kelingwang/causation_strength_rating huggingface dataset:
Risk factor management was improved with reduced utilization of antihypertensive medications, statins, and insulin (82).
In age-stratified analyses, older adults in the trial (60 to early 70s) had similar benefits compared with younger people (83,84).
In addition, lifestyle intervention produced benefits on aging relevant outcomes such as reductions in multimorbidity and improvements in physical function and quality of life (85–88).
Older adults are at higher risk of hypoglycemia for many reasons, including erratic meal intake, insulin deficiency necessitating insulin therapy, and progressive renal insufficiency (29).
As described above, older adults have higher rates of unidentified cognitive impairment and dementia, leading to difficulties in adhering to complex self-care activities (e.g., glucose monitoring and insulin dose adjustment).
Cognitive decline has been associated with increased risk of hypoglycemia, and conversely, severe hypoglycemia has been linked to increased risk of dementia (30–32).
Therefore, as discussed in Recommendation 13.3, it is important to routinely screen older adults for cognitive impairment and dementia and discuss findings with the individuals and their caregivers.
People with diabetes and their caregivers should be routinely queried about hypoglycemia (e.g., selected questions from the Diabetes Care Profile) (33) and impaired hypoglycemia awareness as discussed in Section 6, �Glycemic Goals and Hypoglycemia.�
Older adults can also be stratified for future risk for hypoglycemia with validated risk calculators (e.g., Kaiser Hypoglycemia Model) (34) and with consideration of hypoglycemia risk factors (Table 6.5).
An important step to mitigate hypoglycemia risk is to determine whether the person with diabetes is skipping meals or inadvertently repeating doses of their medications.
Glycemic goals and pharmacologic treatments may need to be adjusted to minimize the occurrence of hypoglycemic events (2).
This recommendation is supported by results from multiple randomized controlled trials, such as the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the Veterans Affairs Diabetes Trial (VADT), which showed that intensive treatment protocols aimed to achieve an A1C <6.0% with complex drug plans significantly increased the risk for hypoglycemia requiring assistance compared with standard treatment (35,36).
However, these intensive treatment plans included extensive use of insulin and minimal use of GLP-1 receptor agonists, and they preceded the availability of sodium�glucose cotransporter 2 (SGLT2) inhibitors.
While the current evidence base for older adults is primarily in type 1 diabetes, the evidence demonstrating the clinical benefits of CGM for people with type 2 diabetes using insulin is growing (42) (see Section 7, �Diabetes Technology�).
The DIAMOND (Multiple Daily Injections and Continuous Glucose Monitoring in Diabetes) study demonstrated that in adults =60 years of age with either type 1 or type 2 diabetes using multiple daily injections, CGM use was associated with improved A1C and reduced glycemic variability (43).
Older adults with physical or cognitive limitations who require monitoring of blood glucose by a surrogate or reside in group homes or assisted living centers are other populations for which CGM may play a useful role.
The care of older adults with diabetes is complicated by their clinical, cognitive, and functional heterogeneity and their varied prior experience with disease management.
Some older individuals may have developed diabetes years earlier and have significant complications, others are newly diagnosed and may have had years of undiagnosed diabetes with resultant complications, and still, other older adults may have truly recent-onset disease with few or no complications (47).
Some older adults with diabetes have other underlying chronic conditions, substantial diabetes-related comorbidity, limited cognitive or physical functioning, or frailty (48,49).
Other older individuals with diabetes have little comorbidity and are active.
Life expectancies are highly variable but are often longer than clinicians realize.
Multiple prognostic tools for life expectancy for older adults are available (50,51).
Notably, the Life Expectancy Estimator for Older Adults with Diabetes (LEAD) tool was developed and validated among older adults with diabetes, and a high risk score was strongly associated with having a life expectancy of <5 years (52).
These data may be a useful starting point to inform decisions about selecting less stringent glycemic goals (52,53).
Older adults also vary in their preferences for the intensity and mode of glucose management (54).
Health care professionals caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals (9,10) (Table 13.1 ).
