There is an emerging population of older adults (≥65 years) living with type 1 diabetes. Optimizing health through nutrition during this life stage is challenged by multiple and ongoing changes in diabetes management, comorbidities, and lifestyle factors. There is a need to understand nutritional status, dietary intake, and nutrition-related interventions that may maximize well-being throughout the life span in type 1 diabetes, in addition to nutrition recommendations from clinical guidelines and consensus reports. Three reviewers used Cochrane guidelines to screen original research (January 1993–2023) and guidelines (2012–2023) in two databases (MEDLINE and CENTRAL) to characterize nutrition evidence in this population. We found limited original research explicitly focused on nutrition and diet in adults ≥65 years of age with type 1 diabetes (six experimental studies, five observational studies) and meta-analyses/reviews (one scoping review), since in the majority of analyses individuals ≥65 years of age were combined with those age ≥18 years, with diverse diabetes durations, and also individuals with type 1 and type 2 diabetes were combined. Further, existing clinical guidelines (n = 10) lacked specificity and evidence to guide clinical practice and self-management behaviors in this population. From a scientific perspective, little is known about nutrition and diet among older adults with type 1 diabetes, including baseline nutrition status, dietary intake and eating behaviors, and the impact of nutrition interventions on key clinical and patient-oriented outcomes. This likely reflects the population’s recent emergence and unique considerations. Addressing these gaps is foundational to developing evidence-based nutrition practices and guidelines for older adults living with type 1 diabetes.

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As treatments for type 1 diabetes improve and the U.S. population continues to age, a growing number of individuals with type 1 diabetes are living into their sixth and seventh decades of life and beyond. As a result of these intersecting trends, there is an emerging population of older adults (≥65 years) living with type 1 diabetes (1). These individuals have unique and rapidly changing physiological needs (e.g., frailty, sarcopenia, loss of appetite and dexterity, accumulating comorbidities), behavioral, interpersonal, social, and economic needs that shape diabetes self-management and outcomes (1–3). As such, strategies underpinning self-care in earlier decades may no longer be optimal through older adulthood. Though avoidance of hypoglycemia, consideration of patient preferences, and preservation of quality of life remain the objectives for care (3,4), data to support best practices in this age-group remain sparse (2).

Nutrition is foundational to type 1 diabetes self-management and a crucial determinant of overall glycemic control and long-term progression to complications (5). While traditional dietary counseling for type 1 diabetes typically focuses on counting carbohydrates accurately to dose insulin, increased fiber in the diet, greater nutrition knowledge, higher dietary quality, and fewer instances of food intake throughout the day have been demonstrated to be associated with lower hemoglobin A1c (HbA1c) (4,5). The American Diabetes Association (ADA) recommends a varied diet to reach individual health goals but cautions that no diet has been demonstrated to be superior for the management of type 1 diabetes (4).

For all individuals, regardless of health status, the multiple biopsychosocial changes during older adulthood pose unique challenges to optimal nutrition, in turn increasing risks of malnutrition, frailty, sarcopenia, morbidity, and mortality (1). Despite widespread acceptance of the importance of nutrition in supporting longevity and type 1 diabetes management, there are no age-specific nutrition guidelines for older adults with type 1 diabetes.

In the absence of guidelines, there is a compelling need to summarize the existing evidence surrounding nutritional status, dietary intake, and nutrition-related interventions, in addition to nutrition-related clinical practice guidelines designed to support glycemic management and overall health among older adults with type 1 diabetes. We thus undertook a narrative review of the literature, including original research and current clinical guidelines and consensus papers, to characterize the evidence base relevant to this emerging and understudied population. Our goal is to set the stage for future research and evidence-based clinical practice guidelines to guide best nutrition practices for health care providers as they engage with the highly specialized and complex needs of this population.

To summarize the state of the evidence regarding nutritional status, dietary intake, and nutrition-related interventions specific to older adults with type 1 diabetes, in April 2023 we used the Cochrane rapid review strategy to search without date limitations combinations of terms in MEDLINE and CENTRAL (6). The search strategy is summarized in Supplementary Table 1 and depicted in Fig. 1. Authors calibrated the search strategy by independently screening two rounds of 10 random articles from those yielded from the database search (A.C.S., R.M., and A.R.K.). Once consensus on the search strategy had been achieved, three analysts screened the remaining full-text articles for inclusion (A.C.S., G.E., and A.R.K.).

Figure 1
PRISMA diagram.
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PRISMA diagram.

The combined searches in MEDLINE (n = 5,333) and CENTRAL (n = 2,454) yielded 7,787 reports. Articles were screened and excluded if the title and abstract indicated the publication was unrelated to type 1 diabetes, older adults, nutrition status, behavior, or strategies. Of the 7,787 abstracts identified, 7,622 were excluded through screening, leaving 165 articles to be reviewed in full.

After duplicates (n = 13) were removed, full-text articles were assessed for eligibility (n = 152). Determination of studies relevant to older adults ≥65 years of age with type 1 diabetes posed a major challenge to the full-text screening process because in the majority of studies screened, individuals <65 years of age were combined with those ≥65 years of age and included few individuals with type 1 diabetes ≥65 years of age. We therefore included studies with samples that met at least one of the following criteria: 1) participants mean/median age ≥65 years (regardless of SD) or no participants age ≤60 years or 2) participants mean age ≥60 years if the SD included age 65 years. Full-text articles were screened and excluded if the study population did not meet any age criteria or if the articles were not related to type 1 diabetes (defined as <10 participants with type 1 diabetes); not related to nutrition status, behavior, or strategies; unpublished or published before 1 January 1993; or not in English. Of the 152 full-text articles assessed, 141 were excluded. Characteristics of excluded studies were as follows: lack of relevance to older adults (n = 99), type 1 diabetes (n = 4), or nutritional status, behaviors, and strategies (n = 13); study population with <10 individuals with type 1 diabetes (n = 10); published before 1 January 1993 (n = 5); not published in English (n = 1); not original research (n = 4); unpublished or not full text (n = 3); incorrect study design (n = 1 case report); and added to clinical guidelines and consensus papers (n = 1).

As complementary to the review of the primary literature, with a review of nutrition-related clinical practice guidelines, two reviewers (A.R.K. and G.E.) performed a separate review of the most updated clinical guidelines and consensus papers relevant to type 1 diabetes and clinical geriatrics to summarize key guidance relevant to the topic of nutrition, type 1 diabetes, and older adulthood. This separate review yielded work that spanned the years 2012–2023 and included ADA 2023 Standards of Care in Diabetes (1); ADA 2012 consensus report (3); Diabetes UK clinical guidelines (7); Endocrine Society 2019 practice guidelines (8); American Geriatrics Society 2013 guidelines (9); International Association of Gerontology and Geriatrics, European Diabetes Working Party for Older People, and International Task Force of Experts in Diabetes 2012 practice guidelines (10); Diabetes Canada 2018 clinical practice guidelines (11); Joslin 2018 guidelines (12); and the International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance Diabetes and Ramadan: Practical Guidelines 2021 (13).

In our search we identified a sparse evidence base of 11 original research studies (6 experimental [14–19] and 5 observational [20–24]), one scoping review (25), and 10 clinical guidelines (1,3,6,8–13,26). Table 1 summarizes main original research study characteristics, findings, and limitations. Table 2 summarizes one relevant scoping review identified among the full-text articles assessed for eligibility. Table 3 summarizes the guidance relevant to nutrition from clinical guidelines and consensus papers. Supplementary Appendix 1 specifies the age criteria used to guide the literature search, and Supplementary Appendix 2 includes an in-depth summary of each included article.

Table 1

Summary of findings of included studies (n = 11)

