How to manage uncontrolled diabetes in the elderly?

Hello,

Welcome to icliniq.com.

I have read your query and understand your concern.

I will try my best to provide you with the best available treatment. I have seen his medications and the test reports (attachments removed to protect the patient's identity) you have sent me. His sugars are really up, and it has been for months; it seems as if his HbA1c is over 10. The target HbA1c for him should be near seven.

Diabetes has many complications, so it is not just about bringing down the numbers but also monitoring and treating complications associated with diabetes. Check his eyes for retinopathy by an eye doctor; at least it should be a baseline, and then at least yearly.

Kidneys should be monitored at baseline with the urine albumin creatinine ratio, which is a urine test. Check his feet for any ulcers, wounds or callous sensations which can decrease diabetes and can later lead to diabetic foot. At least an ECG (Electrocardiogram) should be done, and depending on his symptoms, other tests may be needed to rule out any cardiovascular issues that may come with long-term diabetes at his age.

1. Does he have any chest discomfort, breathing issues, or palpitations?
2. How is his lifestyle?
3. Is he active in his life?
4. How is his daily routine from morning to evening?
5. What does he eat and like to eat from breakfast to dinner?

By knowing these, I will be in a better position to know him and accordingly suggest lifestyle modifications to control his diabetes. Lifestyle is much more important than medications only. Lifestyle modifications are the best treatment for diabetes. Generally, I suggest the following things, but we can modify them if I know him by his daily routine.

1. Low-carbohydrate diet and no added sugar.

2. No sugary juices.

3. No bread, rice, pasta, or potatoes. If you cannot stop, at least take as little as possible. More vegetables, salads, and fiber. Fruits are not only a sweet dish.

4. Do not take mangoes, grapes, and bananas. Apple is not more than one piece. Strawberries and other berries are fine along with peaches, apricots, and small amounts of plums. Intermittent fasting will also help you control your diabetes.

5. You can fast for 16 hours, like taking your dinner at 7 pm and not eating anything after that, and then the next day you can take breakfast at 11 am. During fasting, just drink water and green tea without sugar. You can extend fasting to 24 hours, then 36 hours as your body adapts.

6. You can do fasting two times a week, or as you feel comfortable; it will control your sugar. Drink at least 0.6 gallons of water a day. Sleep well, at least six to seven hours a day, and the best time to sleep is from 9:30 to 10 pm because during this time, a sleep hormone, melatonin, is released, which gives the best sleep.

7. Exercise, at least walk 45 minutes daily or above 7000 steps. The more he practices these things, the better his control will be. Check his sugar frequently, at least after fasting and after eating.

If you want to add anything to your meals, check the sugar before taking it and then after two hours of eating to see how much it increases your sugar. Anything that increases sugar by 20 to 30 mmHg is fine. And he can eat it frequently, but if his blood sugar increases over 30 to 40 mmHg, take it less frequently. Your fasting target should be 90 to 130 mmHg, two hours after eating, 150 to 160 mmHg, and HbA1c should be less than 7.

Coming to your questions: As the duration increases, the pancreas, which makes insulin, gets tired and cells die, and insulin requirements increase. There can be many reasons why his requirements increase. It can be any infection, change in diet, mental stress, loss of proper sleep, or decreased physical activity. When using insulin, it should not be taken at any one point; the place of insulin injection should be changed on the body frequently. It may lead to lumps on the body where insulin is given frequently at one point.

1. Does he have any? Insulin should be kept at a proper temperature of less than 25°C.
2. Can you please tell me how long he has been on insulin?
3. What were the last oral medications he was taking, and then what was his HbA1c?

His weight is also a bit above the range. If you have a list of his sugar values for the last week, please send me so I can see at what times of the day his sugars are high. About the book for recipes, you can check online.

You can search for yourself as well for the recipe book, which will be according to your culture and eating habits. The principle is that a diet should have less than 20 percent carbohydrates, and it should have good carbohydrates, such as more vegetables, which have more fiber.