In addition, older adults with diabetes should be assessed for disease treatment and self-management knowledge, health literacy, and mathematical literacy (numeracy) at the onset of treatment.
See Fig. 6.2 for individual/disease-related factors to consider when determining individualized glycemic goals.
(Table13.1) Healthy (few coexisting chronic illnesses, intact cognitive and functional status), Longer remaining life expectancy, <7.0–7.5% (<53–58 mmol/mol), 80–130 mg/dL (4.4–7.2 mmol/L), 80–180 mg/dL (4.4–10.0 mmol/L), <130/80 mmHg, Statin, unless contraindicated or not tolerated.
A1C may have limitations in those who have medical conditions that impact red blood cell turnover (see Section 2, �Diagnosis and Classification of Diabetes,� for additional details on the limitations of A1C) (55).
Many conditions associated with increased red blood cell turnover, such as hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, are commonly seen in older adults and can falsely increase or decrease A1C.
In these instances, blood glucose monitoring and/or CGM should be used for goal setting (Table 13.1 ).
Serum glycated protein assays (fructosamine and glycated albumin) may also be useful for glycemic monitoring in conjunction with other measures (see Section 6, �Glycemic Goals and Hypoglycemia�) (56–60).
There are few long-term studies in older adults demonstrating the benefits of intensive glycemic, blood pressure, and lipid management.
Older adults who can be expected to live long enough to realize the benefits of long-term intensive diabetes management, who have good cognitive and physical function, and who choose to do so via shared decision-making may be treated using therapeutic interventions and goals similar to those for younger adults with diabetes (Table 13.1 ).
As for all people with diabetes, diabetes self-management education and ongoing diabetes self-management support are vital components of diabetes care for older adults and their caregivers.
Self-management knowledge and skills should be reassessed when treatment plan changes are made or an individual�s functional abilities diminish.
In addition, declining or impaired ability to perform diabetes self-care behaviors may be an indication that an older person with diabetes needs a referral for cognitive and physical functional assessment, using age-normalized evaluation tools, as well as help establishing a support structure for diabetes care (3,28).
Older adults with diabetes categorized as having complex or intermediate health (Table 13.1 ) are heterogeneous with respect to their function and life expectancy (61–63).
Based on concepts of competing mortality and time to benefit, some people in this category with shorter life expectancy will have less benefit from glucose lowering and should have less stringent glycemic goals (64).
This is especially true for individuals with advanced diabetes complications, life-limiting comorbid illnesses, frailty, or substantial cognitive or functional impairments.
These individuals are also more likely to suffer serious adverse effects of therapeutics, such as hypoglycemia (65).
However, those with poorly managed diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma.
Glycemic goals should, at a minimum, avoid these consequences.
Factors to consider for individualizing glycemic goals are outlined in Fig. 6.2.
While Table 13.1  provides overall guidance for identifying complex and very complex patients, there is not yet global consensus on geriatric patient classification.
Ongoing empiric research on the classification of older adults with diabetes based on comorbid illness has repeatedly found three major classes of patients: a healthy, a geriatric, and a cardiovascular class (9,61,66).
The geriatric class has the highest prevalence of obesity, hypertension, arthritis, and incontinence, and the cardiovascular class has the highest prevalence of myocardial infarctions, heart failure, and stroke.
Compared with the healthy class, the cardiovascular class has the highest risk of frailty and subsequent mortality.
Additional research is needed to develop a reproducible classification scheme to distinguish the natural history of disease as well as differential response to glucose management and specific glucose-lowering agents (67).
(Note from Table) Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. �Multiple� means at least three, but many individuals may have five or more (74).
For people with diabetes receiving palliative care and end-of-life care, the focus should be to avoid hypoglycemia and symptomatic hyperglycemia while reducing the burdens of glycemic management.
Thus, as organ failure develops, several agents will have to be deintensified or discontinued.
For a dying person, most agents for type 2 diabetes may be removed (68).
There is, however, no consensus for the management of type 1 diabetes in this scenario (69).
