Diet and weight gain of elderly diabetic patients

Introduction

Type 2 diabetes mellitus (DM) is a complex, progressive disease which requires a variety of risk management strategies. The disease is considered to be an epidemic, and therefore affects all levels of the healthcare system [1].

Previous research has highlighted the importance of doctor–patient communication, which is crucial in influencing patients’ perception of disease seriousness and their subsequent compliance to treatment. Besides lifestyle modifications, effective treatment with drugs and the adequate treatment of co-morbidities, medical nutritional therapy (MNT), commonly called diet, is of fundamental importance. Previously strict dietary exclusions have been replaced by recommended rations, and the dietary recommendations for diabetic patients have become milder in recent decades [2], [3].

MNT is a key feature of the treatment and management of type 2 diabetes, and is often a source of conflict between practitioners and patients [4]. Family doctors, who have wide access to information on patient lifestyle, often face abnormal laboratory results after initiation of the recommended treatment. Some of these abnormalities could be explained by patient diet being far from that of the recommendations.

The aim of our research was to obtain information on nutritional habits, physical activity and lifelong weight gain among the elderly, and to compare the data of diabetic (DM) patients to those without diabetes mellitus (n-DM).

Methods

Our evaluation was performed between 2001 and 2004, and was linked to a wider study on elderly people in Budapest, Hungary [5]. The subjects (247 people (99 men and 148 women) over 60 y) were recruited consecutively from patients visiting our surgery. Seventy-one DM patients (33 men and 38 women) and 176 patients without diabetes (n-DM) (66 men and 110 women) were compared.

The method of evaluation consisted of a 7-page-long questionnaire with 75 questions on morbidity, education, living circumstances, lifestyle, eating habits, and lifetime body-weight development (based on patient recall), followed by the measurement of standard anthropometric parameters. The questions concerning nutritional habits and meal patterns were based on a validated food frequency questionnaire (FFQ) used in 1990 in the Euronut-seneca study [6], which was also used in a previous Hungarian nationwide survey [7].

Results

The results show that all parameters relating to obesity—body weight, waist and hip circumferences, and BMI—were significantly higher in the DM group. Among people with lower educational level, the incidence of DM was higher.

The number of daily servings within BMI groups (normal, overweight and obese) and the distribution of daily meal patterns on weekdays and holidays were compared in the DM and n-DM groups (see Table I). The overweight and obese patients ate less frequently, and the fewer the number of daily meals, the higher the BMI.

Table I.  Meal patterns: number of daily servings in BMI groups on weekdays and holidays (percent).

	BMI group (kg/m^2)			Weekdays		Holidays
Meals/day	<25	25–30	<30	DM	n-DM	DM	n-DM
2	18	50	32	9	14	3	12
3	30	47	23	43	61	41	60
4	36	47	17	27	15	30	16
5	48	28	20	22	10	27	11

p<0.05.

The number of daily meals taken by DM patients significantly differed between workdays and holidays (p<0.05). However, within the n-DM group, similar responses were registered. Responses to the FFQ are presented in Table II.

Table II.  Weight gain: the increase of body weight from youth, by decade.

	Men				Women
	(n=33)		(n=66)		(n=38)		(n=110)
Decade of life	DM	Δ%	n-DM	Δ%	DM	Δ%	n-DM	Δ%
20 y	64.4		66.8		56.2		53.7
30 y	68.1	5.7	69.3	3.7	58.7	4.4	56.9	5.9
40 y	68.7	1.0	72.1	4.0	65.3	11.1	59.9	5.2
50 y	70.6	2.7	75.5	4.7	59.4	−9.1	65.6	9.5
60 y	75.8	7.3	76	1.0	63.5	6.9	67.4	2.7
Maximum	83.6		81.4		74.4		71.7
Actual	84.9		76.9		72.2		66.7

Results were similar regarding the consumption of different types of bread, potato, rice and noodles. It was clear, however, that a low-fat diet was not characteristic for diabetic patients who should refrain from eating fat. The responses also showed that food choices among the study population were strongly influenced by income.

None of this elderly population did regular sport. The mean number of hours per week spent doing outdoor activities (gardening, walking, cycling) was 14.0 for men and 9.7 for women in the n-DM population. These figures were lower (12.3 and 8.0, respectively) in the DM group.

Using retrospective body-weight analysis (i.e. the increase of body weight, based on subject recall), differences between age decades and groups were compared (see Table III). The retrospective body-weight analysis uncovered some interesting characteristics of weight gain prior to diabetes diagnosis; diabetic men had lower, while diabetic women had higher body weight in their youth, and weight gains were not parallel.

Table III.  Responses to FFQ.

	% of the group
	DM	n-DM
Food choices are influenced by income	72	57
Following medical advice in MNT	49	63
Regularly used for cooking:
animal fat	41	53
vegetable oil	54	53
butter	3	3
margarine	3	5
Consumed at least once a week:
fish	22	13
1–3 times:
poultry	68	72
Daily use of
butter	24	13
margarine	44	49
lard	16	14
Daily consumption of fresh vegetables	41	27
Added salt never used for dish	24	17
Never drink alcoholic beverages (abstinent)	43	32

Discussion

This study shows that this elderly population was overweight, which is representative of the general Hungarian population. In the analyses of the responses to the FFQ, similar results were recorded. Obesity is closely linked to DM, and the lifestyle of patients is partly responsible for the onset of diabetes. After these patients become diabetic, they tend not follow therapeutic and lifestyle recommendations.

Prior to the evaluation, we anticipated greater differences between the diet of diabetic patients and non-diabetic patients. This assumption was based on the belief that primary-care physicians and nurses do their best to educate patients and force them to keep to a recommended diet, informing them of preferred meals and helping to change their possibly unhealthy eating habits. Healthy eating and increased physical activity can prevent or delay diabetes and its complications. Techniques that facilitate adherence to these lifestyle changes can be adapted to primary care [8].

It is never too late to start lifestyle intervention, even in middle-aged patients in whom the highest body-weight increases are registered, and there is great scope for improved management within general practice [9]. However, it is hard to change the eating habits of elderly people, and the occurrence of diabetes does not seem to have enough impact to achieve expected lifestyle modification goals.

The main suggestion of this study is that the diet of DM patients should be kept under closer and most effective control by primary-care staff.