Endocrine and Metabolic Problems and Nutrition in the Aged

Chapter 11

Diabetes Mellitus

• Type 1 diabetes mellitus– Lack of insulin production

• Type 2 diabetes mellitus– Resistance to insulin by the tissues leading to beta

cell failure

Diabetes Mellitus

• Epidemiology– Prevalence of T2DM = 180 million– 6th most frequent disease-specific cause of death

in the U.S.– T1DM

• Generally diagnosed in the younger population• 5% to 10% of all cases of DM

Diabetes Mellitus

Centers for Disease Control and Prevention. Prevalence of diagnosed diabetes by age in the United States, 1980–2005. Available at: http://www.cdc.gov/Diabetes/statistics/prev/national/figbyage.htm. Accessed February 12, 2008.

Diabetes Mellitus

• Types of Diabetes mellitus– Type 1

• Beta cell destruction or dysfunction• Usually leads to insulin deficiency

– Type 2• Occurs over time • B cells of pancreas produce less insulin as the

tissues develop resistance to insulin• Impaired insulin-mediated glucose uptake

Diabetes Mellitus

• Types of Diabetes– Third type of diabetes stems from a number of

possible causes– Gestational diabetes

• Risk Factors– Metabolic Syndrome

• Group of risk factors associated with insulin resistance

–Hypertension, dyslipidemia, hyperglycemia, central obesity

Diabetes Mellitus• Risk Factors

– Metabolic Syndrome (cont.)• A complex, poorly understood disorder• The obese older adult is at higher risk than

those at a normal weight• Easy screening method is waist circumference

– Sleep Disorders• Altered sleep patterns result in insulin

resistance and a decrease in carbohydrate tolerance

Diabetes Mellitus

• Prevention of Diabetes– Micro- and macro-vascular damage may have

already been done by the time of diagnosis

• Prediabetes– Recognize risk factors to plan an intervention to

avoid the onset of diabetes– Lifestyle changes– Antidiabetic pharmacotherapy

Diabetes Mellitus• Symptoms and Diagnosis of Diabetes

– Older adults with one risk factor should be screened for DM

– Hemoglobin A1C• Glycosylated hemoglobin

–Glucose in blood binds to Hgb–Stable over lifespan of the RBC–Value does not fluctuate like daily blood

glucose–Gives overview of blood sugars over a 3-

month period

Diabetes Mellitus

• Complications of Diabetes– Older adults often not diagnosed until

complications appear• Diabetes Management

– Lifestyle changes– Balance between tight glucose control,

management of comorbidities, and quality of life– Goals for blood lab values– Other components

Diabetes Mellitus• Diabetes Management (cont.)

– Collaborative health care team– Self-management, holistic approach– Diet and exercise

• Diet– Eat healthy, lose weight, and exercise regularly– Attain optimal metabolic outcomes– Maintain a healthy blood pressure and body

weight– Manage glucose control

Diabetes Mellitus

• Diet

Adapted from American Diabetes Association. Diabetes Food Pyramid. Available at: http://www.diabetes.org/food-nutrition-lifestyle/nutrition/meal-planning/diabetes-food-pyramid.jsp. Accessed July 6, 2009.

Diabetes Mellitus

• Diet (cont.)– Portion size– Use MyPyramid.gov to plan diet

Diabetes Mellitus

• Diet (cont.)– If overweight, moderate reduction in calories – If consume alcohol, do so in moderation– Less than 7% saturated fat in diet– RDA for Protein is 0.8 g per kilogram

Diabetes Mellitus

• Exercise– Individualized programs– Helps to reduce insulin resistance– Monitor BG to avoid hypoglycemia

• Insulin Injections– Subcutaneous

• Syringe or insulin pump, nasally inhaled insulin

Diabetes Mellitus

• Oral Medications– Sulfonylureas

• Enhances release of insulin from beta cells– Meglitinides

• Stimulates beta cells of pancreas to produce insulin

– Metformin• Decreases glucose absorption and improves

insulin sensitivity

Diabetes Mellitus

• Oral Medications (cont.)– Thiazolidinediones

• Lowers insulin resistance– Alpha-glucosidase

• Delays the digestion and absorption of carbohydrates

• Manage hypoglycemia– Eating 10 to 15 g of carbohydrates– Know signs and symptoms

A Summary of Diabetes Mellitus• Complex metabolic disorders• Most older adults have type 2 diabetes• Chronic and progressive disease• Requires a collaborative approach for

management• Four keys to successful management

– Diet– Exercise– Medications– Self-care strategies

The Endocrine System

National Institutes of Health, 2007.

The Endocrine System• Pituitary Gland and Hypothalamus

– Makes up the hypothalamic-pituitary axis– Increase or decrease

inhibitory/stimulating/trophic hormones– Hypothalamus

• Located at base of brain• Connected to the anterior pituitary and

posterior pituitary• Help control the trophic hormones• Produces appetite-reducing or stimulating

hormones

The Endocrine System

• Thyroid Glands– Thyroid diseases increase with age

• The Thyroid Gland and Its Dysfunctions– Hypothyroidism

• Results from a decrease in thyroid gland function

• Multiple causes• Signs and symptoms• Hypercholesterolemia

The Endocrine System

• The Thyroid Gland and Its Dysfunctions– Treatment

• Low-dose replacement of T4• Monitor lab values

The Endocrine System

• Hyperthyroidism– Increase in the function of the thyroid gland– Result of an overactive gland– Thyroxtoxicos

