides by 11–31% [20].
Energy from saturated or trans fatty acids may be replaced by energy from unsaturated fatty acids.
If a reduced energy intake is a goal, reduction rather than replacement of saturated fat energy is recommended.
Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months after initiating MNT.
A meta-analysis of studies of non-diabetic people reported that reductions in sodium intake to =2.4 g/day decreased blood pressure by 5/2 mmHg in hypertensive subjects.
Meta-analyses, clinical trials and expert committees support the role of reduced sodium intake, modest weight loss (4–5 kg), increased physical activity, a low-fat diet that includes fruits, vegetables and low-fat dairy products, and moderate alcohol intake, in reducing blood pressure [21].
A systematic review and meta-analysis of exercise (aerobic, resistance training or both) reported an HbA1c reduction of 0.7%/8 mmol/mol, independent of changes in body weight, in people with type 2 diabetes [22].
In long-term prospective cohort studies of people with type 2 diabetes, higher physical activity levels predicted lower long-term morbidity and mortality and increases in insulin sensitivity.
Interventions included both aerobic exercise (such as walking) and resistance exercise (such as weight-lifting) [2,23,24].
The Canadian Diabetes Association and ADA guidelines have a section on the management of obesity in type 2 diabetes, which addresses lifestyle measures and also pharmacotherapy and surgical options [5,9].
In addition to behavioural and medical approaches, various types of surgery on the gastrointestinal tract, originally developed to treat morbid obesity (�bariatric surgery�), constitute powerful options to ameliorate diabetes in severely obese patients, often normalising blood glucose levels, reducing or avoiding the need for medications and providing a potentially cost-effective approach to treating the disease [25].
A recent IDF position paper recommended bariatric surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes [26].
Eligible patients include those who have type 2 diabetes and a BMI =35 kg/m2; or with a BMI between 30 and 35 kg/m2 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major CVD risk factors.
It is noted than in general costs of educational initiatives to change lifestyle are low, because unlike pharmacotherapy they are provided on an intermittent rather than continuing basis.
From a health-provider perspective many of the costs fall outside their budget, healthier foods and exercise programmes and equipment generally being a cost met directly by the person with diabetes.
For these reasons, and because, for glucose control, the gain from lifestyle modification is greater than that from any individual therapy, lifestyle measures are heavily promoted.
Lifestyle modification is, however, sometimes difficult for the individual to maintain in the long-term, or to develop further after early changes have been made.
Where professional nutritionists are unavailable, it was noted that other health-care professionals should be trained in basic nutritional and other lifestyle education.
Diabetes is common in older people and is often undiagnosed.
While undiagnosed, diabetes may produce symptoms, result in complications and aggravate existing comorbidities.
Type 2 diabetes has a long asymptomatic preclinical phase which frequently goes undetected and complications are commonly present at the time of diagnosis.
Although there is debate about screening and early detection of diabetes in the general population, it is usually favoured in older people because of its high prevalence and the potential negative impact on health.
Populations throughout the world consistently show an increase in prevalence of diagnosed and undiagnosed type 2 diabetes with increasing age, reaching a plateau or even declining slightly in the very old.
For example, in Australia in the age group 25-34, 0.2% have diagnosed and 0.1% have undiagnosed diabetes, increasing respectively to 9.4% and 8.5% in 65-74 year olds and 10.9% and 12.1% for people aged 75 years and older [24].
In the US in the age groups 70-74, 75-79, 80-84, and = 85 years the prevalence of diabetes was 20%, 21.1%, 20.2%, and 17.3%, respectively [25].
The DECODE Study analysed data from nine European countries and reported a prevalence of type 2 diabetes of < 10% in people age < 60 years and 10-20% in those aged 60-79 years [26].
The findings of the DECODA study in 11 Asian cohorts were similar [27].
The usual risk factors for undiagnosed diabetes also apply in older people, including increasing weight and ethnicity.
Undiagnosed diabetes is particularly common in older people with acute myocardial infarction (34% in the Glucose Tolerance in Acute Myocardial Infarction study in people over 80 years of age) [28], and with cerebrovascular disease (46% with newly diagnosed diabetes of people with a mean age of 71 years with acute ischaemic stroke) [29].
Mental illness seems to be associated with an increase in type 2 diabetes [30] but data regarding antipsychotic medication varies with the strongest association reported for treatment with olanzapine in people with major psychiatric illness [31,32].
However it is difficult to differentiate the effect of the mental illness from its treatment [33].Postprandial hyperglycaemia is common in older people [34].
Therefore older people are more likely to have a non-diabetic fasting plasma glucose and a diabetic 2 hour post-challenge glucose level [35].
This has implications for diagnosis and results in differences in prevalence depending on which diagnostic test is used [36].
In addition, a number of studies in older populations have demonstrated that isolated post-challenge hyperglycaemia is associated with adverse outcomes compared with normal glucose-tolerant individuals [37-39].
The implications for the individual require balancing the risks and benefits of performing an OGTT and the likelihood of missing significant hyperglycaemia.
For example, an individual with a non-diabetic fasting plasma glucose and HbA1c is unlikely to have clinically relevant hyperglycaemia.