Study categoryAuthorship, date, study type (reference no.)Study location, duration, recruitmentParticipant characteristicsIntervention or exposure, comparator, study designOutcomes and resultsSummary of findingsLimitations
Experimental Battista et al., 2012, RCT (14) Two diabetes clinic/hospital sites, Canada; 24 months; recruitment April 2007–April 2008 T1D, n = 15, and T2D, n = 73; mean ± SD age 60 ± 11 years (DC group), 59 ± 11 years (control group). Inclusion: T1D with LDL-C ≥2.0 mmol/L, BP ≥130/80 or taking BP medication, triglycerides >1.5 mmol/L, HDL-C <0.90 mmol/L, or total cholesterol– to–HDL-C ratio >4.0. Exclusion: pregnancy, corticosteroid use, or >3 follow-up visits with endocrinologist Intervention (n = 44): DC = diabetes self-management education every 3 months, monthly phone calls with dietitians between visits, and annual endocrinologist follow-up. Comparator (n = 44): conventional endocrinologist follow-up Change in median dietary intake (g/day) in intervention vs. comparator group, respectively, at 24 months: protein −14 vs. 1 (P = 0.014), CHO −25 vs. 4 (P = 0.393), total fat −30 vs. −5 (P = 0.028), fibers 2 vs. 0 (P = 0.240); change in median % energy intake (% kcal/day) in intervention vs. comparator group at 24 months: energy −548 vs. −74 (P = 0.045). Correlation between improved HbA1c and fasting glucose among intervention group: r = 0.52 (P = 0.001) For the intervention group there was a greater net reduction in median daily caloric intake, protein intake, and overall fat intake compared with the control group over the 24-month intervention. The intervention did not result in significant differences in the change in daily CHO consumption between groups Small sample of participants with T1D, no specific result reporting for T1D or age ≥65 years, no measurement of adherence 
Experimental Bell et al., 2016, single-arm crossover study (15) Joslin Clinical Research Center (U.S.); visits repeated up to four times until achievement of glucose criteria; recruitment years not reported Mean ± SD age 60.4 ± 11.3 years; T1D, n = 10, T1D duration >3 years. Inclusion: age 18–75 years, using insulin pump for >6 months, using CGM, and HbA1c >8.5%. Exclusion: not specified Intervention: 1) HFHP meal and LFLP meal consumed with identically calculated insulin bolus based on CIR using 50%-50% combination bolus over 2 h. Then, at a later time, the HFHP meal was repeated with an adaptive MPB algorithm. 2) MPB algorithm for HFHP meal vs. calculated CIR bolus for HFHP meal *Mealtime insulin dosing for HFHP and LFLP meals: mean dose 4.7 units/day; mean combination wave split 50%-50%, mean insulin combination wave duration 120 min. Glycemic metrics comparing HFHP vs. LFLP meal: glucose iAUC 27,092 ± 1,709 vs. 13,320 ± 2,960 (P = 0.0013), mean ± SD incremental change in plasma glucose 73 ± 4 vs. 23 ± 11 mg/dL, difference between glucose iAUC ≥180 min P < 0.05, differences in postprandial plasma glucose at 6 h >100 mg/dL HFHP meal resulted in more time to peak in plasma glucose as well as higher incremental peak plasma glucose. After 6 h, HFHP resulted in higher postprandial plasma glucose, requiring more insulin to achieve target glucose levels Small sample of participants with T1D, participants predominantly male, no. of participants age ≥65 years unknown, no specific results reporting for ages ≥65 years, unable to differentiate individual gylcemic effects of fat or protein 
Experimental Dussol et al., 2005, unblinded RCT (16) Centre d’Investigation Clinique, Sainte-Marguerite Hospital, France; 24 months; recruitment June 1999–June 2001 from endocrinology units of three university hospitals Mean ± SD age 63 ± 9 years (usual-protein diet), 52 ± 12 years (low-protein diet); T1D, n = 10, and T2D, n = 37. Inclusion: age 18–75 years, T1D or T2D with evidence of diabetic nephropathy without other kidney or urinary tract disease. Exclusion: absence of nephropathy, end-stage renal disease, pregnancy, cachexia, and BMI >33 kg/m2 Intervention (N = 22): low-protein diet with advice on partial replacement of animal protein with unsaturated fat and CHO with dietary fiber and support from research dietitians. Comparator (N = 25): usual-protein diet unless prestudy diet was high in protein Nutrient intake according to FFQ at 24 months in intervention vs. comparator group: energy 1,704 ± 276 vs. 1,855 ± 620 cal/day (P > 0.05), animal protein 42 ± 15 vs. 60 ± 21 g/day (P < 0.001), protein 16 ± 3 vs. 19 ± 4 % cal/day (P < 0.02), CHO 42 ± 7 vs. 37 ± 8 % cal/day (P < 0.02), fat 37 ± 6 vs. 39 ± 7% cal/day (P > 0.05), protein intake according to 24-h urinary urea excretions 1.03 ± 0.15 vs. 1.10 ± 0.2 g/kg/day (P > 0.05) After 24 months, in the intervention group animal protein intake overall was lower and more of diet came from CHO, compared with usual-protein diet. 24-h urinary urea excretion did not show difference in protein intake among groups at any time Small sample of participants with T1D, no. of participants age ≥65 years unknown, no specific results reporting for participants with T1D or those ages ≥65 years, variable adherence (as suggested by 24-h urea and 16% withdrawals) 
Experimental Petersen et al., 2015, RCT, parallel design (17) Unspecified no. of clinics, Australia; 12 months; recruitment August 2012–December 2013 Mean age 56 ± 14 years, intervention group, and 57 ± 14 years, control group; T1D, n = 20, and T2D, n = 126. Inclusion: age >18 years with T1D or T2D. Exclusion: unstable cardiovascular disease, heart failure, renal impairment, liver disease, cancer, or allergy to or intolerance/dislike of fruits, vegetables, or dairy Intervention (N = 58): improved diet quality group attended dietitian sessions at BL and received additional nutritional counseling every 3 months to increase consumption of fruits, vegetables, and dairy. Comparator (N = 60): usual intake group Mean ± SD effect on CCA IMT regression (mm) at month 12 in intervention vs. comparator group, respectively: −0.02 ± 0.04 vs. −0.004 ± 0.04 mm (P = 0.009). BL intake and change in fruit, vegetable, and dairy intakes at month 3 and month 12: not predictive of mean or mean maximum CCA IMT change; mean change in nutrient intake based on FFQ from BL to month 12 for improved diet quality group vs. usual diet group (time × treatment effect): energy 177 vs. −629 kJ/day (P = 0.14), protein 7 vs. −3 g/day (P = 0.28), total fat 1 vs. −7 g/day (P = 0.33), saturated fat 1 vs. −3 g/day (P = 0.45), monounsaturated fat 1 vs. −2 g/day (P = 0.35), polyunsaturated fat 0 vs. −1 g/day (P = 0.26), CHO 5 vs. −15 g/day (P = 0.01), sugar 9 vs. −3 g/day (P = 0.0001), fiber 2 vs. −1 g/day (P = 0.0001), sodium 75 vs. −226 mg/day (P = 0.15), potassium 359 vs. −102 mg/day (P = 0.0001), calcium 108 vs. −30 mg/day (P = 0.01), magnesium 25 vs. −9 mg/day (P = 0.004), alcohol −2 vs. −1 g/day (P = 0.053) Participants receiving additional nutrition counseling increased fruit and vegetable intake in first 3 months of study, but this effect was no longer significant at 1 year. Intervention group had greater decrease in CCA IMT No specific results reporting for T1D or age ≥65 years 
Experimental Roem et al., 2022, randomized crossover trial (19) Two hospitals affiliated with University of Melbourne, Australia; 3–6 weeks (run-in period) and 2 weeks (prerandomization measures) followed by two 4-month stages; recruitment April 2019–April 2020 Median age 68 years (IQR 64–71); T1D, n = 30. Inclusion: age ≥60 years, T1D duration ≥10 years, using insulin pump with rapid-acting insulin, HbA1c ≤10.5%, managing diabetes independently or with caregiver assistance. Exclusion: non-T1D, moderate-to-severe dementia, any physical or psychological condition or medication deemed by investigators to impact protocol compliance or result interpretation Intervention (N = 30): group 1, continuation of sensor-augmented pump therapy for 4 months and then closed loop therapy for 4 months; group 2, closed loop therapy for 4 months and then sensor-augmented pump therapy; CHO-counting ability assessed by dietitian based on 5-day food diary and further education provided to those who had >3 errors in CHO counting in diary n = 17 participants (57%) met the proficiency criterion after one consultation, n = 12 (40%) required a second consultation, and n = 10 required >2 consultations; the reasons for CHO counting errors were 1) overestimation due to using raw instead of cooked values for foods and 2) underestimation when eating away from home The majority of participants met the CHO counting proficiency criteria after one consultation; errors in food diaries were similar to those made by younger adults Small sample; high technologically literate and numerate participants; linited detail about how CHO proficiency, was defined and assessed as well as the content and dose of education provided 
Experimental Valero et al., 2001, double-blind RCT (18) Hospital (Spain); 5–46 days, mean 11.4 days (until gastrointestinal tolerance of oral or enteral diets); recruitment years not reported Mean ± SD age 67.6 ± 10.6 years, intervention group, and 69.6 ± 9.2 years, control group; T1D, n = 29, and T2D, n = 109. Inclusion: age >18 years, requiring TPN. Exclusion: tolerance of oral or enteral diets, ketoacidosis or nonketotic hyperosmolar coma, or TPN use for <5 days Intervention (N = 67): received isocaloric amount of glucose-fructose-xylitol 2:1:1 during TPN infusion. Comparator (N = 71): received isocaloric amount of glucose during TPN infusion Mean ± SD days until glycemic control was achieved after TPN was started for intervention vs. comparator group, 2.4 ± 2.1 vs. 2.5 ± 1.7; % of n with end-of-treatment glycemia <200 mg/dL, 85.1% vs. 74.6% (intervention vs. comparator); CHO in TPN on the last day, 187 ± 45 vs. 191 ± 36 g/day (intervention vs. comparator) No differences in daily mean glycemia or insulin requirements were noted by treatment group No specific results reporting for T1D, age ≥65 years; limited detail about how inclusion and exclusion criteria and outcomes were specified 
Observational Altman et al., 2009, retrospective cross-sectional study (20) Unspecified no. of outpatient clinical centers, France; duration not reported; recruitment years not reported Mean ± SD age 67.1 ± 10.8 years; T1D, n = 57; mean ± SD T1D duration 49.8 ± 7.6 years Study design: surveys of quality of life including classifying burdens of T1D that impair life and main improvement in treatment of T1D during lifetime Continual dieting was reported as the second-most common burden related to T1D management; loosening dietary restrictions were noted by participants as improving quality of life over time Diet was a commonly reported burden of managing T1D but also a source of improving quality of life over time among adults with ≥40 years of management duration Limited detail reported about methodology used to develop and analyze questionnaire and its structure 
Observational Aparasu and Aparasu, 2008, cross-sectional study (21) Unspecified no. of clinics, U.S.; visits between 2003 and 2004; recruitment years not reported 45% of total visits estimated to be by adults >65 years; diagnosis of diabetes (ICD-9-CM 250) and hypertension (ICD-9-CM 401–404) Study design: data from 2 surveys (National Ambulatory Medical Care Survey and the outpatient portion of National Hospital Ambulatory Care Survey) between 2003 and 2004 used for understanding characteristics of visits for diabetes and hypertension 57% of outpatient visits for diabetes and hypertension included education and counseling. Of those, 53% were related to diet and nutrition A smaller proportion of visits for diabetes and hypertension included education and counseling than the proportion expected based on clinical guidelines. An even smaller proportion of visits included education or counseling related to diet and nutrition ICD-9 codes captured outpatient visits that included education and counseling; dose of education and counseling (and that specific to diet and nutrition) received at visits not reported 
Observational Cox et al., 1996, cross-sectional study (22) Outpatient diabetes clinic at North Chicago VA Medical Center, U.S.; ∼45 min to complete interview and survey; recruitment years not reported Mean ± SD age 63.5 ± 8.1 years; T1D, n = 17.71, and T2D, n = 136.29. Inclusion: males at North Chicago VA Medical Center. Exclusion: severe medical or psychiatric conditions Study design: individual interview and questionnaires (AEQ; AUSR: Concerns about Drinking Scale, Negative Consequences of Drinking Scale, Amount Consumed Scale; investigator-designed 12-item treatment compliance questionnaire; DQOL questionnaire) to assess relationships among diabetes, alcohol use and expectancies, treatment compliance, and quality of life †Mean ± SD daily alcohol consumption 0.39 ± 1.2 oz (n = 154) (0.66 ± 1.5 oz for n ∼91 who indicated that they drink), mean ± SD score on AUSR Amount Consumed Scale 2.1 ± 2.1, mean ± SD treatment compliance self-reported score for diet (12-component questionnaire, range 1–5) 2.9 ± 0.6 (n = 132), association between self-reported diet compliance P < 0.05, physiological measures of compliance (fasting blood glucose and HbA1c levels) and alcohol use P > 0.05 Overall, participants consumed relatively low amounts of alcohol, were generally compliant with treatment, and had good diabetes outcomes. Greater alcohol use is significantly related to poorer diet compliance Small sample of participants with T1D, all male participants, majority of participants abstained from alcohol, no specific results reporting for T1D or age ≥65 years 
Observational Petersen et al., 2018, cohort study after RCT (23) Unspecified no. of clinics, Australia; ∼12 months of follow-up following a 12-month RCT; recruitment August 2012–December 2013 Mean ± SD age 60 ±13 years; T1D, n = 12, and T2D, n = 75. Inclusion: age >18 years with T1D or T2D. Exclusion: unstable cardiovascular disease, heart failure, renal impairment, liver disease, cancer, or allergy to or intolerance/dislike of fruits, vegetables, or dairy Study design: observed nutrient intake to assess dietary quality over 2 years for participants in RCT AHEI score (0, nonadherence, to 80, adherence) at BL and CCA IMT regression (mm) at 24 months compared between highest and lowest AHEI tertiles: mean −0.043 mm (95% CI −0.084, −0.003), P = 0.029. Correlation between nutrient intake (g/day) and AHEI score at BL and mean CCA IMT (mm) at 24 months (after adjustment for age and BL mean CCA IMT): CHO intake, r = −0.28, P = 0.01; sugar intake, r = −0.27, P = 0.01; fiber intake, r = −0.26, P = 0.02; magnesium intake, r = −0.25, P = 0.02; AHEI score, r = −0.23, P = 0.03. Correlation between nutrient intake (g/day) at 12 months (adjustment for age, BL CCA IMT, and energy intake at 12 months) and mean CCA IMT (mm) at 24 months: total dairy intake, r = −0.185, P = 0.048; total reduced-fat dairy intake, r = −0.268,P = 0.007; fruit intake, P > 0.05; vegetable intake, P > 0.05. Association of dietary intake at BL and dietary changes at 24 months with cfPWV (m/s) at Higher dietary quality (reflected by AHEI scores) at BL was associated with greater CCA IMT regression after 24 months; BL CHO, sugar, fiber, and magnesium intake were inversely associated with mean CCA IMT at 24 months, and greater total and reduced fat dairy intake at 12 months was associated with lower mean CCA IMT at 24 months. There were no associations between BL dietary intake and cfPWV at 24 months Small sample of participants with T1D, results not stratified by intervention group, no specific results reported for T1D or age ≥65 years 
     24 months P > 0.05. Dietary intake month 24 vs. month 0, respectively (time-by-treatment P value): protein 83 ± 34 vs. 92 ± 38 g/day (P = <0.009), total fat 66 ± 29 vs. 73 ± 33 g/day (P = 0.04), saturated fat 27 ± 12 vs. 28 ± 14 g/day (P = 0.12), CHO 159 ± 64 vs. 180 ± 67 g/day (P = 0.001), sugar 73 ± 26 vs. 76 ± 25 g/day (P < 0.001), fiber 20 ± 7 vs. 21 ± 7 g/day (P < 0.001), alcohol 10 ± 18 vs. 12 ± 20 g/day (P = 0.01), fruit 267 ± 176 vs. 237 ± 129 g/day (P < 0.001), vegetable 165 ± 74 vs. 170 ± 64 g/day (P = 0.01), dairy 373 ± 187 vs. 394 ± 196 g/day (P = 0.11), bread and cereal 180 ± 108 vs. 236 ± 124 g/day (P = 0.41), meat and alternative 186 ± 108 vs. 200 ± 113 g/day (P = 0.14)   
Observational Zimbudzi et al., 2017, cross-sectional study (24) Unspecified no. of diabetes and renal outpatient clinics of hospitals, Australia; one-time questionnaire, completed between December 2013 and December 2014; recruitment years not reported Median age 68 years (IQR 14.8); T1D, n = 45, T2D, n = 249, and unsure, n = 14. Inclusion: T1D or T2D based on WHO 2006 definition with moderate-to-severe CKD (stages 3–5: GFR <50 mL/min/1.73 m2) and receiving routine care at specified hospitals. Exclusion: not specified Study design: one-time questionnaire Mean ± SD SDSCA score (days) by subscale‡ (8-point Likert scale, range 0–7 days): general diet 5.0 ± 1.9, diabetes-specific diet 3.2 ± 1.5, composite 3.9 ± 1.1. Associations between self-management subscales (SDSCA, 0–7 days) and HRQOL subscales (KDQOL-36) (range 0–100): general diet, PCS 0.29 (95% CI −0.06, 0.63), MCS 0.73 (0.40, 1.06), symptom/problem list 0.99 (0.46, 1.52), effects of CKD 0.87 (0.14, 1.39), burden of CKD 1.37 (0.42, 2.32); diabetes-specific diet, PCS 0.07 (−0.37, 0.51), MCS −0.31 (−0.73, 0.11), symptom/problem list −0.07 (−0.76, 0.61), effects of CKD −0.35 (−1.30, 0.58), burden of CKD −1.24 (−2.46, 0.02). Association between self-management (SDSCA subscales, range 0–7 days) and HRQOL (KDQOL-36, range 0–100) using model adjusted for age, estimated GFR, diabetes duration, and CKD duration: general diet, PCS R2 = 7.8 (P > 0.05), MCS R2 = 11.3 (P < 0.01), symptom/problem list R2 = 9.7 (P < 0.01), effects of CKD R2 = 17.7 (P > 0.05), burden of CKD R2 = 31.6 (P < 0.01); diabetes-specific diet, PCS R2 = 7.8 (P > 0.05), MCS R2 = 11.8 (P > 0.05), symptom/problem list R2 = 9.7 (P > 0.05), effects of CKD R2 = 17.7 (P > 0.05), burden of CKD R2 = 32.3 (P > 0.05). Participation in diabetes self-management, especially activities related to general diet, was associated with higher HRQOL. General diet was positively associated with several HRQOL measures, but diabetes-specific diet was not SDSCA was not developed or evaluated for validity among individuals with diabetes; SDSCA does not objectively or granularly characterize eating behavior or dietary adherence, as the constructs “general diet” and “diabetes-specific diet” are each captured by 2 self-report items; no specific results reported for T1D or age ≥65 years 