• Very severe form of hyperthyroidism– Grave’s disease

• Most common hyperthyroid state in older adults

Hyperthyroidism

• Epidemiology– Occurs more often in women than in men– More common in parts of the world with low

iodine availability– Clinical presentation

• Vague, nonspecific symptoms• Elevated T and T4 test and low TSH• See box 11-6 for general manifestations

– May be caused by certain foods– May result from autoimmune disease

Hyperthyroidism

• Epidemiology (cont.)– Apathetic hyperthyroidism

• Exclusively seen in frail older adults• Multiple clinical presentations

– Nutritional problems associated with hyperthyroidism• Hyponatremia, worsening of glucose tolerance,

milk hyperglycemia, anemia, and possibly osteoporosis

Hyperthyroidism

• Treatment– Medications– Radioiodine or surgery may be used– Surgery usually reserved for older patients with

large goiter or ophthalmapathy• Nodular Goiter and Thyroid Cancer in the

Older Adult– Common in adults older than age 70– Treatment: surgery, external radiation, and

chemotherapy

Hyperthyroidism

• Parathyroid Glands and Calcium Metabolism– Four glands– Secretes the parathyroid hormone

• Maintains serum calcium levels– Release of parathyroid hormone increases

between ages of 30 and 80– Calcitonin

• Inhibits the release of calcium– Vitamin D

• Facilitates calcium absorption

Hyperthyroidism

Insel P, Turner RE, Ross D. Nutrition. 3rd ed. Sudbury, MA: Jones & Bartlett; 2007. Reproduced with permission.

Hyperthyroidism

• Hyperparathyroidism– More common in women– Primarily the result of gland hyperplasia– Often milk and asymptomatic – Detected by serum calcium laboratory report– Multiple symptoms– Hypercalciuria and nephrolithiasis– Severe hypercalcemia– Treatment through surgery or pharmacological

treatment

Hyperthyroidism

• Hypocalcemia– Most common cause is inadequate intake of

dietary products, with decreased albumin, and vitamin D intake or activation

– Decrease exposure to sunlight and vitamin D synthesis by the skin

– Treated with calcitriol and oral calcium supplements, other medications, IV infusion of calcium

Osteoporosis

• Risk factors are known and identifiable• DEXA scans recommended for women 65

years and older• Postmenopausal osteoporosis

– Low bone mass– Micro-architectural deterioration of bone– Fragile bone– Heightened susceptibility to fracture

Osteoporosis

Visible Symptoms of Osteoporosis Due to Collapsed Vertebrae

Normal and Abnormal Bone in Osteoporosis

© Bill Aron/PhotoEdit © Dr. Michael Klein/Peter Arnold, Inc.

Osteoporosis

• Risk Factors/Prevention– Peak bone mass during ages 20 – 30– Prevention through adequate calcium and vitamin

D intake, enough sunlight, and weight-bearing exercises

– Hormone-replacement therapy– See Box 11-7 for risk and contributing factors for

osteoporosis

Osteoporosis• Treatment

– Vitamin D3 best supports bone health• Manufactured in skin following direct exposure

to sunlight• Food sources: fortified milk, egg yolks,

saltwater fish, liver, and supplements– Calcium intake recommendations

• 1,000 mg/day in ages 31 – 50 years• 1,200 mg/day for those older than 50

Osteoporosis• Medications

– Multiple medications used• Positive effects of estrogen• Reducing hip and vertebral fractures• New approach medications reduce survival of

osteoclasts and slow the rate of bone resorption

• Effect skeletal muscle tissues• Enhance bone mass and bone turnover• Help regulate secretion of calcitonin• Inhibit osteoclastic functions

Paget’s Disease

• Occurs in 1.3 of every 100 adults age 45 to 74• Changes bone and causes deformity and

increases tendency to fracture

Paget’s Disease: Normal and Abnormal Bone

Paget’s Disease

• Usually asymptomatic• Usually found by x-ray• Bones most commonly affected

– Skull, pelvis, spine, femur, and tibia

• Occasionally transforms to osteosarcoma

Adrenal Glands

• Aldosterone– Conserves sodium by increasing the activity of the

sodium pump of the epithelial cells

Water Metabolism

• Thirst perception diminishes with age• Edema

– Collection of excessive fluid in interstitial compartments

– May occur secondary to other conditions– Water intoxication– Aldosterone retains sodium, which retains water

Diseases of the Adrenal Cortex

• Antidiuretic hormone secretion tends to be excessive in aged individuals

• Hyponatremia may be caused by many of the illnesses that affect older adults

Adrenal Insufficiency: Addison’s disease

• A decrease in cortisol secretion• Most often caused by failure of the adrenal gland • Onset is primarily between ages of 30 and 50• Can be caused by autoimmune disorders, tumors,

infections, or suppression of the adrenal gland• Multiple symptoms• Management focuses on finding and treating the

cause and replace mineralcorticoids and glucocorticoids

Cushing’s Syndrome

• Exposure to excessive amounts of cortisol for a prolonged period of time

• Most common cause in older adults is exogenous corticoids

• Treatment – eliminating the excess cortisol

• Signs and Symptoms

Reproduced from An Introduction to Human Disease. 7th ed. Photos courtesy of Leonard V. Crowley, M.D., Century College.

Conclusion

• In conjunction with the nervous system, the endocrine system synthesizes and regulates hormones that send messages throughout the body.

• Nutrition plays a very important role in the management of the disorders discussed in this chapter.