Potatoes should be consumed in moderation. Low-carb foods include lean meats, such as sirloin, chicken breast, or pork, fish, eggs, leafy green vegetables, cauliflower and broccoli, nuts and seeds, including nut butter oils, such as coconut oil, olive oil, and rapeseed oil, some fruit, such as apples, blueberries, and strawberries, unsweetened dairy products, including plain whole milk and plain Greek yogurt too. Know the carb counts and serving sizes of foods.

Most low-carb diets only allow for 0.7 to 1.7 ounces (oz) of carbohydrates per day. Because of this, it is essential that people following low-carb diets choose foods that have a lower carb count but a high nutritional value per serving.

The foods in the quantities listed below all contain approximately 0.4 oz of carbs: one tennis ball-sized apple or orange, one cup of berries, one cup of melon cubes, half a medium banana, two tablespoons of raisins, eight ounces of milk, six ounces of plain yogurt, half a cup of corn, half a cup of peas, half a cup of beans or legumes, one small baked potato, one slice of bread, or 1/3 cup of cooked rice. While the foods listed above all contain roughly equal amounts of carbohydrates, they are not all nutritionally equivalent.

The dairy products on the list contain protein and vital nutrients, such as Vitamin D and calcium, in addition to the carbohydrate content. The fruit and vegetables also contain essential vitamins and minerals. Choosing whole-grain varieties of bread and rice will provide more nutrients than white varieties, even though the carb content is similar.

In my discussion above, I talked about intermittent fasting. I want to give you some details about it. You can look into it and see if it appeals to you. It is one of the options for controlling your dad’s sugar. But still, it depends upon him if he is willing to do it. There is nothing to force, but my job will be to give you the options, and then after discussion, we can make a proper plan for his sugars to be controlled appropriately. Fasting may be the oldest and most powerful dietary intervention we know. Weight loss is the most obvious health benefit. Other physical benefits of intermittent fasting include:

1. Weight and body fat loss.
2. Increased fat burning.
3. Lowered blood insulin and sugar levels.
4. Reduction in HbA1C.
5. Improved mental clarity and concentration.
6. Increased energy and increased growth hormone.

How do I get started? Fasts vary.

1. Only water is allowed during fasting, usually, but coffee and green tea with a sweetener but without milk can be taken as well.

2. Fast 16/8, 24 hours, 36 hours, or extended fasting

3. You need to check how ready your body is to do this. Once you decide on your fasting regimen, it is time to implement your plan.

When we eat, food is converted to either glucose from carbohydrates, amino acids from proteins, or fatty acids from fats. Sugar is stored as glycogen in the liver. This energy store is easy to access but limited in storage capacity. Dietary glucose and protein in excess of glycogen storage capacity are turned into fat for storage by the liver in a process called de novo lipogenesis (literally, making new fat). This form of energy storage is more complicated, but there is virtually no limit to storage capacity. These two food energy storage systems complement each other.

Glycogen is easily accessible but has limited storage space. Body fat is more difficult to access but has unlimited storage space. When we do not eat, insulin levels fall, telling the body to start burning the stored energy, glycogen, and body fat. Glycogen is used first. Once glycogen stores are depleted, the body will start breaking down body fat for energy. If feeding and fasting are balanced, then there should be no net weight change. You do not gain weight and lose weight. If feeding (high insulin) predominates, then we gain weight. If we start eating the minute we roll out of bed and do not stop until we go to sleep, we spend all our time in the fed state.

Over time, we will gain weight because our body spends insufficient time in the fasted state, where it burns the stored food energy. If we want to lose weight, then we simply need to increase the amount of time spent burning food energy. That is intermittent fasting. It essentially allows the body to use its stored energy. After all, that is what we stored it for. It is a completely natural process.

Type 2 diabetes (DMII) is fundamentally a disease of too much sugar in the body. When we eat glucose, insulin allows it to be used by all the cells of our body for energy and to store the excess. Over time, if all our cells and storage systems become overloaded, the remaining glucose spills over into the blood. Those high blood glucose levels are measured, resulting in the diagnosis of type 2 diabetes.