See the section end-of-life care below for additional information.
(Notes from Table) The presence of a single end-stage chronic illness, such as stage 3–4 heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy; adapted from Kirkman et al. (3).
Clinicians should also consider the balance of risks and benefits of an individual�s diabetes medications, including disease-specific benefits (such as reducing symptomatic heart failure) and burdens such as hypoglycemia risk, tolerability, difficulties of administration, and financial cost.
In addition, attention to oral health, foot care, fall prevention, and early detection of depression will improve quality of life.
Screening for prediabetes and type 2 diabetes risk through an assessment of risk factors (Table 2.5) or with an assessment tool, such as the American Diabetes Association risk test (Fig. 2.2), is recommended to guide whether to perform a diagnostic test for prediabetes (Table 2.2) and type 2 diabetes (Table 2.1) (see Section 2, �Diagnosis and Classification of Diabetes�).
Testing high-risk adults for prediabetes is warranted because the laboratory assessment is safe and reasonable in cost, substantial time exists before the development of type 2 diabetes and its complications during which one can intervene, and there are effective approaches delaying type 2 diabetes in those with prediabetes with an A1C 5.7–6.4% (39–47 mmol/mol), impaired glucose tolerance (IGT), or impaired fasting glucose (IFG).
The utility of screening with A1C for prediabetes and diabetes may be limited in the presence of hemoglobinopathies and conditions that affect red blood cell turnover.
See Section 2, �Diagnosis and Classification of Diabetes,� and Section 6, �Glycemic Goals and Hypoglycemia,� for additional details on the appropriate use and limitations of A1C testing.
Individualized risk-to-benefit ratio should be considered in screening, intervention, and monitoring to lower the risk of type 2 diabetes and associated comorbidities.
Multiple factors, including age, BMI, and other comorbidities, may influence the risk of progression to diabetes and lifetime risk of complications (121,122).
Prediabetes is associated with increased cardiovascular disease and mortality (102), which emphasizes the importance of attending to cardiovascular risk in this population.
In the DPP, which enrolled high-risk individuals with IGT, elevated fasting glucose, and elevated BMI, the crude incidence of diabetes within the placebo group was 11 cases per 100 person-years, with a cumulative 3-year incidence of diabetes of 29% (4).
Characteristics of individuals in the DPP/DPPOS who were at particularly high risk of progression to diabetes (crude incidence of diabetes 14–22 cases per 100 person-years) included BMI =35 kg/m2, higher glucose levels (e.g., fasting plasma glucose 110–125 mg/dL [6–6.9 mmol/L], 2�h postchallenge glucose 173–199 mg/dL [9.6–11.0 mmol/L], and A1C =6.0% [=42 mmol/mol]), and a history of GDM (4,91,92).
In contrast, in the community-based Atherosclerosis Risk in Communities (ARIC) study, observational follow-up of adults with mean age 75 years with laboratory evidence of prediabetes (based on A1C 5.7–6.4% [39–47 mmol/mol] and/or fasting glucose 100–125 mg/dL [5.6–6.9 mmol/L]), but not meeting specific BMI criteria, found lower progression to diabetes over 6 years: 9% of those with A1C-defined prediabetes, 8% with IFG (122).
Thus, it is important to individualize the risk-to-benefit ratio of intervention and consider person-centered goals.
Risk models have generally found higher benefit of the intervention in those at highest risk (12).
Diabetes prevention trials and observational studies highlight key principles that may guide person-centered goals.
In the DPP, which enrolled a high-risk population meeting criteria for overweight or obesity, weight loss was an important mediator of diabetes prevention or delay, with greater metabolic benefit seen with greater weight loss (12,123).
In the DPP/DPPOS, progression to diabetes, duration of diabetes, and mean level of glycemia were important determinants of the development of microvascular complications (10).
Achieving normal glucose regulation, even once, during the DPP was associated with a lower risk of diabetes and lower risk of microvascular complications (124).