However, an OGTT may be clinically indicated in an older individual with equivocal results.
Screening for diabetes will also identify individuals with intermediate hyperglycaemia (IGT and impaired fasting glucose IFG) who may benefit from interventions to prevent or delay progression to diabetes, and to prevent cardiovascular disease (CVD) and other diabetes-specific complications.
The prevalence of IGT and IFG also increase with increasing age.
For example in the NHANES III study [40] the prevalence of IGT increased from 11.1% in people aged 40-49 to 20.9% in those aged 60-74 years.
IGT and IFG are important risk factors for the development of future diabetes and increase risk 10-20 fold compared with those with normal glucose tolerance.
This increased risk does not seem to vary with age.
Several studies have shown that progression to diabetes can be prevented or delayed in people with IGT [41,42].
In the US Diabetes Prevention Program (DPP), lifestyle modification achieved a 58% reduction compared with a 31% reduction with metformin in progression to diabetes.
The effect of lifestyle modification was greatest in people aged = 60 years, whereas the effect of metformin was not significant in this age group [42].
Follow-up of the DPP cohort for 10 years showed that the group 60 years and over age group appeared to benefit more from the lifestyle intervention than younger participants, but did not appear to benefit from metformin (49% risk reduction in those aged > 60 years at randomization compared with 34% for the total cohort) [43] and additional benefits of the lifestyle intervention that might impact older adults, such as reduction in urinary incontinence [44] and improvement in quality of life [45].
The benefits of identifying IGT or IFG in older adults depend on the time taken to achieve benefit and the person�s life expectancy.
Although prevention studies suggest a benefit in relatively healthy older adults, these studies did not enrol significant numbers over the age of 70 years or those with functional or cognitive impairments.
Nutrition is an important part of diabetes care for all age groups.
However, there are important additional concerns for older adults with diabetes [46].
Malnutrition is common in older people, especially in aged care homes [47].
Malnutrition is associated with longer length of stay in hospital and increased mortality [48], is a strong predictor of readmission and is associated with pressure ulcers, delirium, and depression [49].
Concomitant diseases that increase the risk of malnutrition in older people with diabetes include: Gastroparesis, which is present in up to 25-55% of people with type 1 and 30% with type 2 diabetes [50] and may affect glucose stability and orally administered medicines absorption and may cause significant discomfort;  Parkinson's disease; Psychiatric disorders and depression; Chronic obstructive pulmonary disease; Renal failure; Neurological dysfunction;  Dental disease.
Energy needs decline with age, but micronutrient needs remain similar throughout adulthood.
Meeting micronutrient needs where there is lower energy intake can be challenging and older people often have micronutrient deficiencies and are at risk of under nutrition due to anorexia, altered taste and smell, swallowing difficulties, oral and dental issues, and functional impairments, which compromise their capacity to shop for, prepare, and eat a healthy, balanced diet [5] , especially when they live alone and have financial difficulties.
Food in aged care homes is rarely the same as the person is accustomed to.
Over restrictive eating patterns, either self-imposed or provider-directed can contribute additional nutritional risks for older people.
Several specific nutrition assessment tools designed for older adults are available and can identify older people at risk.
For example, the Mini Nutritional Assessment (MNA) and helps determine whether referral to a dietitian is needed [5].
Other tools include the Malnutrition Universal Screening Tool (MUST), the Simplified Nutritional Assessment Questionnaire (SNAQ), Subjective Global Assessment (SGA), and the Patient-Generated SGA (PG-SGA) [47].
Sometimes it is easier to assess malnutrition by measuring the mid-arm circumference, especially in frail older people.
Biochemical assessment may include electrolytes, serum transferrin, albumin, prealbumin, thyroid function tests, cholesterol, iron, vitamin B12, folate, and vitamin D.
Hydration status can be assessed using the Hydration Assessment Checklist.
Even mild dehydration can contribute to cognitive changes.
In addition, a medicine review may be required because some medicines affect vitamin B12 absorption (e.g. digitalis, metformin, and sedatives).
Alcohol also affects the absorption of vitamin B12.
Supplementary vitamins and minerals may be needed.
Likewise, antihypertensive medications such as angiotensin converting enzyme (ACE)-inhibitors, angiotensin 2 receptor antagonists (ARB), and thiazide diuretics may cause a diverse range of disturbances in electrolyte homeostasis [51].
Food-medicine interactions should be considered as part of the structured medicine review.
When nutritional needs are not met by the person's usual food intake, the following strategies might help: encourage smaller more frequent meals, fortify usual foods, change food texture, or include liquid nutrition supplements between meals [5,52].
Some older people are overweight or obese.
However the body mass index (BMI) is not an accurate predictor of the degree of adiposity in older people due to age related changes in body composition [53].
Obesity exacerbates the age related decline in physical function and increases the risk of frailty [54].
Intentional weight loss in overweight and obese older people can worsen bone mineral density and nutritional deficits [55].
Strategies that combine physical activity with nutritional therapy to promote weight loss may result in improved physical performance and function and reduced cardio-metabolic risk in older adults [54].
