Running head: A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY
A Holistic Approach to Diabetes in the Elderly
Dayle Lauren
Stenberg College
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A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY
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A Holistic Approach to Diabetes in the Elderly
Treatment of diabetes mellitus in the elderly is complicated by aging, health status and
risk factors such as depression. By identifying the effects that depression has on diabetes, one
can approach care of the elderly diabetic in a more holistic manner, incorporating
empowerment, complementary and alternative health practices and focused aged care.
According to the American Diabetes Association, and the Centers for Disease Control
and Prevention (2003), two out of five adults over age of 65 have diabetes or impaired glucose
tolerance (DeCoster & Dabelko, 2008).
Highly prevalent among these diabetics is the presence
of depression. According to Atlantis, Browning, Sims & Kendig (2009), depression significantly
increases the risk of developing type II diabetes by 60%: several theories actually consider
depression the etiology of diabetes. The connection between the two is found in the fact that the
cortisol levels of depressed individuals is inversely associated with glucose control as well
(Atlantis, Browning, Sims, & Kendig, 2009). A ten year follow up study was conducted by
Atlantis et al., (2009) and their findings indicated that several depressive episodes “at least
doubled the risk of developing diabetes” (Atlantis et al., 2009, p. 693). These depressive
episodes may cause increases in cortisol levels in circulation (Atlantis et al, 2009). Furthermore,
Atlantis et al point out that binge eating disorders are strongly associated with both diabetes and
depression, and as well low levels of physical activities are strong predictors of depression and
diabetes (2009). By understanding the underlying health risks associated with the depressed
patient, and educating them further about the risks of binge eating, insufficient exercise, and how
their anti-depressant medications may exacerbate their risk for developing type II diabetes, a
good nurse can develop a holistic approach to patient care that encompasses recognition and
treatment of depression as a possible risk factor in diabetes II (Atlantis et al., 2009).
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Using empowerment techniques can be a powerful tool in the management of diabetes
(DeCoster & Dabelko, 2008). DeCoster & Dabelko (2008) offer 44 techniques to help empower
the older diabetic, taking into consideration the following areas: Validation and Support,
External Barriers, Problem Solving, Adequate Knowledge and Skills, and Mutual Aid and SelfHelp. Under the heading of Validation and Support, DeCoster & Dabelko suggest empowerment
occurs when we “acknowledge and champion the experiences of marginalized people” (2009,
p.77), recognize them as experts, assist them with support in acknowledging their diabetes,
encourage them to express their feelings and maximize opportunities by encouraging older adults
to interact, support and problem solve together (2009). Furthermore, DeCoster & Dabelko
(2009) state that by creating a psychologically safe environment that honors diabetic support and
respect is vital to empowerment. Working alongside the patient and helping to create groups in
which they can all advocate for their needs is another way to promote empowerment, as is
supporting familial balance (DeCoster & Dabelko, 2009). In the area of External Barriers,
empowering the elderly diabetic comes with recognizing the elder in their environment by
constructing a goal-oriented and diabetic-friendly community map, as well as enlisting various
organizations to act as mediators within the larger community, (DeCoster & Dabelko, 2009).
DeCoster & Dabelko also suggest that by promoting equal balance of control among health care
providers, the diabetic, and other older adults, there is a fostering of relationships that “support
and supplement rather than supplant” (2009, p.78). Problem Solving empowerment can come in
many different forms, such as encouraging 5 minute walks each day: although there may be little
physical gain in it, the feeling of wellness and self control gained from that moment can be
significant for the older diabetic (DeCoster & Dabelko, 2009). Teaching the older adult diabetic
how to capitalize on resources, identifying their own existing strengths, reinforcing their
A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY
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perception of control by illustrating behavior and subsequent outcome, and teaching them about
doing more of “what works” aids further in the development of empowerment (DeCoster &
Dabelko, 2009, p. 78). DeCoster & Dabelko point out that empowerment gained through
Adequate Knowledge and Skills can be fostered by providing the older adult diabetic with
accessible materials to help educate them on their condition and their resources and raising their
awareness on how others influence their health: this can assist them in focusing on taking
accountability for their own behaviours, leading to the encouragement of “solution experiments”
(p. 78) in which the older adult is urged to try new behavior strategies and assess problems and
effectiveness (2009). DeCoster & Dabelko (2009) state that Mutual Aid and Self Help can also
foster empowerment when older adults are encouraged to create buddy systems through which
they can dialogue about living with diabetes and its challenges, promote storytelling of their
successes and failures, and even encourage older adults to run health fairs, teach classes and
establish partner systems when attending medical appointments.