Study categoryAuthorship, date, study type (reference no.)Study location, duration, recruitmentParticipant characteristicsIntervention or exposure, comparator, study designOutcomes and resultsSummary of findingsLimitations
Experimental Battista et al., 2012, RCT (14) Two diabetes clinic/hospital sites, Canada; 24 months; recruitment April 2007–April 2008 T1D, n = 15, and T2D, n = 73; mean ± SD age 60 ± 11 years (DC group), 59 ± 11 years (control group). Inclusion: T1D with LDL-C ≥2.0 mmol/L, BP ≥130/80 or taking BP medication, triglycerides >1.5 mmol/L, HDL-C <0.90 mmol/L, or total cholesterol– to–HDL-C ratio >4.0. Exclusion: pregnancy, corticosteroid use, or >3 follow-up visits with endocrinologist Intervention (n = 44): DC = diabetes self-management education every 3 months, monthly phone calls with dietitians between visits, and annual endocrinologist follow-up. Comparator (n = 44): conventional endocrinologist follow-up Change in median dietary intake (g/day) in intervention vs. comparator group, respectively, at 24 months: protein −14 vs. 1 (P = 0.014), CHO −25 vs. 4 (P = 0.393), total fat −30 vs. −5 (P = 0.028), fibers 2 vs. 0 (P = 0.240); change in median % energy intake (% kcal/day) in intervention vs. comparator group at 24 months: energy −548 vs. −74 (P = 0.045). Correlation between improved HbA1c and fasting glucose among intervention group: r = 0.52 (P = 0.001) For the intervention group there was a greater net reduction in median daily caloric intake, protein intake, and overall fat intake compared with the control group over the 24-month intervention. The intervention did not result in significant differences in the change in daily CHO consumption between groups Small sample of participants with T1D, no specific result reporting for T1D or age ≥65 years, no measurement of adherence 
Experimental Bell et al., 2016, single-arm crossover study (15) Joslin Clinical Research Center (U.S.); visits repeated up to four times until achievement of glucose criteria; recruitment years not reported Mean ± SD age 60.4 ± 11.3 years; T1D, n = 10, T1D duration >3 years. Inclusion: age 18–75 years, using insulin pump for >6 months, using CGM, and HbA1c >8.5%. Exclusion: not specified Intervention: 1) HFHP meal and LFLP meal consumed with identically calculated insulin bolus based on CIR using 50%-50% combination bolus over 2 h. Then, at a later time, the HFHP meal was repeated with an adaptive MPB algorithm. 2) MPB algorithm for HFHP meal vs. calculated CIR bolus for HFHP meal *Mealtime insulin dosing for HFHP and LFLP meals: mean dose 4.7 units/day; mean combination wave split 50%-50%, mean insulin combination wave duration 120 min. Glycemic metrics comparing HFHP vs. LFLP meal: glucose iAUC 27,092 ± 1,709 vs. 13,320 ± 2,960 (P = 0.0013), mean ± SD incremental change in plasma glucose 73 ± 4 vs. 23 ± 11 mg/dL, difference between glucose iAUC ≥180 min P < 0.05, differences in postprandial plasma glucose at 6 h >100 mg/dL HFHP meal resulted in more time to peak in plasma glucose as well as higher incremental peak plasma glucose. After 6 h, HFHP resulted in higher postprandial plasma glucose, requiring more insulin to achieve target glucose levels Small sample of participants with T1D, participants predominantly male, no. of participants age ≥65 years unknown, no specific results reporting for ages ≥65 years, unable to differentiate individual gylcemic effects of fat or protein 
Experimental Dussol et al., 2005, unblinded RCT (16) Centre d’Investigation Clinique, Sainte-Marguerite Hospital, France; 24 months; recruitment June 1999–June 2001 from endocrinology units of three university hospitals Mean ± SD age 63 ± 9 years (usual-protein diet), 52 ± 12 years (low-protein diet); T1D, n = 10, and T2D, n = 37. Inclusion: age 18–75 years, T1D or T2D with evidence of diabetic nephropathy without other kidney or urinary tract disease. Exclusion: absence of nephropathy, end-stage renal disease, pregnancy, cachexia, and BMI >33 kg/m2 Intervention (N = 22): low-protein diet with advice on partial replacement of animal protein with unsaturated fat and CHO with dietary fiber and support from research dietitians. Comparator (N = 25): usual-protein diet unless prestudy diet was high in protein Nutrient intake according to FFQ at 24 months in intervention vs. comparator group: energy 1,704 ± 276 vs. 1,855 ± 620 cal/day (P > 0.05), animal protein 42 ± 15 vs. 60 ± 21 g/day (P < 0.001), protein 16 ± 3 vs. 19 ± 4 % cal/day (P < 0.02), CHO 42 ± 7 vs. 37 ± 8 % cal/day (P < 0.02), fat 37 ± 6 vs. 39 ± 7% cal/day (P > 0.05), protein intake according to 24-h urinary urea excretions 1.03 ± 0.15 vs. 1.10 ± 0.2 g/kg/day (P > 0.05) After 24 months, in the intervention group animal protein intake overall was lower and more of diet came from CHO, compared with usual-protein diet. 24-h urinary urea excretion did not show difference in protein intake among groups at any time Small sample of participants with T1D, no. of participants age ≥65 years unknown, no specific results reporting for participants with T1D or those ages ≥65 years, variable adherence (as suggested by 24-h urea and 16% withdrawals) 
Experimental Petersen et al., 2015, RCT, parallel design (17) Unspecified no. of clinics, Australia; 12 months; recruitment August 2012–December 2013 Mean age 56 ± 14 years, intervention group, and 57 ± 14 years, control group; T1D, n = 20, and T2D, n = 126. Inclusion: age >18 years with T1D or T2D. Exclusion: unstable cardiovascular disease, heart failure, renal impairment, liver disease, cancer, or allergy to or intolerance/dislike of fruits, vegetables, or dairy Intervention (N = 58): improved diet quality group attended dietitian sessions at BL and received additional nutritional counseling every 3 months to increase consumption of fruits, vegetables, and dairy. Comparator (N = 60): usual intake group Mean ± SD effect on CCA IMT regression (mm) at month 12 in intervention vs. comparator group, respectively: −0.02 ± 0.04 vs. −0.004 ± 0.04 mm (P = 0.009). BL intake and change in fruit, vegetable, and dairy intakes at month 3 and month 12: not predictive of mean or mean maximum CCA IMT change; mean change in nutrient intake based on FFQ from BL to month 12 for improved diet quality group vs. usual diet group (time × treatment effect): energy 177 vs. −629 kJ/day (P = 0.14), protein 7 vs. −3 g/day (P = 0.28), total fat 1 vs. −7 g/day (P = 0.33), saturated fat 1 vs. −3 g/day (P = 0.45), monounsaturated fat 1 vs. −2 g/day (P = 0.35), polyunsaturated fat 0 vs. −1 g/day (P = 0.26), CHO 5 vs. −15 g/day (P = 0.01), sugar 9 vs. −3 g/day (P = 0.0001), fiber 2 vs. −1 g/day (P = 0.0001), sodium 75 vs. −226 mg/day (P = 0.15), potassium 359 vs. −102 mg/day (P = 0.0001), calcium 108 vs. −30 mg/day (P = 0.01), magnesium 25 vs. −9 mg/day (P = 0.004), alcohol −2 vs. −1 g/day (P = 0.053) Participants receiving additional nutrition counseling increased fruit and vegetable intake in first 3 months of study, but this effect was no longer significant at 1 year. Intervention group had greater decrease in CCA IMT No specific results reporting for T1D or age ≥65 years 
Experimental Roem et al., 2022, randomized crossover trial (19) Two hospitals affiliated with University of Melbourne, Australia; 3–6 weeks (run-in period) and 2 weeks (prerandomization measures) followed by two 4-month stages; recruitment April 2019–April 2020 Median age 68 years (IQR 64–71); T1D, n = 30. Inclusion: age ≥60 years, T1D duration ≥10 years, using insulin pump with rapid-acting insulin, HbA1c ≤10.5%, managing diabetes independently or with caregiver assistance. Exclusion: non-T1D, moderate-to-severe dementia, any physical or psychological condition or medication deemed by investigators to impact protocol compliance or result interpretation Intervention (N = 30): group 1, continuation of sensor-augmented pump therapy for 4 months and then closed loop therapy for 4 months; group 2, closed loop therapy for 4 months and then sensor-augmented pump therapy; CHO-counting ability assessed by dietitian based on 5-day food diary and further education provided to those who had >3 errors in CHO counting in diary n = 17 participants (57%) met the proficiency criterion after one consultation, n = 12 (40%) required a second consultation, and n = 10 required >2 consultations; the reasons for CHO counting errors were 1) overestimation due to using raw instead of cooked values for foods and 2) underestimation when eating away from home The majority of participants met the CHO counting proficiency criteria after one consultation; errors in food diaries were similar to those made by younger adults Small sample; high technologically literate and numerate participants; linited detail about how CHO proficiency, was defined and assessed as well as the content and dose of education provided 
Experimental Valero et al., 2001, double-blind RCT (18) Hospital (Spain); 5–46 days, mean 11.4 days (until gastrointestinal tolerance of oral or enteral diets); recruitment years not reported Mean ± SD age 67.6 ± 10.6 years, intervention group, and 69.6 ± 9.2 years, control group; T1D, n = 29, and T2D, n = 109. Inclusion: age >18 years, requiring TPN. Exclusion: tolerance of oral or enteral diets, ketoacidosis or nonketotic hyperosmolar coma, or TPN use for <5 days Intervention (N = 67): received isocaloric amount of glucose-fructose-xylitol 2:1:1 during TPN infusion. Comparator (N = 71): received isocaloric amount of glucose during TPN infusion Mean ± SD days until glycemic control was achieved after TPN was started for intervention vs. comparator group, 2.4 ± 2.1 vs. 2.5 ± 1.7; % of n with end-of-treatment glycemia <200 mg/dL, 85.1% vs. 74.6% (intervention vs. comparator); CHO in TPN on the last day, 187 ± 45 vs. 191 ± 36 g/day (intervention vs. comparator) No differences in daily mean glycemia or insulin requirements were noted by treatment group No specific results reporting for T1D, age ≥65 years; limited detail about how inclusion and exclusion criteria and outcomes were specified 
Observational Altman et al., 2009, retrospective cross-sectional study (20) Unspecified no. of outpatient clinical centers, France; duration not reported; recruitment years not reported Mean ± SD age 67.1 ± 10.8 years; T1D, n = 57; mean ± SD T1D duration 49.8 ± 7.6 years Study design: surveys of quality of life including classifying burdens of T1D that impair life and main improvement in treatment of T1D during lifetime Continual dieting was reported as the second-most common burden related to T1D management; loosening dietary restrictions were noted by participants as improving quality of life over time Diet was a commonly reported burden of managing T1D but also a source of improving quality of life over time among adults with ≥40 years of management duration Limited detail reported about methodology used to develop and analyze questionnaire and its structure 
Observational Aparasu and Aparasu, 2008, cross-sectional study (21) Unspecified no. of clinics, U.S.; visits between 2003 and 2004; recruitment years not reported 45% of total visits estimated to be by adults >65 years; diagnosis of diabetes (ICD-9-CM 250) and hypertension (ICD-9-CM 401–404) Study design: data from 2 surveys (National Ambulatory Medical Care Survey and the outpatient portion of National Hospital Ambulatory Care Survey) between 2003 and 2004 used for understanding characteristics of visits for diabetes and hypertension 57% of outpatient visits for diabetes and hypertension included education and counseling. Of those, 53% were related to diet and nutrition A smaller proportion of visits for diabetes and hypertension included education and counseling than the proportion expected based on clinical guidelines. An even smaller proportion of visits included education or counseling related to diet and nutrition ICD-9 codes captured outpatient visits that included education and counseling; dose of education and counseling (and that specific to diet and nutrition) received at visits not reported 
Observational Cox et al., 1996, cross-sectional study (22) Outpatient diabetes clinic at North Chicago VA Medical Center, U.S.; ∼45 min to complete interview and survey; recruitment years not reported Mean ± SD age 63.5 ± 8.1 years; T1D, n = 17.71, and T2D, n = 136.29. Inclusion: males at North Chicago VA Medical Center. Exclusion: severe medical or psychiatric conditions Study design: individual interview and questionnaires (AEQ; AUSR: Concerns about Drinking Scale, Negative Consequences of Drinking Scale, Amount Consumed Scale; investigator-designed 12-item treatment compliance questionnaire; DQOL questionnaire) to assess relationships among diabetes, alcohol use and expectancies, treatment compliance, and quality of life †Mean ± SD daily alcohol consumption 0.39 ± 1.2 oz (n = 154) (0.66 ± 1.5 oz for n ∼91 who indicated that they drink), mean ± SD score on AUSR Amount Consumed Scale 2.1 ± 2.1, mean ± SD treatment compliance self-reported score for diet (12-component questionnaire, range 1–5) 2.9 ± 0.6 (n = 132), association between self-reported diet compliance P < 0.05, physiological measures of compliance (fasting blood glucose and HbA1c levels) and alcohol use P > 0.05 Overall, participants consumed relatively low amounts of alcohol, were generally compliant with treatment, and had good diabetes outcomes. Greater alcohol use is significantly related to poorer diet compliance Small sample of participants with T1D, all male participants, majority of participants abstained from alcohol, no specific results reporting for T1D or age ≥65 years 
Observational Petersen et al., 2018, cohort study after RCT (23) Unspecified no. of clinics, Australia; ∼12 months of follow-up following a 12-month RCT; recruitment August 2012–December 2013 Mean ± SD age 60 ±13 years; T1D, n = 12, and T2D, n = 75. Inclusion: age >18 years with T1D or T2D. Exclusion: unstable cardiovascular disease, heart failure, renal impairment, liver disease, cancer, or allergy to or intolerance/dislike of fruits, vegetables, or dairy Study design: observed nutrient intake to assess dietary quality over 2 years for participants in RCT AHEI score (0, nonadherence, to 80, adherence) at BL and CCA IMT regression (mm) at 24 months compared between highest and lowest AHEI tertiles: mean −0.043 mm (95% CI −0.084, −0.003), P = 0.029. Correlation between nutrient intake (g/day) and AHEI score at BL and mean CCA IMT (mm) at 24 months (after adjustment for age and BL mean CCA IMT): CHO intake, r = −0.28, P = 0.01; sugar intake, r = −0.27, P = 0.01; fiber intake, r = −0.26, P = 0.02; magnesium intake, r = −0.25, P = 0.02; AHEI score, r = −0.23, P = 0.03. Correlation between nutrient intake (g/day) at 12 months (adjustment for age, BL CCA IMT, and energy intake at 12 months) and mean CCA IMT (mm) at 24 months: total dairy intake, r = −0.185, P = 0.048; total reduced-fat dairy intake, r = −0.268,P = 0.007; fruit intake, P > 0.05; vegetable intake, P > 0.05. Association of dietary intake at BL and dietary changes at 24 months with cfPWV (m/s) at Higher dietary quality (reflected by AHEI scores) at BL was associated with greater CCA IMT regression after 24 months; BL CHO, sugar, fiber, and magnesium intake were inversely associated with mean CCA IMT at 24 months, and greater total and reduced fat dairy intake at 12 months was associated with lower mean CCA IMT at 24 months. There were no associations between BL dietary intake and cfPWV at 24 months Small sample of participants with T1D, results not stratified by intervention group, no specific results reported for T1D or age ≥65 years 
     24 months P > 0.05. Dietary intake month 24 vs. month 0, respectively (time-by-treatment P value): protein 83 ± 34 vs. 92 ± 38 g/day (P = <0.009), total fat 66 ± 29 vs. 73 ± 33 g/day (P = 0.04), saturated fat 27 ± 12 vs. 28 ± 14 g/day (P = 0.12), CHO 159 ± 64 vs. 180 ± 67 g/day (P = 0.001), sugar 73 ± 26 vs. 76 ± 25 g/day (P < 0.001), fiber 20 ± 7 vs. 21 ± 7 g/day (P < 0.001), alcohol 10 ± 18 vs. 12 ± 20 g/day (P = 0.01), fruit 267 ± 176 vs. 237 ± 129 g/day (P < 0.001), vegetable 165 ± 74 vs. 170 ± 64 g/day (P = 0.01), dairy 373 ± 187 vs. 394 ± 196 g/day (P = 0.11), bread and cereal 180 ± 108 vs. 236 ± 124 g/day (P = 0.41), meat and alternative 186 ± 108 vs. 200 ± 113 g/day (P = 0.14)   
Observational Zimbudzi et al., 2017, cross-sectional study (24) Unspecified no. of diabetes and renal outpatient clinics of hospitals, Australia; one-time questionnaire, completed between December 2013 and December 2014; recruitment years not reported Median age 68 years (IQR 14.8); T1D, n = 45, T2D, n = 249, and unsure, n = 14. Inclusion: T1D or T2D based on WHO 2006 definition with moderate-to-severe CKD (stages 3–5: GFR <50 mL/min/1.73 m2) and receiving routine care at specified hospitals. Exclusion: not specified Study design: one-time questionnaire Mean ± SD SDSCA score (days) by subscale‡ (8-point Likert scale, range 0–7 days): general diet 5.0 ± 1.9, diabetes-specific diet 3.2 ± 1.5, composite 3.9 ± 1.1. Associations between self-management subscales (SDSCA, 0–7 days) and HRQOL subscales (KDQOL-36) (range 0–100): general diet, PCS 0.29 (95% CI −0.06, 0.63), MCS 0.73 (0.40, 1.06), symptom/problem list 0.99 (0.46, 1.52), effects of CKD 0.87 (0.14, 1.39), burden of CKD 1.37 (0.42, 2.32); diabetes-specific diet, PCS 0.07 (−0.37, 0.51), MCS −0.31 (−0.73, 0.11), symptom/problem list −0.07 (−0.76, 0.61), effects of CKD −0.35 (−1.30, 0.58), burden of CKD −1.24 (−2.46, 0.02). Association between self-management (SDSCA subscales, range 0–7 days) and HRQOL (KDQOL-36, range 0–100) using model adjusted for age, estimated GFR, diabetes duration, and CKD duration: general diet, PCS R2 = 7.8 (P > 0.05), MCS R2 = 11.3 (P < 0.01), symptom/problem list R2 = 9.7 (P < 0.01), effects of CKD R2 = 17.7 (P > 0.05), burden of CKD R2 = 31.6 (P < 0.01); diabetes-specific diet, PCS R2 = 7.8 (P > 0.05), MCS R2 = 11.8 (P > 0.05), symptom/problem list R2 = 9.7 (P > 0.05), effects of CKD R2 = 17.7 (P > 0.05), burden of CKD R2 = 32.3 (P > 0.05). Participation in diabetes self-management, especially activities related to general diet, was associated with higher HRQOL. General diet was positively associated with several HRQOL measures, but diabetes-specific diet was not SDSCA was not developed or evaluated for validity among individuals with diabetes; SDSCA does not objectively or granularly characterize eating behavior or dietary adherence, as the constructs “general diet” and “diabetes-specific diet” are each captured by 2 self-report items; no specific results reported for T1D or age ≥65 years 