Observational follow-up of the Da Qing study also showed that regression from IGT to normal glucose tolerance or remaining with IGT rather than progressing to type 2 diabetes at the end of the 6-year intervention trial resulted in significantly lower risk of cardiovascular disease and microvascular disease over 30 years (125).
Three distinct stages of type 1 diabetes have been defined, with symptomatic type 1 diabetes being stage 3 (Table 2.3).
In individuals at risk for development of clinical type 1 diabetes, younger age of seroconversion (particularly under age 3 years), the total number of diabetes related autoantibodies (1), and the development of autoantibodies against islet antigen 2 (IA-2) have all been associated with more rapid progression to clinical type 1 diabetes.
While continuous glucose monitoring can predict progression to overt diabetes in children with autoantibodies (2), oral glucose tolerance testing�based metrics are superior in predicting progression compared with continuous glucose monitoring (3).
The decision to perform an oral glucose tolerance test may depend on such factors as eligibility and interest for stage-specific treatments, participation in clinical research, and availability and burden of testing.
Several major randomized controlled trials, including the Diabetes Prevention Program (DPP) trial (4), the Finnish Diabetes Prevention Study (DPS) (5), and the Da Qing Diabetes Prevention Study (Da Qing study) (6), demonstrate that lifestyle/behavioral intervention with an individualized reduced-calorie meal plan is highly effective in preventing or delaying type 2 diabetes and improving other cardiometabolic risk factors (such as blood pressure, lipids, and inflammation) (7).
The strongest evidence for diabetes prevention in the U.S. comes from the DPP trial (4).
The DPP demonstrated that intensive lifestyle intervention could reduce the risk of incident type 2 diabetes by 58% over 3 years.
Follow-up of three large trials of lifestyle intervention for diabetes prevention showed sustained reduction in the risk of progression to type 2 diabetes: 39% reduction at 30 years in the Da Qing study (8), 43% reduction at 7 years in the Finnish DPS (5), and 34% reduction at 10 years (9) and 27% reduction at 15 years (10) in the U.S. Diabetes Prevention Program Outcomes Study (DPPOS).
The DPP lifestyle intervention was a goal-based intervention.
All participants were given the same weight loss and physical activity goals, but individualization was permitted in the specific methods used to achieve the goals (11).
The two major goals of the DPP intensive lifestyle intervention were to achieve and maintain a minimum of 7% weight loss and 150 min of moderate-intensity physical activity per week, such as brisk walking.
Although weight loss was the most important factor in reducing the risk of incident diabetes, achieving the behavioral goal of at least 150 min of physical activity per week, even without achieving the weight loss goal, reduced the incidence of type 2 diabetes by 44% (12).
The 7% weight loss goal was selected because it was feasible to achieve and maintain and likely to lessen the risk of developing diabetes (as well as improve other cardiometabolic risk factors).
Participants were encouraged to achieve the =7% weight loss during the first 6 months of the intervention.
Further analysis suggests higher benefit for prevention of diabetes with at least 7–10% weight loss with lifestyle interventions (12).
The recommended pace of weight loss was 1–2 lb/week.
Calorie goals were calculated by estimating the daily calories needed to maintain the participant�s initial weight and subtracting 500–1,000 calories/day (depending on initial body weight).
The initial focus of the dietary intervention was on reducing total fat rather than calories.
After several weeks, the concept of calorie balance and the need to restrict calories and fat was introduced (11).
The goal for physical activity was selected to approximate at least 700 kcal/week expenditure from physical activity.
For ease of translation, this goal was described as at least 150 min of moderate-intensity physical activity per week, similar in intensity to brisk walking.
Participants were encouraged to distribute their activity throughout the week with a minimum frequency of three times per week and at least 10 min per session.
A maximum of 75 min of strength training could be applied toward the total 150 min/week physical activity goal (11).
To implement the weight loss and physical activity goals, the DPP used an individual model of treatment rather than a group-based approach.
This choice was based on a desire to intervene before participants had the possibility of developing diabetes or losing interest in the program.