Our body is like a sugar bowl. It starts off empty. Over time, if we continually put a little more sugar in than we take out, it becomes full, just like the cells of our body. Now, if we put in a little more sugar, it spills out into the blood, with high blood sugar leading to type 2 diabetes. If the core issue is glucose overfilling the cells, then the solution is obvious: get that glucose out of the cell. There are really only two ways of getting the toxic glucose overload out:

1. Stop putting glucose in. Low carbohydrates reduce the amount of dietary glucose. Fasting also eliminates carbohydrates and all other foods, for that matter.

2. Burn off the excess glucose. Your body requires a certain amount of energy every day to survive.

The heart, brain, kidneys, liver, etc., all require energy even if you are lying in bed. If you do not eat food (fasting), then the body must burn its stored energy. The first place it will get that energy from is the glucose in the blood. As you continue fasting, your body will start to burn body fat.

As you lose body fat, type 2 diabetes will start to reverse. Indeed, more and more research is showing that intermittent fasting has the potential to reverse type 2 diabetes without medications, surgery, or even cost. Both fasting and exercise significantly increase the beneficial BDNF (brain-derived neurotrophic factor) effects in several parts of the brain. In human studies, a 30 percent reduction in calories significantly improved memory and synaptic electrical activity in the brain.

Lower insulin levels are correlated with better memory. Further, a higher body mass index is linked to a decline in mental abilities and decreased blood flow to those areas of the brain involved in attention, focus, reasoning, and more complex, abstract thought. Autophagy is a form of cellular cleansing: it is a regulated, orderly process of breaking down and recycling cell components when there’s not enough energy to sustain them.

Once all the diseased or broken-down cell parts have been cleansed, the body can start the process of renewal. Autophagy keeps our bodies running well. Our diet, especially protein intake, stops this process of cleansing. When we eat food, our bodies detect it through nutrient sensors like insulin. Constant snacking reduces autophagy. When we fast, the body senses the absence of nutrients and worries that there won’t be enough food to feed the whole body. It must prioritize which cell parts to keep. The oldest and most worn-out cell parts get discarded. At the same time, fasting also stimulates growth hormones.

When we eat again, this signals the production of new cell parts, giving our bodies a complete renovation. Since it triggers both the breakdown of old cellular parts and the creation of new ones, Fasting may be considered one of the most potent anti-aging methods in existence. Along with intermittent fasting, a low-carbohydrate diet is great for controlling diabetes, and even in some cases, it can reverse it if it is newly diagnosed diabetes.

I hope you find this helpful.

Thank you.

Hello,

Welcome back to icliniq.com.

Thanks for your feedback.

I have seen the reports (attachment removed to protect patient's identity), which show blood sugars are in the target range except one morning after breakfast, which is 210. His fasting sugars are in a good range. I am happy with the sugar readings that you have sent me.

All grains have carbohydrates, but millet is better than others. He can use it in moderate amounts, like a slice of bread of 0.8 ounces once a day, three to four times a week. Corn flour is not suggested. He should repeat HbA1c after two months of the last HbA1c.

Smoking itself does not increase or decrease sugar, but it definitely has bad effects on the lungs and heart, so it would be better if he could stop. Usually, intermittent fasting is useful when it is at least 16 hours. So if he takes his dinner at 6 PM, he should eat his breakfast at 10 AM the next day, but if he finds it harder, he can start with a fasting time of 12 hours and slowly increase as his body adapts. He can drink water, black coffee and green tea during these fasting hours without sugar and milk. His current plan is quite good, but you can check those recipes I suggested as well.

Whenever you want to add anything new to your meal plan, check his sugars before eating it and check them after two hours. If it does not increase sugar over 20 to 25 mmHg, he can use it frequently; for something that increases near 30 to 35 mmHg, use it rarely, and for anything more than 40, try not to use it. It is nice to know he is currently not having any serious complications of diabetes, and his ECG (electrocardiogram), eye exam, and urine are fine. His sugar levels are satisfactory right now.

I think he can continue the same regimen right now. But he needs frequent monitoring of his sugar levels.

I hope this helps.

Thank you.