AEQ, Alcohol Expectancy Questionnaire; AHEI, Alternative Health Eating Index; AUSR, Alcohol Use Self-Report; BL, baseline; BP, blood pressure; CCA IMT, common carotid artery intima-media thickness; cfPWV, carotid femoral pulse wave velocity; CGM, continuous glucose monitoring; CHO, carbohydrates; CIR, carbohydrate-to-insulin ratio; CKD, chronic kidney disease; DC, dietician coached; DQOL, Diabetes Quality-of-Life; GFR, glomerular filtration rate; FFQ, food-frequency questionnaire; HDL-C, HDL high-density lipoprotein cholesterol; HFHP, high-fat, high-protein; HRQOL, health-related quality of life; iAUC, incremental area under the curve; IQR, interquartile range; KDQOL-36, Kidney Disease Quality of Life 36-item short form survey; LDL-C, low-density lipoprotein cholesterol; LFLP, low-fat, low-protein; MCS, Mental composite summary; MPB, model predictive bolus; PCS, Physical composite summary; SDSCA, Summary of Diabetes Self-Care Activities; T1D, type 1 diabetes; T2D, type 2 diabetes; TPN, total parenteral nutrition; WHO, World Health Organization.

*

Refer to publication for results pertaining to the HFHP meal with the optimized insulin dose found using an MPB.

†

Refer to publication for additional results related to alcohol use and expectancies, treatment compliance, and quality of life and further analysis of relationships among them.

‡

Refer to publication for results pertinent to the exercise and blood glucose testing SDSCA subscales.

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Table 2

Reviews and meta-analyses

ReferenceStatements relevant to older adults with type 1 diabetes: key findings for diet recommendations based on 11 guidelinesNotes
A scoping review of best practice guidelines for the dietary management of diabetes in older adults in residential aged care (2019, Farrer et al. [25]) 1) Healthy eating: low-fat, low–added sugar, high-fiber focus (11 guidelines); more explicit reference to population-based recommendations or dietary reference values and country-specific publications (4 guidelines); no explicit dietary composition established (1 guideline); low-fat, -sugar, and -salt and high-fiber diets (3 guidelines); reference to alternative healthy eating diets (DASH, Mediterranean diet) to manage cardiovascular comorbidities (2 guidelines); meals emphasizing CHO targets and regular daily CHO volumes, discord in dietary inclusion of sugar and full-fat foods (4 guidelines). 2) Fiber and GI: starchy CHO should be high-fiber and low-GI (consensus among guidelines); >1 component of each meal should be low-GI (dietitian-developed guidelines). 3) Low-fat vs. full-fat diet: less consensus, especially on dairy products; low-fat diet with emphasis on low saturated fat (5 guidelines); fat restriction in meals not recommended for older adults (2 guidelines, Australian); topic not addressed (3 guidelines); individualized fat intake targets suggested (1 guideline). 4) Added sugar: the greatest inconsistency in recommendations is regarding dietary sugar (raw form or in drinks/“discretionary food items”). Low or moderate added sugar consumption in diet (6 guidelines); do not avoid sugar, but prohibit regular provision of soft drinks and cordials for older adults with diabetes (3 guidelines); avoid fruit juice (1 guideline); quantified level of sugar restriction, i.e., 2 tablespoons granulated sugar/day with meals (1 guideline), smaller portions of “very sweet” desserts are better for older adults with diabetes, icing on cakes discouraged (2 guidelines). 5) Weight management: combine physical activity and weight loss (4 guidelines); exercise only for specific health outcomes, i.e., to increase mobility or improve disease outcomes (1 guideline) There are no systems-based, integrative, evidence-based guidelines. Current dietary management guidelines for older adults with diabetes are variable and may impact health outcomes and quality of life. Existing practice documents are inconsistent and range in quality level. 
ReferenceStatements relevant to older adults with type 1 diabetes: key findings for diet recommendations based on 11 guidelinesNotes
A scoping review of best practice guidelines for the dietary management of diabetes in older adults in residential aged care (2019, Farrer et al. [25]) 1) Healthy eating: low-fat, low–added sugar, high-fiber focus (11 guidelines); more explicit reference to population-based recommendations or dietary reference values and country-specific publications (4 guidelines); no explicit dietary composition established (1 guideline); low-fat, -sugar, and -salt and high-fiber diets (3 guidelines); reference to alternative healthy eating diets (DASH, Mediterranean diet) to manage cardiovascular comorbidities (2 guidelines); meals emphasizing CHO targets and regular daily CHO volumes, discord in dietary inclusion of sugar and full-fat foods (4 guidelines). 2) Fiber and GI: starchy CHO should be high-fiber and low-GI (consensus among guidelines); >1 component of each meal should be low-GI (dietitian-developed guidelines). 3) Low-fat vs. full-fat diet: less consensus, especially on dairy products; low-fat diet with emphasis on low saturated fat (5 guidelines); fat restriction in meals not recommended for older adults (2 guidelines, Australian); topic not addressed (3 guidelines); individualized fat intake targets suggested (1 guideline). 4) Added sugar: the greatest inconsistency in recommendations is regarding dietary sugar (raw form or in drinks/“discretionary food items”). Low or moderate added sugar consumption in diet (6 guidelines); do not avoid sugar, but prohibit regular provision of soft drinks and cordials for older adults with diabetes (3 guidelines); avoid fruit juice (1 guideline); quantified level of sugar restriction, i.e., 2 tablespoons granulated sugar/day with meals (1 guideline), smaller portions of “very sweet” desserts are better for older adults with diabetes, icing on cakes discouraged (2 guidelines). 5) Weight management: combine physical activity and weight loss (4 guidelines); exercise only for specific health outcomes, i.e., to increase mobility or improve disease outcomes (1 guideline) There are no systems-based, integrative, evidence-based guidelines. Current dietary management guidelines for older adults with diabetes are variable and may impact health outcomes and quality of life. Existing practice documents are inconsistent and range in quality level. 

CHO, carbohydrates; DASH, Dietary Approaches to Stop Hypertension; GI, gastrointestinal.