The individual approach also allowed for the tailoring of interventions to reflect the diversity of the population (11).
The DPP intervention was administered as a structured core curriculum followed by a flexible maintenance program of individual counseling, group sessions, motivational campaigns, and restart opportunities.
The 16-session core curriculum was completed within the first 24 weeks of the program.
It included sessions on lowering calories, increasing physical activity, self-monitoring, maintaining healthy lifestyle behaviors (such as how to choose healthy food options when eating out), and guidance on managing psychological, social, and motivational challenges.
Further details are available regarding the core curriculum sessions (11).
Moderate-intensity physical activity, such as brisk walking for 150 min/week, has shown beneficial effects in those with prediabetes (4).
Similarly, moderate-intensity physical activity has been shown to improve insulin sensitivity and reduce abdominal fat in children and young adults (27,28).
Health care professionals are encouraged to promote a DPP-style program to all individuals who have been identified to be at an increased risk of type 2 diabetes.
In addition to aerobic activity, a physical activity plan designed to prevent diabetes may include resistance training (11,29,30).
Breaking up prolonged sedentary time may also be encouraged, as it is associated with moderately lower postprandial glucose levels (31,32).
The effects of physical activity appear to extend to the prevention of gestational diabetes mellitus (GDM) (33).
Nutrition counseling for weight loss in the DPP lifestyle intervention arm included a reduction of total dietary fat and calories (4,11,12).
However, evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people to prevent diabetes; therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals (13).
Based on other trials, a variety of eating patterns (13,14) may also be appropriate for individuals with prediabetes (13), including Mediterranean-style and low-carbohydrate eating plans (15–18).
Observational studies have also shown that vegetarian, plant-based (may include some animal products), and Dietary Approaches to Stop Hypertension (DASH) eating patterns are associated with a lower risk of developing type 2 diabetes (19–22).
Evidence suggests that the overall quality of food consumed (as measured by the Healthy Eating Index, Alternative Healthy Eating Index, and DASH score), with an emphasis on whole grains, legumes, nuts, fruits, and vegetables and minimal refined and processed foods, is also associated with a lower risk of type 2 diabetes (21,23–25).
As is the case for those with diabetes, individualized medical nutrition therapy (see Section 5, �Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,� for more detailed information) is effective in lowering A1C in individuals diagnosed with prediabetes (26).
Because the intensive lifestyle intervention in the DPP was effective in preventing type 2 diabetes among those at high risk for the disease and lifestyle behavior change programs for diabetes prevention were shown to be cost-effective, broader efforts to disseminate scalable lifestyle behavior change programs for diabetes prevention with coverage by third-party payers ensued (34–38).
Group delivery of DPP content in community or primary care settings has demonstrated the potential to reduce overall program costs while still producing weight loss and diabetes risk reduction (39–43).
The Centers for Disease Control and Prevention (CDC) developed the National Diabetes Prevention Program (National DPP), a resource designed to bring such evidence-based lifestyle change programs for preventing type 2 diabetes to communities (cdc.gov/diabetes/prevention/index.htm).
This online resource includes locations of CDC-recognized diabetes prevention lifestyle change programs (cdc.gov/diabetes/prevention/find-a-program.html).
To be eligible for this program, individuals must have a BMI in the overweight range and be at risk for diabetes based on laboratory testing, a previous diagnosis of GDM, or a positive risk test (cdc.gov/prediabetes/takethetest/).
During the first 4 years of implementation of the CDC�s National DPP, 36% achieved the 5% weight loss goal (44).
The CDC has also developed the Diabetes Prevention Impact Tool Kit (nccd.cdc.gov/toolkit/diabetesimpact) to help organizations assess the economics of providing or covering the National DPP (45).
To expand preventive services using a cost-effective model, the Centers for Medicare & Medicaid Services expanded Medicare reimbursement coverage for the National DPP to organizations recognized by the CDC that become Medicare suppliers for this service (innovation.cms.gov/innovation-models/medicare-diabetes-prevention-program).