According to statistics cited by Yeh, Eisenberg, Davis and Phillips (2002), one in 7 health
care dollars within the US is spent on persons with diabetes. At the same time, Yeh et al posit
that the care of the diabetic is influenced by growing interest in complementary or alternative
methods of treatment: this has resulted in a growing interest in research and clinical studies
(2002). Of the population of people surveyed by Yeh et al (2002), 35% of the diabetic
respondents report the use of complementary and alternative medicine in the management of
their diabetes. This primarily involves the use of spiritual prayer or spiritual practices: of the
number of participants that utilized alternative medicine in the management of their diabetes,
26.5% stated that they had sought the advice of an alternative practitioner as well, with the
second most common therapy utilized next to prayer being herbal remedies (Yeh, Eisenberg,
A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY
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Davis, & Phillips, 2002). Interestingly enough, according to Yeh et al., the bulk of the diabetics
find solitary prayer to be “very helpful” in the management of their diabetes, even over herbal
remedies (2002, p. 1650). A separate study done by Polychronopolous, Zeimbekis, Kastorini,
Papairakleous, Vlachou, Bountziouka, & Panagiotakos (2008) weighed the benefits of the
consumption of green tea for diabetics. Tea has been credited with decreased risk of mortality
and morbidity in some studies, and its intake has been associated with lower blood glucose levels
in non-obese people specifically, with analysis of various studies showing that moderate tea
consumption of 1-2 cups per day lowered the risk of obtaining diabetes by 88%
(Polychronopoulos et al., 2008). Biochemical analysis has shown that green tea contains
significant vitamins and minerals such as Vitamin C, riboflavin, niacin, folic acid, pantothenic
acid, magnesium, potassium, manganese and fluoride, and ”may reduce the risk of many chronic
disease, including cardiovascular disease and cancer” (Polychronopoulos et al., 2008, p. 11).
According to Polychronopoulos et al., (2008), this may be attributed to the high quantities of
polyphenols; potent antioxidants that are beneficial in lowering blood pressure and reducing
blood glucose levels and body weight. A recent study in Japan showed that green tea
consumption of 1-6 cups per week was directly associated with a remarkable 34% decrease in
risk for diabetes following a five year follow-up (Polychronopoulos et al., 2008). Besides diet
considerations, exercise plays a pivotal role in maintaining health and wellness: diabetes is
predominant among obese people and lack of proper exercise is therefore considered a
contributing factor in the progression to diabetes due to “impaired metabolism, imbalance of
trace elements, and abnormal expression of inflammation” (Chen, Ueng, Lee, Sun, & Lee, 2010,
p. 1153). A study conducted by Chen et al., (2010) considered the effects that T’ai Chi exercise
had on obese diabetics in Taiwan. Chen et al posited that it is a known fact that strenuous
A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY
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exercise increases the burden on the cardiovascular system of obese diabetics, and therefore
increases the incidence of hypoglycemia, but at the same time, it is known that aerobic exercise
and moderate stretching enhances cardio-respiratory function and aids in reducing UTIs,
respiratory disease and facilitates efficient management of blood glucose levels (2010). It was
not surprising then, when they discovered that T’ai Chi exercise significantly improved BMI
(Body Mass Index), triglyceride serum levels, HDL levels and reactive protein levels in diabetic
patients (Chen et al., 2010). Chen et al concluded that T’ai Chi exercise “can be an alternative
exercise intervention for increasing glucose control, diabetic self-care activities, and quality of
life” (p. 1157), while also citing Wang et al (2008) as stating that an 8 week T’ai Chi study
showed positive effects on blood glucose, high and low affinity insulin receptor numbers and
their binding capacity in those with type II diabetes (2010). The key benefits of incorporating
T’ai Chi exercise into diabetes management is not focused on consumed calories, but rather in
the efficacy of “enhanced metabolism, cardiopulmonary function, and antioxidation and antiinflammatory activation” (Chen et al., 2010, p. 1158).