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Table 3

Guidance relevant to nutrition in clinical guidelines and consensus papers

Diabetes UK, Clinical Guidelines for Type 1 Diabetes Mellitus With an Emphasis on Older Adults, 2019 (8)*
Weight, malnutrition, restrictive diets 
 • Body weight, waist circumference maintenance per sex and race† 
Insulin 
 • Basal-bolus insulin regimen from diagnosis; rapid-acting insulin analogs 
 • Twice-daily regimen of longer-acting insulin as alternative basal regimen 
 • High-concentration insulins for suboptimal control or nocturnal hypoglycemia 
 • Insulin delivery and BG monitoring technology to reduce adverse effects of insulin injections† 
Nutrient intake, physical activity 
 • Meal planning and patterns with consideration of glycemic control, optimal foods, snacking behaviors, food content in the context of insulin regimen, alcohol, and sodium 
 • Adequate protein intake and hydration 
 • Consideration of drug-nutrient interactions; consistent daily CHO intake for fixed insulin regimens 
 • Routine micronutrient supplementation not recommended 
 • Limited alcohol and high–glycemic index foods or beverages 
 • Regular exercise and limited daily sitting time to maintain fitness, strength, and balance and lower HbA1c toward target levels 
 • Minimum of 120–150 min moderate aerobic exercise/week and two ≥20-min resistance training sessions per week 
 • Reduced salt and alcohol to manage blood pressure 
 • Reduced saturated fat, trans fat, and cholesterol and increased n-3 fatty acid intake to manage dyslipidemia 
 • High-protein diet avoidance in CKD 
 • Hydration and small low-fat/low-fiber meals for gastroparesis 
 • Increased salt and fluid intake for postural hypotension 
 • 3-day food diaries, questionnaires, dietary analyses to identify challenges† 
Glycemic and hypoglycemia management 
 • Glycemic targets determined with consideration of prevention of vascular complications, DKA, and hypoglycemia and hyperglycemic symptom relief, quality of life, activity level, lifestyle, physical and mental health status, and estimated hypoglycemia risk 
 • Frequent self-monitoring of BG to reduce severe hypoglycemia risk in intensive insulin therapy 
 • CGM among those with hypoglycemic unawareness may reduce hypoglycemic episodes and lower HbA1c 
 • HbA1c measured at least 2–4 times/year 
 • For avoidance of hypoglycemia during exercise, reduced or omitted short-acting insulin at previous meals or consumption of CHO 
 • Reduced insulin dose the night after exercise to reduce risk of delayed postexercise hypoglycemia 
 • Simple CHO source to prevent and treat hypoglycemia before and after exercise 
 • Hypoglycemia unawareness assessed at least annually 
 • CSII or CGM for hypoglycemic unawareness and recurrent episodes 
 • Hypoglycemia treatment protocol in place at admitting institutions 
 • Staff education on age-specific risk factors for and signs of hypoglycemia, and complicating factors† 
Individualized treatment 
 • Provider-patient collaboration to structure self-management and develop individualized eating plan 
 • Access to a specialist nutritional therapist needed to individualize nutritional programs 
 • Dietary plans formulated with consideration of preferences, culture, cognitive capacity, insulin, and regimen 
 • Individualized management plans developed with consideration of insulin regimen, BG and ketone monitoring, hypoglycemia, and sick day management 
 • Deteriorating glycemic control and self-care errors indicate need to assess for new clinical, functional, or psychosocial barriers† 
Cognitive capacity, age-related changes and comorbidities 
 • Speech and language therapists for swallowing difficulties 
 • Insulin therapy adjusted based on age-related barriers and changes 
 • Strategies for general population to prevent and identify CVD† 
Education and community resources 
 • Education on CHO counting; flexible meal patterns and insulin dosing; glycemic management and control; managing basal-bolus insulin regimens; adjusting prandial insulin doses with consideration of daily CHO intake, premeal capillary glucose estimates, and physical activity; exercise and hypoglycemia; how aging impacts self-management ability; consequences of hypoglycemia that differ from those in younger individuals; implications of hypoglycemia unawareness 
 • Self-management education focused on T1D management and not a modified version of type 2 diabetes education 
 • Caretaker and family member trainings on CHO control and creating a balanced diet and exercise and hypoglycemia 
 • Caretaker education involvement for those with impaired self-care ability 
 • Teaching strategy and environment accommodates learning styles and abilities of adult and/or caretaker 
 • Support for accessing education strategies that include technology and social media 
 • Home- and community-based exercise programs 
 • Repeated education about risks and benefits of tight glycemic control when individuals are unwilling to change behavior and practices 
 • DKA and insulin management education for admitting institutions 
 • Clear, relevant, and consistent messages from multidisciplinary diabetes team† 
Screening and assessment tools 
 • MUST, MNA, or dietary software analysis to identify dietary concerns in cases of frailty or excessive comorbidity (32–34) 
 • Routine assessment of factors related to hypoglycemia using a validated method, including the Hypoglycemia Patient Questionnaire,‡ the Edinburgh Hypoglycemia Scale,† and the Hypoglycemia Perspectives Questionnaire‡ (35–37) 
LTC, hospitals, end-of-life care 
 • Variable glycemic targets for inpatients† 
 • Subcutaneous basal-bolus insulin when patient is able to eat and not in critical condition† 
 • Familiar intravenous insulin regimen for those who are acutely unwell or about to undergo surgery or who lack glycemic control† 
 • Assessment by an in-hospital diabetes specialist team within 24 h of hospital admission† 
Diabetes UK, Clinical Guidelines for Type 1 Diabetes Mellitus With an Emphasis on Older Adults, 2019 (8)*
Weight, malnutrition, restrictive diets 
 • Body weight, waist circumference maintenance per sex and race† 
Insulin 
 • Basal-bolus insulin regimen from diagnosis; rapid-acting insulin analogs 
 • Twice-daily regimen of longer-acting insulin as alternative basal regimen 
 • High-concentration insulins for suboptimal control or nocturnal hypoglycemia 
 • Insulin delivery and BG monitoring technology to reduce adverse effects of insulin injections† 
Nutrient intake, physical activity 
 • Meal planning and patterns with consideration of glycemic control, optimal foods, snacking behaviors, food content in the context of insulin regimen, alcohol, and sodium 
 • Adequate protein intake and hydration 
 • Consideration of drug-nutrient interactions; consistent daily CHO intake for fixed insulin regimens 
 • Routine micronutrient supplementation not recommended 
 • Limited alcohol and high–glycemic index foods or beverages 
 • Regular exercise and limited daily sitting time to maintain fitness, strength, and balance and lower HbA1c toward target levels 
 • Minimum of 120–150 min moderate aerobic exercise/week and two ≥20-min resistance training sessions per week 
 • Reduced salt and alcohol to manage blood pressure 
 • Reduced saturated fat, trans fat, and cholesterol and increased n-3 fatty acid intake to manage dyslipidemia 
 • High-protein diet avoidance in CKD 
 • Hydration and small low-fat/low-fiber meals for gastroparesis 
 • Increased salt and fluid intake for postural hypotension 
 • 3-day food diaries, questionnaires, dietary analyses to identify challenges† 
Glycemic and hypoglycemia management 
 • Glycemic targets determined with consideration of prevention of vascular complications, DKA, and hypoglycemia and hyperglycemic symptom relief, quality of life, activity level, lifestyle, physical and mental health status, and estimated hypoglycemia risk 
 • Frequent self-monitoring of BG to reduce severe hypoglycemia risk in intensive insulin therapy 
 • CGM among those with hypoglycemic unawareness may reduce hypoglycemic episodes and lower HbA1c 
 • HbA1c measured at least 2–4 times/year 
 • For avoidance of hypoglycemia during exercise, reduced or omitted short-acting insulin at previous meals or consumption of CHO 
 • Reduced insulin dose the night after exercise to reduce risk of delayed postexercise hypoglycemia 
 • Simple CHO source to prevent and treat hypoglycemia before and after exercise 
 • Hypoglycemia unawareness assessed at least annually 
 • CSII or CGM for hypoglycemic unawareness and recurrent episodes 
 • Hypoglycemia treatment protocol in place at admitting institutions 
 • Staff education on age-specific risk factors for and signs of hypoglycemia, and complicating factors† 
Individualized treatment 
 • Provider-patient collaboration to structure self-management and develop individualized eating plan 
 • Access to a specialist nutritional therapist needed to individualize nutritional programs 
 • Dietary plans formulated with consideration of preferences, culture, cognitive capacity, insulin, and regimen 
 • Individualized management plans developed with consideration of insulin regimen, BG and ketone monitoring, hypoglycemia, and sick day management 
 • Deteriorating glycemic control and self-care errors indicate need to assess for new clinical, functional, or psychosocial barriers† 
Cognitive capacity, age-related changes and comorbidities 
 • Speech and language therapists for swallowing difficulties 
 • Insulin therapy adjusted based on age-related barriers and changes 
 • Strategies for general population to prevent and identify CVD† 
Education and community resources 
 • Education on CHO counting; flexible meal patterns and insulin dosing; glycemic management and control; managing basal-bolus insulin regimens; adjusting prandial insulin doses with consideration of daily CHO intake, premeal capillary glucose estimates, and physical activity; exercise and hypoglycemia; how aging impacts self-management ability; consequences of hypoglycemia that differ from those in younger individuals; implications of hypoglycemia unawareness 
 • Self-management education focused on T1D management and not a modified version of type 2 diabetes education 
 • Caretaker and family member trainings on CHO control and creating a balanced diet and exercise and hypoglycemia 
 • Caretaker education involvement for those with impaired self-care ability 
 • Teaching strategy and environment accommodates learning styles and abilities of adult and/or caretaker 
 • Support for accessing education strategies that include technology and social media 
 • Home- and community-based exercise programs 
 • Repeated education about risks and benefits of tight glycemic control when individuals are unwilling to change behavior and practices 
 • DKA and insulin management education for admitting institutions 
 • Clear, relevant, and consistent messages from multidisciplinary diabetes team† 
Screening and assessment tools 
 • MUST, MNA, or dietary software analysis to identify dietary concerns in cases of frailty or excessive comorbidity (32–34) 
 • Routine assessment of factors related to hypoglycemia using a validated method, including the Hypoglycemia Patient Questionnaire,‡ the Edinburgh Hypoglycemia Scale,† and the Hypoglycemia Perspectives Questionnaire‡ (35–37) 
LTC, hospitals, end-of-life care 
 • Variable glycemic targets for inpatients† 
 • Subcutaneous basal-bolus insulin when patient is able to eat and not in critical condition† 
 • Familiar intravenous insulin regimen for those who are acutely unwell or about to undergo surgery or who lack glycemic control† 
 • Assessment by an in-hospital diabetes specialist team within 24 h of hospital admission† 
ADA, Standards of Care, Older Adults, 2023 (1)
Insulin 
 • Basal insulin to avoid DKA even when patient is unable to ingest meals† 
 • Insulin therapy injections or pump delivery† 
 • Reduced but continued insulin dosing if oral food intake decreases in advanced T1D† 
Nutrient intake, physical activity 
 • Adequate nutrition and protein intake and exercise (aerobic, weight-bearing, and resistance) to manage sarcopenia and frailty‡ 
 • Simplified dietary plans if cognitive dysfunction affects meal content and timing‡ 
Glycemic and hypoglycemia management 
 • CGM to improve HbA1c, reduce glycemic variability, and prevent hypoglycemia† 
 • Automated insulin delivery systems and advanced insulin delivery devices (i.e., connected pens) based on individual ability to reduce hypoglycemia risk† 
Cognitive capacity, age-related changes and comorbidities 
 • Insulin administration with caregiver assistance to overcome cognitive and functional impairment† 
 • Adequate nutrition and protein intake with exercise to manage sarcopenia and frailty‡ 
LTC, hospitals, end-of-life care 
 • No consensus on managing end-of-life care† 
 • Insulin to adjust for actual amount of CHO consumed postmeals in LTC‡ 
 • Staff familiarity with insulin pumps, CGM, differences between T1D and T2D, individual diabetes management plans† 
 • Reduced but continued insulin as oral food intake decreases in organ failure† 
 • Small basal insulin dose delivered to dying patients may stabilize BG and reduce complications of hyperglycemia† 
 • Adequate hydration to prevent hypoglycemia in organ failure‡ 
 • Diets may decrease food intake and cause unplanned weight loss and malnutrition in LTC‡ 
 • LTC residents may experience irregular meal schedules, malnutrition, anorexia, and difficulty swallowing and higher risk of hypoglycemia‡ 
 • Support during transitions to acute and LTC to prevent dosing errors and manage changes in nutrition and activity‡ 
 • Individualized meal planning with consideration of culture, preferences, and goals to increase quality of life, meal satisfaction, and nutrition status in LTC‡ 
ADA, Standards of Care, Older Adults, 2023 (1)
Insulin 
 • Basal insulin to avoid DKA even when patient is unable to ingest meals† 
 • Insulin therapy injections or pump delivery† 
 • Reduced but continued insulin dosing if oral food intake decreases in advanced T1D† 
Nutrient intake, physical activity 
 • Adequate nutrition and protein intake and exercise (aerobic, weight-bearing, and resistance) to manage sarcopenia and frailty‡ 
 • Simplified dietary plans if cognitive dysfunction affects meal content and timing‡ 
Glycemic and hypoglycemia management 
 • CGM to improve HbA1c, reduce glycemic variability, and prevent hypoglycemia† 
 • Automated insulin delivery systems and advanced insulin delivery devices (i.e., connected pens) based on individual ability to reduce hypoglycemia risk† 
Cognitive capacity, age-related changes and comorbidities 
 • Insulin administration with caregiver assistance to overcome cognitive and functional impairment† 
 • Adequate nutrition and protein intake with exercise to manage sarcopenia and frailty‡ 
LTC, hospitals, end-of-life care 
 • No consensus on managing end-of-life care† 
 • Insulin to adjust for actual amount of CHO consumed postmeals in LTC‡ 
 • Staff familiarity with insulin pumps, CGM, differences between T1D and T2D, individual diabetes management plans† 
 • Reduced but continued insulin as oral food intake decreases in organ failure† 
 • Small basal insulin dose delivered to dying patients may stabilize BG and reduce complications of hyperglycemia† 
 • Adequate hydration to prevent hypoglycemia in organ failure‡ 
 • Diets may decrease food intake and cause unplanned weight loss and malnutrition in LTC‡ 
 • LTC residents may experience irregular meal schedules, malnutrition, anorexia, and difficulty swallowing and higher risk of hypoglycemia‡ 
 • Support during transitions to acute and LTC to prevent dosing errors and manage changes in nutrition and activity‡ 
 • Individualized meal planning with consideration of culture, preferences, and goals to increase quality of life, meal satisfaction, and nutrition status in LTC‡ 
ADA, Standards of Care, Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes, 2023 (26)
Nutrient intake, physical activity 
 • Multivitamin supplementation, especially in the case of vegetarian, low-calorie, or low-CHO diets‡ 
 • Flexibility and balance training 2–3 times/week to maintain range of motion, strength, and balance‡ 
 • Yoga and tai chi based on individual preferences‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Active screening to assess cognition, frailty, mental health, and decision-making ability‡ 
 • Cognitive capacity monitored cautiously, especially in those with history of severe hypoglycemia or cognitive impairments‡ 
 • Actively surveil treatment-related behaviors that may be impaired due to age-related cognitive changes‡ 
ADA, Standards of Care, Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes, 2023 (26)
Nutrient intake, physical activity 
 • Multivitamin supplementation, especially in the case of vegetarian, low-calorie, or low-CHO diets‡ 
 • Flexibility and balance training 2–3 times/week to maintain range of motion, strength, and balance‡ 
 • Yoga and tai chi based on individual preferences‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Active screening to assess cognition, frailty, mental health, and decision-making ability‡ 
 • Cognitive capacity monitored cautiously, especially in those with history of severe hypoglycemia or cognitive impairments‡ 
 • Actively surveil treatment-related behaviors that may be impaired due to age-related cognitive changes‡ 
ADA, consensus report, Diabetes in Older Adults, 2012 (3)
Weight, malnutrition, restrictive diets 
 • Adequate micronutrient consumption to prevent deficiencies amid decreased caloric needs‡ 
 • Unplanned weight loss may lead to nutritional concerns‡ 
 • Weight loss in individuals who are overweight or obese may cause nutritional deficits, worsen sarcopenia, and decrease bone mineral density‡ 
 • Physical activity and nutrition therapy as a weight loss approach to benefit physical fitness and cardiometabolic outcomes‡ 
 • Monitor insulin-induced weight gain‡ 
Insulin 
 • Monitor insulin dosing after illness and dietary changes‡ 