Age-related changes in the immune system increase the susceptibility of older people to bacterial and viral infections, and this is exacerbated by medical comorbidities such as diabetes, renal impairment, and multiple drug therapies.
Although immune responses to antigens can be impaired with advancing age, all people in high-risk groups such as those with diabetes are recommended to receive a seasonal influenza vaccination as this has been associated with a reduction in complications, hospitalizations, and death [56].
In older people with diabetes, this may also be associated with reduced admissions to intensive care units and reduced hospitalization costs [57].
Exercise should be an integral component of the management of diabetes in older people and can be associated with benefits relating to mobility, balance, reduced falls risk, psycho-social benefits, and enhancing quality of life.
Muscle mass and muscle strength decline with age and may be exacerbated by diabetes complications, other comorbidities, and periods of hospitalization.
People with diabetes of longer duration and those with higher HbA1c levels have lower muscle strength per unit of muscle mass than BMI and age matched people without diabetes and people with shorter duration of diabetes or who have better glycaemic control [58].
Although age and diabetes both reduce fitness and strength, physical activity improves functional status in older adults with and without diabetes [59].
Even light intensity physical activity is associated with higher self-rated physical health and psychosocial well-being [60].
Ways of facilitating increased physical activity and fitness include healthcare professional recommendation and encouragement, and referral to community supervised walking schemes, and community-based group exercise and fitness programmes where these are available.
Falls are a leading cause of morbidity and mortality in older people and associated disability and declined quality of life are one of the greatest challenges facing the frail older population.
Older people with diabetes are at high risk of falls, recurrent falls, and fractures [278-280].
Risks factors for falls in older persons with diabetes include polypharmacy, muscle weakness, previous stroke, motor and sensory neuropathy, poor glycaemic control, hypoglycaemia, insulin use, cognitive dysfunction, orthostatic hypotension, and visual impairment [281-283].
Lower HbA1c (< 7.0% / 53 mmol/mol) has been associated with higher risk of falls frail elderly people [284] and hip fracture [285], especially in those treated with insulin [282].
Measurement of gait velocity and ankle muscle strength have been used to identify people at risk of falling [286].
Many studies using gait, balance, and strength training have shown reduced risk of falls for people with diabetes [287-300].
Pain is common and often undetected in older people and older people are at increased risk of pain and the pain is often chronic.
People in pain are at increased risk of falling and other adverse events.
People with diabetes are at increased risk of all types of pain including �silent pain� from myocardial infarction and urinary tract infections.
Pain is often under-reported and under-treated in many older people with diabetes and is particularly prevalent in people with long duration of diabetes.
Changes in body language, grimacing, restlessness, increased wandering, crying out, groaning, hypertension, tachycardia, and rapid shallow breathing may be indications of pain.
Pain can be acute, chronic, or intermittent.
Managing pain in older people is a key aspect of the national strategies for all healthcare settings [22,291].
Pain is defined as �a subjective, unpleasant sensory, and emotional experience of actual or potential tissue damage� [292,293].
Pain is always subjective.
It is important to distinguish between acute and chronic pain.
Chronic and recurrent pain is often associated with depression and affects quality of life and social, psychological, and physical functioning, with implications for self-care and independence.
Significantly, older people often under-report or do not report the sensory and affective components of pain and attribute pain to other things including age [294].
Some people deny pain out fear (e.g. having to go into hospital) and some do not disclose their pain because healthcare professionals do not ask about it.
Consequently even serious problems (e.g. silent myocardial infarction and peritonitis) may not be recognized or reported [294].
Assessment of pain is not straightforward but a number of key instruments have been designed to bring objectivity to this area (Table 3).
More than 20% of people over 65 years experience persistent pain which affects their quality of life [295].
Pain becomes more prevalent with increasing age: 30% of women aged 80-84 years have pain and 80% of these are under-treated.
Peripheral neuropathy occurs in up to 50% of people with long duration of diabetes and is associated with increased morbidity and mortality [296,297] and is often not reported.
Significantly, 80% of older people who do report pain have moderate to severe pain and lower quality of life [298].
A recent study in aged care home residents found 23% with documented pain did not have scheduled analgesia prescribed and those with cognitive impairment were less likely to receive analgesia [299].
Recently, changes in brain grey matter density and cortical thickness have been linked to chronic pain [300] but the clinical significance of the finding is unclear.
Pain is costly and the costs are expected to increase throughout most of the world.
Pain management is a fundamental human right [301].
In addition it represents a significant caregiver burden that is difficult to quantify.
Pain may present atypically [302,303].
Physical consequences of pain include: Respiratory changes e.g. unable to take a deep breath or cough which increase the risk of chest infection and delays recovery; Increased cardiovascular sympathetic activity which can lead to hypertension, tachycardia, and myocardial ischaemia especially if the person has pre-existing CVD and can increase the risk of venous stasis and pressure ulcers; Gastrointestinal pain can affect gastric emptying and intestinal motility, lead to erratic blood glucose levels, nausea, vomiting, and constipation; Depression, sleep deprivation, and worry [303,304].