ReviewA scoping review of best practice guidelines for the dietary management of diabetes in older adults in residential aged care
Introduction
Changes to the philosophical approach, scientific recommendations and terminology in the nutritional management of all adults with diabetes have come about since the paper ‘Nutrition Recommendations and Principles for people with diabetes mellitus’ was released by the American Diabetes Association (ADA) in 1994 [1]. The paradigm of the ADA diet based on caloric restriction and macronutrient distribution became obsolete and a new model of medical nutrition therapy that included lifestyle assessment, individualisation of metabolic parameters and nutrition goals for therapeutic outcomes was introduced [1], [2]. Particular changes to prior dietary recommendations included acknowledgement that total carbohydrate had impact on metabolic outcomes (blood glucose levels) not just the type of carbohydrate, and therefore recommendations for fibre and sucrose (sugar) could be more aligned with those for people without diabetes [1]. Medical nutrition therapy also replaced traditional terminology ‘diet therapy’, and self-management training replaced patient education. While the diet was significantly liberalised from previously restricted macronutrient recommendations, individuals were encouraged to maintain a consistent carbohydrate eating pattern proven to lower glycated haemoglobin (HbA1c) [1], [3].
In 2002, the ADA commissioned a taskforce to again review the evidence for medical nutrition therapy and the dietary management of types 1 and 2 diabetes [4]. This was the first document to include a brief section on special considerations for older adults, with all prior dietary advice being aligned with generic adult (18–64 years) recommendations. The core dietary recommendations for the inclusion of wholegrains, adequate fruit and vegetable serves and low glycaemic index (GI) foods remained the same for all people with diabetes and similar to healthy eating documents applicable to the wider population. While sugar in the diet could still be included without restriction it was recommended that foods with added sugar, “should be substituted for other carbohydrate sources or covered with insulin or glucose lowering medication” [4]. The specific guidance aimed at older adults in this document was based on expert consensus only and stated, “In the elderly, undernutrition is more likely than over nutrition and therefore caution should be exercised when prescribing weight loss diets” [4].
The Academy of Nutrition and Dietetics (AND) also released a position statement (2002) supporting the liberalisation of therapeutic diets for older adults with diabetes and highlighting two goals of care; maintenance of health and maintenance of quality of life [5]. They also recommended a regular diet with no restriction of food choice to promote oral intake and minimise risk of malnutrition in this cohort. However the document highlighted the need for reinstatement of a more ‘controlled diet’ if individuals did not tolerate dietary liberalisation [5].
Since their release, ADA updates have been conducted and published as medical care standards and position statements (generally updated every 5 years) with minor changes [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]. Also, but with less frequency, updated position statements from the AND [19], [20]. Dietary recommendations remained broad in nature and thus recognising the need for best practice guidance for older adults with diabetes, international and local clinician guidelines have been developed. At the present time there is no one document mandated for use, although in some countries, such as the UK, professional organisations do promote a more unified approach to diabetes care by endorsing a particular guideline [21]. However, within Australia no guidelines are mandated or endorsed by the dietetic professional body. In addition, best practice guidelines available locally and internationally are not widely known about by health professionals working with older adults with diabetes here [22]. The aim of this scoping review was to identify local and international guidelines available for the management of older adults with diabetes and to compare key nutrition messages and the evidence that underpins them. A second aim of the review is to evaluate the guidelines to determine their quality and applicability in guiding future best practice management of diet and diabetes in older adults, particularly those in a residential aged care (RAC) setting.
Section snippets
Methods
A targeted electronic database search, online grey literature search and hand searching of reference lists was conducted by the primary author. The database search was conducted in Medline (via Pubmed) and Cumulative Index of Nursing and Allied health literature database (CINAHL) with no restriction on date of publication. Search strings were developed and used for database searching (Table 1) with a more simplistic key word search in Google Scholar. The first 10 pages of grey literature (100
Data selection
Titles and abstracts of each reference retrieved were reviewed and final eligibility was determined by screening of full texts based on inclusion criteria. Essential inclusion criteria were that the document was intended as best practice guidelines (excluding position statements) and was particularly focused on diabetes management in older adults (although this could be limited to a section of the document) ideally referring to an aged care setting, at least in part. Finally the documents
Data extraction
The relevant data from included documents was entered into a spreadsheet and the quality of each guideline determined using the Agree II-Global Rating scale (Agree II-GRS) instrument. The original Agree II tool for appraising guidelines is an internationally recognised tool for determining guideline quality [24]. The Agree II-GRS is the short item tool for rapid review, but is recognised as an acceptable critical appraisal tool for clinician guidelines [25]. The tool appraises the guidelines
Results
A total of 185 references were retrieved from all steps of the search strategy, with 165 remaining after 20 duplicates were removed. A further 144 were excluded after screening by title and abstract as they were not guidelines or did not refer to older adults (≥65 years) with diabetes. Of the remaining 21 references, following full-text screening, 10 were excluded on the basis of not being guidelines and therefore 11 documents were included in the critical appraisal having met all inclusion
Guideline quality
The three diet specific guidelines in Table 2 [21], [26], [27] were primarily compiled by dietitians and scored the lowest quality values as determined using the AGREE II-GRS tool (≤4). A broad range of stakeholders contributed to the content of these guidelines including food service, aged care and allied health professionals [25], [26], [27]. While they scored highly in sub-categories relating to relevance to the target population, usability and presentation: they lacked detail and
Healthy eating
Each of the 11 guidelines made reference to healthy eating in their dietary recommendations comprising a low fat, low added sugar, high fibre focus. Four documents [21], [30], [31], [35] referred more explicitly to the relevant population based healthy eating recommendations (UK and Australian) such as the Dietary Guidelines for Australian Adults [36] or the UK Dietary reference values and country specific publication [37] on healthy eating. While the guidelines issued by the Australian
Discussion
The findings of this scoping review are that documents guiding best practice for older adults with diabetes are variable in quality and applicability to practice, but the evidence on which all dietary recommendations are based appear to be the same two studies examining a liberalised diet on diabetes outcomes [43], [44] or documents that have subsequently cited these studies. Overall there is uniformity of opinion on the importance of regular meals loosely based on healthy eating principles.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors state that they have no conflict of interest
Acknowledgements
Nil.
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