 • Monitor challenges with visual and manual dexterity, which may be barriers to insulin therapy‡ 
Nutrient intake, physical activity 
 • If nutritional needs are not met, consider the following modifications to meals: smaller, more frequent portions; fortified foods; food consistency; and formula supplements in liquids‡ 
 • Physical activity to improve functional status‡ 
 • Exercise to targets recommended for all adults with diabetes‡ 
 • Slight physical activity increase in individuals with poor health‡ 
Glycemic and hypoglycemia management 
 • Exercise, erratic meals, and insulin use increase risk of hypoglycemia‡ 
Individualized treatment 
 • Individualized treatment and MNT with consideration of preferences, skills, and lifestyles‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Cognitive dysfunction screening to assess need for simplified treatment regimens if ability to maintain a health-promoting diet, time meals, and provide self-care is impaired‡ 
Education and community resources 
 • Nutritional support (i.e., Meals on Wheels, senior centers, and the Older Americans Act Nutrition Program) for ambulatory individuals‡ 
 • Individualized education and training on diabetes self-management for patients and caretakers with consideration of medical, cultural, and social factors and impaired function, cognition, and sensation‡ 
 • Supervised group exercise and community resources (i.e., senior centers, YMCAs, the EnhanceFitness program, the Arthritis Foundation) to promote activity‡ 
Screening and assessment tools 
 • Mini Nutritional Assessment (validated) to identify risk of malnutrition and need for an RD and MNT (38)‡ 
LTC, hospitals, end-of-life care 
 • Monitor undernutrition, anorexia, difficulty swallowing, and irregular eating patterns‡ 
 • Prescribed diets may unintentionally decrease dietary intake and contribute to involuntary weight loss and undernutrition‡ 
 • Individualized meal planning with consideration of desires, abilities, and backgrounds in LTC to support quality of life, meal satisfaction, and nutrition status‡ 
 • Consider glycemic variability of LTC residents during staff turnover‡ 
 • Monitor insulin dosing after transitions between home and hospitals and care facilities‡ 
ADA, consensus report, Diabetes in Older Adults, 2012 (3)
Weight, malnutrition, restrictive diets 
 • Adequate micronutrient consumption to prevent deficiencies amid decreased caloric needs‡ 
 • Unplanned weight loss may lead to nutritional concerns‡ 
 • Weight loss in individuals who are overweight or obese may cause nutritional deficits, worsen sarcopenia, and decrease bone mineral density‡ 
 • Physical activity and nutrition therapy as a weight loss approach to benefit physical fitness and cardiometabolic outcomes‡ 
 • Monitor insulin-induced weight gain‡ 
Insulin 
 • Monitor insulin dosing after illness and dietary changes‡ 
 • Monitor challenges with visual and manual dexterity, which may be barriers to insulin therapy‡ 
Nutrient intake, physical activity 
 • If nutritional needs are not met, consider the following modifications to meals: smaller, more frequent portions; fortified foods; food consistency; and formula supplements in liquids‡ 
 • Physical activity to improve functional status‡ 
 • Exercise to targets recommended for all adults with diabetes‡ 
 • Slight physical activity increase in individuals with poor health‡ 
Glycemic and hypoglycemia management 
 • Exercise, erratic meals, and insulin use increase risk of hypoglycemia‡ 
Individualized treatment 
 • Individualized treatment and MNT with consideration of preferences, skills, and lifestyles‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Cognitive dysfunction screening to assess need for simplified treatment regimens if ability to maintain a health-promoting diet, time meals, and provide self-care is impaired‡ 
Education and community resources 
 • Nutritional support (i.e., Meals on Wheels, senior centers, and the Older Americans Act Nutrition Program) for ambulatory individuals‡ 
 • Individualized education and training on diabetes self-management for patients and caretakers with consideration of medical, cultural, and social factors and impaired function, cognition, and sensation‡ 
 • Supervised group exercise and community resources (i.e., senior centers, YMCAs, the EnhanceFitness program, the Arthritis Foundation) to promote activity‡ 
Screening and assessment tools 
 • Mini Nutritional Assessment (validated) to identify risk of malnutrition and need for an RD and MNT (38)‡ 
LTC, hospitals, end-of-life care 
 • Monitor undernutrition, anorexia, difficulty swallowing, and irregular eating patterns‡ 
 • Prescribed diets may unintentionally decrease dietary intake and contribute to involuntary weight loss and undernutrition‡ 
 • Individualized meal planning with consideration of desires, abilities, and backgrounds in LTC to support quality of life, meal satisfaction, and nutrition status‡ 
 • Consider glycemic variability of LTC residents during staff turnover‡ 
 • Monitor insulin dosing after transitions between home and hospitals and care facilities‡ 
American Geriatrics Society, Guidelines for Improving the Care of Older Adults with Diabetes Mellitus, 2013 (9)
Weight, malnutrition, restrictive diets 
 • Medically supervised weight loss may benefit cardiovascular health‡ 
Nutrient intake, physical activity 
 • MNT, supplemented Mediterranean diet, and physical activity to improve CVD risk‡ 
 • Exercise >3 days/week‡ 
 • Moderate-intensity aerobic activity for at least 150 min/week and resistance exercises if patient is ambulatory‡ 
 • Frequent evaluation of diet and nutrition status. Culturally appropriate MNT for receipt of dietary and/or weight reduction counseling‡ 
Glycemic and hypoglycemia management 
 • Self-monitor BG (per cognitive and functional abilities) to reduce risk of hypoglycemia, although the optimal frequency is unknown‡ 
 • Treatment plan readjustment in severe or recurrent hypoglycemia‡ 
Individualized treatment 
 • Individualized care to improve quality of life‡ 
 • RD as part of MNT to personalize meal planning‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Standardized screening instrument to assess cognitive impairment‡ 
 • Consider the associations of diabetes, cognitive decline, and dementia‡ 
 • Depression, B12 deficiency, and hypothyroidism screens in cognitive impairment‡ 
 • Less stringent glycemic targets (i.e., HbA1c 8.0%) for individuals experiencing frailty or several comorbidities or if risks outweigh potential benefits‡ 
 • Meal planning including consideration of acute and chronic comorbidities, living situations, impairments‡ 
Education and community resources 
 • Education and reeducation as needed on diabetes self-management using the Diabetes Self-Management Education and Support Toolkit in National Standards for Diabetes Self-Management Education and Support (39)‡ 
 • Structured lifestyle counseling on Diabetes Prevention Program strategies‡ 
Screening and assessment tools 
 • MoCA test in clinical and educational settings to assess cognitive functioning (40,41)‡ 
LTC, hospitals, end-of-life care 
 • Less stringent glycemic targets (i.e., HbA1c 8.0%) when patients are nearing end-of-life care‡ 
American Geriatrics Society, Guidelines for Improving the Care of Older Adults with Diabetes Mellitus, 2013 (9)
Weight, malnutrition, restrictive diets 
 • Medically supervised weight loss may benefit cardiovascular health‡ 
Nutrient intake, physical activity 
 • MNT, supplemented Mediterranean diet, and physical activity to improve CVD risk‡ 
 • Exercise >3 days/week‡ 
 • Moderate-intensity aerobic activity for at least 150 min/week and resistance exercises if patient is ambulatory‡ 
 • Frequent evaluation of diet and nutrition status. Culturally appropriate MNT for receipt of dietary and/or weight reduction counseling‡ 
Glycemic and hypoglycemia management 
 • Self-monitor BG (per cognitive and functional abilities) to reduce risk of hypoglycemia, although the optimal frequency is unknown‡ 
 • Treatment plan readjustment in severe or recurrent hypoglycemia‡ 
Individualized treatment 
 • Individualized care to improve quality of life‡ 
 • RD as part of MNT to personalize meal planning‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Standardized screening instrument to assess cognitive impairment‡ 
 • Consider the associations of diabetes, cognitive decline, and dementia‡ 
 • Depression, B12 deficiency, and hypothyroidism screens in cognitive impairment‡ 
 • Less stringent glycemic targets (i.e., HbA1c 8.0%) for individuals experiencing frailty or several comorbidities or if risks outweigh potential benefits‡ 
 • Meal planning including consideration of acute and chronic comorbidities, living situations, impairments‡ 
Education and community resources 
 • Education and reeducation as needed on diabetes self-management using the Diabetes Self-Management Education and Support Toolkit in National Standards for Diabetes Self-Management Education and Support (39)‡ 
 • Structured lifestyle counseling on Diabetes Prevention Program strategies‡ 
Screening and assessment tools 
 • MoCA test in clinical and educational settings to assess cognitive functioning (40,41)‡ 
LTC, hospitals, end-of-life care 
 • Less stringent glycemic targets (i.e., HbA1c 8.0%) when patients are nearing end-of-life care‡ 
Endocrine Society, clinical practice guideline, Treatment of Diabetes in Older Adults, 2019 (6)
Weight, malnutrition, restrictive diets 
 • Malnutrition screening early on, especially in the case of acute and home care settings, to manage complications (i.e., lengthy hospitalization, costs, high readmission frequency)‡ 
 • Weight loss approached cautiously with consideration of unintended nutritional deficiencies‡ 
 • Consider how restrictive diets increases risk of sarcopenia and malnutrition among ambulatory individuals‡ 
Insulin 
 • Postprandial rapid-acting insulin with dose adjustment for the meal eaten to benefit those with variable food intake‡ 
 • Rapid-acting insulin postmeals to match postprandial BG and insulin peaks in stages 4 and 5 CKD and delayed gastric emptying‡ 
 • Avoid sliding-scale regular insulin to prevent hypoglycemia and unstable BG‡ 
 • Holding insulin due to poor appetite may cause hyperglycemia and DKA (especially in LTC and hospitals and during care transitions)‡ 
Nutrient intake, physical activity 
 • Inconsistent benefits of supplementation with protein, branched chain amino acids, and creatine‡ 
 • Daily protein intake 1.0 –1.2 g/kg if patient is healthy, 1.2–1.5 g/kg with acute or chronic diseases‡ 
 • Protein intake >1.5 g/kg/day in cachexia or sarcopenia‡ 
 • Energy- and protein-dense nutrition may not improve food consumption, decrease malnutrition or, increase weight loss‡ 
 • MNT to promote diabetes-specific health‡ 
 • Consider the negative impact of alcohol for those with impaired metabolism (especially due to medications) or at high risk of adverse events‡ 
 • Adequate fluid intake to prevent constipation and fecal impaction‡ 
 • Sodium consumption <2,300 mg/day with consideration of taste, cost, and availability‡ 
 • Dietary patterns with high-quality nutrients (i.e., Mediterranean, DASH, plant-based) to improve weight and blood pressure, meet glycemic and lipid targets, and prevent complications‡ 
 • Vegetables, legumes, whole grains, and certain cereals to increase fiber intake from 25 to 35 g/day (for those without gastroparesis)‡ 
 • Nutrient-dense diet to avoid complications for ambulatory individuals‡ 
Glycemic and hypoglycemia management 
 • Balance stringency of glycemic targets with risks of hypoglycemia† 
 • Surveil glycemic responses to dietary changes (ambulatory and LTC settings)‡ 
 • Reduce simple sugar intake instead of undertaking restrictive diets when patient is at risk of malnutrition and when glycemic control has not been achieved with lifestyle modifications‡ 
Individualized treatment 
 • Individualized strategies for physical activity and nutritional therapy that include target nutrient intake (i.e., calcium and vitamin D)‡ 
 • Individualized nutrition plans with consideration of goals, skills, and preferences‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Insulin regimens with simplifications (i.e., replace CHO and calorie counting with fixed mealtime dosing or replace insulin pump with injections) in cognitive decline† 
 • Meal planning approach emphasizing portion sizes and choosing healthy foods for those with impaired cognition and learning‡ 
 • Consider challenges to adequate nutrition: finances, grocery shopping, meal preparation, changes in taste and smell, changes in dentition and swallowing, gastrointestinal condition, anorexia, cognitive impairment, depression‡ 
 • 25-hydroxyvitamin D supplementation and monitoring, nutritional therapy, and exercise to improve sarcopenia‡ 
 • Protein- and energy-dense diets to address inadequate nutrition and/or weight loss in frailty‡ 
Education and community resources 
 • Education on meal planning and CHO counting to improve glycemic control and simplify insulin dosing for those with active lifestyles‡ 
 • Education on diabetes treatment for nursing and house staff‡ 
Screening and assessment tools 
 • Mini Nutritional Assessment and Short Nutritional Assessment Questionnaire to assess nutrition status and identify malnutrition (32,42)‡ 
LTC, hospitals, end-of-life care 
 • Regular, individualized diets to increase quality of life and nutrition status in LTC‡ 
 • Caloric intake and insulin coverage discordance may cause glycemic variability in hospitalized patients‡ 
 • Insulin in institutional settings† 
 • Nutritionally balanced meals rather than fluids with high sugar content (i.e., fruit juice, shakes, or supplements) to prevent glycemic spikes (LTC and hospital residents)‡ 
 • Consider challenges to food intake: decreased appetite, swallowing difficulties, trouble keeping food down; hydration actively managed in LTC‡ 
 • Safety protocols to avoid hypoglycemia if feeding of patients on enteral or parenteral nutrition is abruptly stopped‡ 
 • Avoid glycemic targets below regular “postprandial” state values (140–180 mg/dL, 7.77–10.00 mmol/L) for those on continuous enteral or parenteral nutrition to prevent dangerous consequences‡ 
Endocrine Society, clinical practice guideline, Treatment of Diabetes in Older Adults, 2019 (6)
Weight, malnutrition, restrictive diets 
 • Malnutrition screening early on, especially in the case of acute and home care settings, to manage complications (i.e., lengthy hospitalization, costs, high readmission frequency)‡ 
 • Weight loss approached cautiously with consideration of unintended nutritional deficiencies‡ 
 • Consider how restrictive diets increases risk of sarcopenia and malnutrition among ambulatory individuals‡ 
Insulin 
 • Postprandial rapid-acting insulin with dose adjustment for the meal eaten to benefit those with variable food intake‡ 
 • Rapid-acting insulin postmeals to match postprandial BG and insulin peaks in stages 4 and 5 CKD and delayed gastric emptying‡ 
 • Avoid sliding-scale regular insulin to prevent hypoglycemia and unstable BG‡ 
 • Holding insulin due to poor appetite may cause hyperglycemia and DKA (especially in LTC and hospitals and during care transitions)‡ 
Nutrient intake, physical activity 
 • Inconsistent benefits of supplementation with protein, branched chain amino acids, and creatine‡ 
 • Daily protein intake 1.0 –1.2 g/kg if patient is healthy, 1.2–1.5 g/kg with acute or chronic diseases‡ 
 • Protein intake >1.5 g/kg/day in cachexia or sarcopenia‡ 
 • Energy- and protein-dense nutrition may not improve food consumption, decrease malnutrition or, increase weight loss‡ 
 • MNT to promote diabetes-specific health‡ 
 • Consider the negative impact of alcohol for those with impaired metabolism (especially due to medications) or at high risk of adverse events‡ 
 • Adequate fluid intake to prevent constipation and fecal impaction‡ 
 • Sodium consumption <2,300 mg/day with consideration of taste, cost, and availability‡ 
 • Dietary patterns with high-quality nutrients (i.e., Mediterranean, DASH, plant-based) to improve weight and blood pressure, meet glycemic and lipid targets, and prevent complications‡ 
 • Vegetables, legumes, whole grains, and certain cereals to increase fiber intake from 25 to 35 g/day (for those without gastroparesis)‡ 
 • Nutrient-dense diet to avoid complications for ambulatory individuals‡ 
Glycemic and hypoglycemia management 
 • Balance stringency of glycemic targets with risks of hypoglycemia† 
 • Surveil glycemic responses to dietary changes (ambulatory and LTC settings)‡ 
 • Reduce simple sugar intake instead of undertaking restrictive diets when patient is at risk of malnutrition and when glycemic control has not been achieved with lifestyle modifications‡ 
Individualized treatment 
 • Individualized strategies for physical activity and nutritional therapy that include target nutrient intake (i.e., calcium and vitamin D)‡ 
 • Individualized nutrition plans with consideration of goals, skills, and preferences‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Insulin regimens with simplifications (i.e., replace CHO and calorie counting with fixed mealtime dosing or replace insulin pump with injections) in cognitive decline† 
 • Meal planning approach emphasizing portion sizes and choosing healthy foods for those with impaired cognition and learning‡ 
 • Consider challenges to adequate nutrition: finances, grocery shopping, meal preparation, changes in taste and smell, changes in dentition and swallowing, gastrointestinal condition, anorexia, cognitive impairment, depression‡ 
 • 25-hydroxyvitamin D supplementation and monitoring, nutritional therapy, and exercise to improve sarcopenia‡ 
 • Protein- and energy-dense diets to address inadequate nutrition and/or weight loss in frailty‡ 
Education and community resources 
 • Education on meal planning and CHO counting to improve glycemic control and simplify insulin dosing for those with active lifestyles‡ 
 • Education on diabetes treatment for nursing and house staff‡ 