Further holistic approach to diabetic care in older adults involves focused aged care
through routine monitoring of three key areas. Giles, Visentin & Phillips (n.d.) label these areas
as The Medical ABCs: the acronym ‘A’ stands for A1c (known as HbA1c), which gives an
overview of blood glucose levels: ideal levels would be 7% or less, dependent on individual
hypoglycemia and complication risks; B is blood pressure, with ideal systolic BP around
130mHg or less; C is for cholesterol ideally around 4mM or less; and S for salicylates: low dose
aspirin to reduce the risk of cardiovascular events. By being aware of these 4 key areas of
consideration, care for the diabetic becomes innately holistic in that the understanding of the
disease surpasses the simple recognition of insulin in their care. Further assessment and
A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY
planning of self-care in the elderly diabetic helps to monitor these key areas. This may include
planning for healthy target weight, physical activity, smoking risks, self-care education and
careful screening for complications such as foot and eye problems related to diabetes (Giles,
Visentin, & Phillips, n.d.).
It is understood that the greatest increase in diabetes diagnoses within the next 40 years
will occur among people 75 years of age and older (Fravel, McDaniel, Ross, Moores, & Starry,
2011). Being prepared to face the large numbers of these aging adults in the health care system
will require health care providers to be diligent in their knowledge surrounding diabetes and the
available tools for preventative and therapeutic modalities. By taking a holistic approach to
diabetes management, the health care provider can offer a variety of lifestyle measures to
incorporate into the care of the diabetic, such as recognition and consideration of the risk that
depression can play in the development of diabetes, personal empowerment, various alternative
measures to help foster a healthy lifestyle, and age-relative care considerations. Staying current
with the latest research, available therapies and education will help create the best possible
environment to facilitate a successful diabetic management plan.
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References
Atlantis, E., Browning, C., Sims, J., & Kendig, H. (2009). Diabetes incidence associated with
depression and antidepressants in the Melbourne Longitudinal Studies on Healthy Aging
(MELSHA). International Journal of Geriatric Psychiatry, 25, 1648-1652.
doi:10.1002/gps.2409
Chen, S., Ueng, K., Lee, S., Sun, K., & Lee, M. (2010). . Effect of T’ai Chi exercise on
biochemical profiles and oxidative stress indicators in obese patients with type 2
diabetes, 16, 1153-1159. doi:10.1089/acm.2009.0560
DeCoster, V. A., & Dabelko, H. I. (2008). Forty-four techniques for empowering older adults
with diabetes. National Association of Social Workers, 77-80. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=32185566&site=ehost
-live
Fravel, M. A., McDaniel, D. L., Ross, M. B., Moores, K. G., & Starry, M. J. (2011, March 15).
Special considerations for treatment of type 2 diabetes mellitus in the elderly. American
Journal of Health-System Pharmacology, 68, 500-509. doi:10.2146/ajhp080085
Giles, J., Visentin, K., & Phillips, P. (n.d.). Diabetes in aged care. Australian Nursing Journal,
16(7), 40. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=
rzh&AN=2010179654&site=ehost-live
Polychronopoulos, E., Zeimbekis, A., Kastorini, C., Papairakleous, N., Bountziouka, V., &
Panagiotakos, D. B. (2008). Effects of black and green tea consumption on blood glucose
levels in non-obese elderly men and women from Mediterranean islands (MEDIS
epidemiological study). European Journal of Nutrition, 47, 10-16. doi:10.1007/s00394007-0690-7
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Yeh, G. Y., Eisenberg, D. M., Davis, R. B., & Phillips, R. S. (2002, October). Use of
complementary and alternative medicine among persons with diabetes mellitus: Results
of a national survey. American Journal of Public Health, 92, 1648-1652. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=8840805&site=ehostlive
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Wednesday, 10 October 2012, 8:30 AM
Vicki Hammond
Nice job, and very interesting. I like that you have decided to take a different
approach and demonstrate alternatives to medication. Insulin makes us hungry and
fat just though its mechanism of action. Green tea! Tai Chi! Buddy systems.
Excellent. the paper is well written with style and mechanics well addressed. YOu
have excellent flow and the literature is relevant. Could I send this paper to the
manger at LMH who has asked for papers related to upcoming inservices?