Screening and assessment tools 
 • Mini Nutritional Assessment and Short Nutritional Assessment Questionnaire to assess nutrition status and identify malnutrition (32,42)‡ 
LTC, hospitals, end-of-life care 
 • Regular, individualized diets to increase quality of life and nutrition status in LTC‡ 
 • Caloric intake and insulin coverage discordance may cause glycemic variability in hospitalized patients‡ 
 • Insulin in institutional settings† 
 • Nutritionally balanced meals rather than fluids with high sugar content (i.e., fruit juice, shakes, or supplements) to prevent glycemic spikes (LTC and hospital residents)‡ 
 • Consider challenges to food intake: decreased appetite, swallowing difficulties, trouble keeping food down; hydration actively managed in LTC‡ 
 • Safety protocols to avoid hypoglycemia if feeding of patients on enteral or parenteral nutrition is abruptly stopped‡ 
 • Avoid glycemic targets below regular “postprandial” state values (140–180 mg/dL, 7.77–10.00 mmol/L) for those on continuous enteral or parenteral nutrition to prevent dangerous consequences‡ 
IAGG, EDWPOP, and International Task Force of Experts in Diabetes, position statement, Diabetes Mellitus in Older People, 2012 (10)
Weight, malnutrition, restrictive diets 
 • Nonrestrictive diets in patients age >70 years and/or in a state of undernutrition‡ 
Insulin 
 • Basal insulin regimens rather than basal/bolus or premixed regimens may decrease risk of hypoglycemia‡ 
Nutrient intake, physical activity 
 • Physical activity programs involving balance exercises, resistance training, and cardiovascular fitness training‡ 
Glycemic and hypoglycemia management 
 • Consider impact of malnourishment on risk of hypoglycemia‡ 
Individualized treatment 
 • Care policies to frequently review and individualize treatment plans in LTC‡ 
Education and community resources 
 • Visit education with individualized materials for patients and caretakers with consideration of cognitive and physical status, self-management of medications and insulin therapy, metabolic targets, standardized strategies to decrease risk of hypoglycemia, “sick-day rules,” and nutrition‡ 
 • Local education programs accessible through increased communication, means of transportation, wheelchair-compatible options‡ 
 • Diabetes education course for LTC facility staff‡ 
Screening and assessment tools 
 • Nutritional screening assessment tools used regularly due to variable nutritional impairment that may interact with other comorbidities‡ 
LTC, hospitals, end-of-life care 
 • Hypoglycemia prevention in LTC to avoid metabolic complications, infection, and hospitalization‡ 
 • End-of-life care and advance care directives in LTC‡ 
IAGG, EDWPOP, and International Task Force of Experts in Diabetes, position statement, Diabetes Mellitus in Older People, 2012 (10)
Weight, malnutrition, restrictive diets 
 • Nonrestrictive diets in patients age >70 years and/or in a state of undernutrition‡ 
Insulin 
 • Basal insulin regimens rather than basal/bolus or premixed regimens may decrease risk of hypoglycemia‡ 
Nutrient intake, physical activity 
 • Physical activity programs involving balance exercises, resistance training, and cardiovascular fitness training‡ 
Glycemic and hypoglycemia management 
 • Consider impact of malnourishment on risk of hypoglycemia‡ 
Individualized treatment 
 • Care policies to frequently review and individualize treatment plans in LTC‡ 
Education and community resources 
 • Visit education with individualized materials for patients and caretakers with consideration of cognitive and physical status, self-management of medications and insulin therapy, metabolic targets, standardized strategies to decrease risk of hypoglycemia, “sick-day rules,” and nutrition‡ 
 • Local education programs accessible through increased communication, means of transportation, wheelchair-compatible options‡ 
 • Diabetes education course for LTC facility staff‡ 
Screening and assessment tools 
 • Nutritional screening assessment tools used regularly due to variable nutritional impairment that may interact with other comorbidities‡ 
LTC, hospitals, end-of-life care 
 • Hypoglycemia prevention in LTC to avoid metabolic complications, infection, and hospitalization‡ 
 • End-of-life care and advance care directives in LTC‡ 
Diabetes Canada, clinical practice guidelines, Diabetes in Older People, 2018 (11)
Weight, malnutrition, restrictive diets 
 • Intensive self-management behaviors, calorie reduction, and increased physical activity may reduce weight and improve glycemic and cardiometabolic markers‡ 
 • Premixed insulin analogs administered after meals as opposed to basal insulins may cause greater weight gain‡ 
Insulin 
 • Individualize insulin regimens to prioritize patient safety‡ 
Nutrient intake, physical activity 
 • Supplement with amino acids to possibly increase glycemic control and insulin sensitivity‡ 
 • Aerobic exercise has inconsistent effects on metabolism‡ 
 • Resistance training to improve glycemic control, strength, mobility, and body composition‡ 
Glycemic and hypoglycemia management 
 • CSII therapy among functional individuals age <75 years to improve glycemic control and reduce hypoglycemia† 
 • Premixed insulin analogs postmeal can lead to longer-lasting control than basal insulins alone but with increased risk of hypoglycemia‡ 
 • Aging is a risk factor for severe hypoglycemia‡ 
Individualized treatment 
 • Customized diabetes treatment and care plan‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Avoid intensive glycemic control (patients with multiple comorbidities, frailty, and/or memory loss)‡ 
 • Cognitive dysfunction increases risk of severe hypoglycemia‡ 
Education and community resources 
 • Nutrition education to improve metabolic control among ambulatory individuals‡ 
 • Self-management education and support programs involving geriatric teams, strategies to improve glycemic control and self-care behaviors between clinic visits‡ 
Screening and assessment tools 
 • Cognitive assessments like the clock drawing test to predict difficulties with insulin therapy (43,44)‡ 
LTC, hospitals, end-of-life care 
 • Protocols specific to T1D management in LTC† 
 • Variable approaches to insulin therapy and treatment strategies in LTC‡ 
 • Regular diets and related formulas in LTC‡ 
 • Regular insulin substituted with lispro at meals in LTC to improve glycemic control and risk of hypoglycemia‡ 
Diabetes Canada, clinical practice guidelines, Diabetes in Older People, 2018 (11)
Weight, malnutrition, restrictive diets 
 • Intensive self-management behaviors, calorie reduction, and increased physical activity may reduce weight and improve glycemic and cardiometabolic markers‡ 
 • Premixed insulin analogs administered after meals as opposed to basal insulins may cause greater weight gain‡ 
Insulin 
 • Individualize insulin regimens to prioritize patient safety‡ 
Nutrient intake, physical activity 
 • Supplement with amino acids to possibly increase glycemic control and insulin sensitivity‡ 
 • Aerobic exercise has inconsistent effects on metabolism‡ 
 • Resistance training to improve glycemic control, strength, mobility, and body composition‡ 
Glycemic and hypoglycemia management 
 • CSII therapy among functional individuals age <75 years to improve glycemic control and reduce hypoglycemia† 
 • Premixed insulin analogs postmeal can lead to longer-lasting control than basal insulins alone but with increased risk of hypoglycemia‡ 
 • Aging is a risk factor for severe hypoglycemia‡ 
Individualized treatment 
 • Customized diabetes treatment and care plan‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Avoid intensive glycemic control (patients with multiple comorbidities, frailty, and/or memory loss)‡ 
 • Cognitive dysfunction increases risk of severe hypoglycemia‡ 
Education and community resources 
 • Nutrition education to improve metabolic control among ambulatory individuals‡ 
 • Self-management education and support programs involving geriatric teams, strategies to improve glycemic control and self-care behaviors between clinic visits‡ 
Screening and assessment tools 
 • Cognitive assessments like the clock drawing test to predict difficulties with insulin therapy (43,44)‡ 
LTC, hospitals, end-of-life care 
 • Protocols specific to T1D management in LTC† 
 • Variable approaches to insulin therapy and treatment strategies in LTC‡ 
 • Regular diets and related formulas in LTC‡ 
 • Regular insulin substituted with lispro at meals in LTC to improve glycemic control and risk of hypoglycemia‡ 
Joslin Guideline for the Care of the Older Adult With Diabetes, 2018 (12)
Weight, malnutrition, restrictive diets 
 • Avoid restrictive diets in chronic care settings. Consistent, moderate CHO intake may prevent undernutrition instead‡ 
 • Meals that are enjoyed, altered medications as needed to prevent unintentional weight loss‡ 
 • Prescribe weight loss–promoting diets with caution to prevent malnutrition‡ 
 • Routine weight measurements to monitor weight loss after acute illness, hospitalization, or other stressors‡ 
Insulin 
 • Assess individual ability to use injectable insulins frequently‡ 
 • Frequent self-management skill reassessment (i.e., treating hypoglycemia and regular meal timing) prior to determination of insulin program‡ 
 • Dietitian assessment of prandial insulin dose timing based on CHO intake‡ 
Nutrient intake, physical activity 
 • Consistent meal timing, CHO/starch at each meal, >1,500 mg/day calcium, >800 units/day vitamin D, and snacking between meals, before physical activity, and at bedtime‡ 
 • Dietitian support for nutritional needs, simplified meal planning, caretaker engagement to create a health-promoting environment, food budgeting, buying and preparing healthy meals, making only necessary dietary changes (i.e., reduce potassium, sodium, and dietary fats when treating coexisting illness)‡ 
Glycemic and hypoglycemia management 
 • Premixed insulins at fixed mealtimes decrease risk of hypoglycemia but may increase risk of nocturnal hypoglycemia at evening meals‡ 
 • Strategies to avoid hypoglycemia: consistent meal timing; CHO/starch at each meal; keeping glucose tablets, gel, or hard candy always nearby; and checking BG anytime something feels off‡ 
Individualized treatment 
 • Individualized assessment to determine preferred treatment goals and plans considering age vs. health status, disease duration and onset, comorbidity, life expectancy, social support, financial status‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Simplified treatment plans and reminders (alarms, notes, pillboxes) to take medications or eat to manage cognitive dysfunction. Avoid tight glucose control and medications that increase risk of hypoglycemia‡ 
 • Consider nutrition impacts of age-related challenges: lower motivation, grocery shopping, meal preparation, skipping meals, cognitive dysfunction, depression, dental impairment, changes in taste, gastrointestinal changes, malnutrition and weight loss, comorbidities, finances‡ 
 • Walk for 5 min before meals, inside, and 1–3 times/day (inactive/frail patients)‡ 
Education and community resources 
 • Education and reeducation on hypoglycemia recognition and treatment for those with cognitive dysfunction and caregivers‡ 
 • Dietitians connect individuals with community resources (i.e., senior centers, food pantries, Meals on Wheels)‡ 
Screening and assessment tools 
 • DETERMINE Your Nutritional Health Nutrition Screening Initiative and other tools to assess malnutrition and weight loss and modify treatment as needed (45–47)‡ 
 • Based on screening results, encourage (as needed) nonrestrictive diets, adequate caloric intake, adequate hydration, adequate protein intake, supplements, dental visits, food pantry, senior centers, community programs‡ 
 • Clock drawing test, Mini-Cog test, MoCA test, and other tests to screen for cognitive dysfunction (41,48–50)‡ 
Joslin Guideline for the Care of the Older Adult With Diabetes, 2018 (12)
Weight, malnutrition, restrictive diets 
 • Avoid restrictive diets in chronic care settings. Consistent, moderate CHO intake may prevent undernutrition instead‡ 
 • Meals that are enjoyed, altered medications as needed to prevent unintentional weight loss‡ 
 • Prescribe weight loss–promoting diets with caution to prevent malnutrition‡ 
 • Routine weight measurements to monitor weight loss after acute illness, hospitalization, or other stressors‡ 
Insulin 
 • Assess individual ability to use injectable insulins frequently‡ 
 • Frequent self-management skill reassessment (i.e., treating hypoglycemia and regular meal timing) prior to determination of insulin program‡ 
 • Dietitian assessment of prandial insulin dose timing based on CHO intake‡ 
Nutrient intake, physical activity 
 • Consistent meal timing, CHO/starch at each meal, >1,500 mg/day calcium, >800 units/day vitamin D, and snacking between meals, before physical activity, and at bedtime‡ 
 • Dietitian support for nutritional needs, simplified meal planning, caretaker engagement to create a health-promoting environment, food budgeting, buying and preparing healthy meals, making only necessary dietary changes (i.e., reduce potassium, sodium, and dietary fats when treating coexisting illness)‡ 
Glycemic and hypoglycemia management 
 • Premixed insulins at fixed mealtimes decrease risk of hypoglycemia but may increase risk of nocturnal hypoglycemia at evening meals‡ 
 • Strategies to avoid hypoglycemia: consistent meal timing; CHO/starch at each meal; keeping glucose tablets, gel, or hard candy always nearby; and checking BG anytime something feels off‡ 
Individualized treatment 
 • Individualized assessment to determine preferred treatment goals and plans considering age vs. health status, disease duration and onset, comorbidity, life expectancy, social support, financial status‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Simplified treatment plans and reminders (alarms, notes, pillboxes) to take medications or eat to manage cognitive dysfunction. Avoid tight glucose control and medications that increase risk of hypoglycemia‡ 
 • Consider nutrition impacts of age-related challenges: lower motivation, grocery shopping, meal preparation, skipping meals, cognitive dysfunction, depression, dental impairment, changes in taste, gastrointestinal changes, malnutrition and weight loss, comorbidities, finances‡ 
 • Walk for 5 min before meals, inside, and 1–3 times/day (inactive/frail patients)‡ 
Education and community resources 
 • Education and reeducation on hypoglycemia recognition and treatment for those with cognitive dysfunction and caregivers‡ 
 • Dietitians connect individuals with community resources (i.e., senior centers, food pantries, Meals on Wheels)‡ 
Screening and assessment tools 
 • DETERMINE Your Nutritional Health Nutrition Screening Initiative and other tools to assess malnutrition and weight loss and modify treatment as needed (45–47)‡ 
 • Based on screening results, encourage (as needed) nonrestrictive diets, adequate caloric intake, adequate hydration, adequate protein intake, supplements, dental visits, food pantry, senior centers, community programs‡ 
 • Clock drawing test, Mini-Cog test, MoCA test, and other tests to screen for cognitive dysfunction (41,48–50)‡ 
IDF-DAR, Diabetes and Ramadan: Practical Guidelines 2021 (13)
Insulin 
 • Evidence-based recommendations on insulin regimens are difficult to make due to limited studies† 
 • Premixed insulin regimens accompanied by rigid nutrition lack flexibility needed for fasting† 
Nutrient intake, physical activity 
 • Reduced but continued physical activity while fasting‡ 
 • Holistic physical activities with consideration of nutrient intake; plan prior to Ramadan‡ 
 • Potential complications and outcomes of fasting evaluated prior to Ramadan‡ 
 • Hydration and adequate nutrient intake after Ramadan‡ 
Glycemic and hypoglycemia management 
 • Medication and dose alterations prior to Ramadan to lower risk of hypoglycemia‡ 
 • Self-monitor BG and CGM more frequently during Ramadan‡ 
 • Active efforts to increase hypoglycemia and hyperglycemia unawareness‡ 
Individualized treatment 
 • Individualized alterations to insulin regimen prior to Ramadan† 
 • Individualized nutrition plans for fasting with consideration of one’s degree of independence‡ 
 • Create with providers before Ramadan‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Fasting reconsidered for those with comorbidities, frailty, and impaired cognition‡ 
Education and community resources 
 • Support systems and community resources (friends, family, caretakers, etc.)‡ 
 • Fasting reconsidered for those age >70 years with no home support‡ 
IDF-DAR, Diabetes and Ramadan: Practical Guidelines 2021 (13)
Insulin 
 • Evidence-based recommendations on insulin regimens are difficult to make due to limited studies† 
 • Premixed insulin regimens accompanied by rigid nutrition lack flexibility needed for fasting† 
Nutrient intake, physical activity 
 • Reduced but continued physical activity while fasting‡ 
 • Holistic physical activities with consideration of nutrient intake; plan prior to Ramadan‡ 
 • Potential complications and outcomes of fasting evaluated prior to Ramadan‡ 
 • Hydration and adequate nutrient intake after Ramadan‡ 
Glycemic and hypoglycemia management 
 • Medication and dose alterations prior to Ramadan to lower risk of hypoglycemia‡ 
 • Self-monitor BG and CGM more frequently during Ramadan‡ 
 • Active efforts to increase hypoglycemia and hyperglycemia unawareness‡ 
Individualized treatment 
 • Individualized alterations to insulin regimen prior to Ramadan† 
 • Individualized nutrition plans for fasting with consideration of one’s degree of independence‡ 
 • Create with providers before Ramadan‡ 
Cognitive capacity, age-related changes and comorbidities 
 • Fasting reconsidered for those with comorbidities, frailty, and impaired cognition‡ 
Education and community resources 
 • Support systems and community resources (friends, family, caretakers, etc.)‡ 
 • Fasting reconsidered for those age >70 years with no home support‡ 

BG, blood glucose; CGM, continuous glucose monitoring; CHO, carbohydrate; CKD, chronic kidney disease; CSII, continuous subcutaneous insulin infusion; CVD, cardiovascular disease; DKA, diabetic ketoacidosis; EDWPOP, European Diabetes Working Party for Older People; IAGG, International Association of Gerontology and Geriatrics; MNA, Mini Nutritional Assessment; MoCA, Montreal Cognitive Assessment; MUST, Malnutrition Universal Screening Tool; T1D, type 1 diabetes; T2D, type 2 diabetes.

*

For the Diabetes UK clinical guidelines, here we include a summary of relevant general recommendations. Refer to the full guidelines for specific recommendations by category.

†

Recommendation is type 1 diabetes specific.

‡

Recommendation is generalized toward older adults with diabetes.

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Experimental Studies

The six experimental studies included four randomized controlled trials (RCTs) (range of n across trials = 47–138, age range of included participants across trials: 18–78 years, study duration across trials: 5 days–24 months) (14,16–18), one single-arm study (n = 10, mean age 60.4 (SD: 11.3 years), duration: up to four clinical visits across unspecified length of time), (15) and one crossover trial (n = 10, age range 18–75 years, duration: four clinical visits spread across unspecified length of time) (19). In these studies investigators examined effects of eating strategies (low-protein diet vs. usual diet [16]; improved diet quality vs. usual [17]; low-fat, low-protein meal vs. high-fat, high-protein meal [15]; combined glucose-fructose-xylitol vs. glucose total parenteral nutrition [18]; dietitian plus endocrinologist follow-up vs. endocrinologist follow-up [14]) on clinical parameters (glomerular filtration rate [16], carotid intima-media thickness [17], glucose incremental area under the curve [15], plasma blood glucose and insulin requirements [18], HbA1c [14]). Three of the randomized controlled studies also characterized participants’ usual nutrient intakes (14,16,17).

Observational Studies

The five observational studies included four cross-sectional analyses (range of n across studies = 57–308, with the mean ages across studies ranging from 63.5 [SD: 8.1] to 68 [SD: 14.8] years) (20–22,24) and one post hoc analysis of a clinical trial (n = 118, age range of included participants: 18–75 years, study duration 24 months) (23). In the majority of studies (n = 4) investigators sought to characterize behaviors (i.e., nutrient and food group intakes, diabetes treatment and self-management behaviors) and psychosocial factors (i.e., diabetes-related quality of life, health-related quality of life) related to nutrition (20,22–24). In two studies nutrition-related (i.e., eating) strategies were evaluated: Roem et al. (19) assessed carbohydrate counting accuracy among participants in the OldeR Adult Closed-Loop (ORACL) trial, and Petersen et al. (23) conducted a post hoc analysis of the differences in nutrient intake and pulse wave velocity between intervention and control groups 1 year after their 120-month RCT where they sought to increase fruit, vegetable, and dairy consumption.

Reviews and Meta-analyses

For the included 2019 scoping review of best practice guidelines for the dietary management of diabetes in older adults in residential aged care, investigators presented a review of 11 previously published guidelines using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool (25). Key findings related to dietary recommendations were summarized, including those on healthy eating, fiber and glycemic index, low-fat versus full-fat diet, added sugar, and weight management. While physician-developed guidelines were generally the most robust, there were some differences compared with dietitian-developed guidelines, especially regarding therapeutic diet use. There was little mention of type 1 diabetes in older adults. It was concluded that the lack of standardized guidelines may impact dietary management among this population. Limitations of the review include that the primary literature was reviewed by one author and that search results were limited to works published in English and research from countries with smaller health systems.

Clinical Consensus and Care Guidelines

Among the 10 clinical care guidelines and consensus publications in Table 3, 7 included guidance relevant to older adults with diabetes (1,3,6,9–12), 2 included guidance relevant to diabetes (13,26), and 1 included guidance relevant to older adults with type 1 diabetes (8). Broadly, the majority of clinical guideline and consensus papers discussed modified dietary and treatment strategies, including regarding nutrient intake and dietary considerations (n = 9) (1,3,6,8,9,11–13,26); glycemic and/or hypoglycemia management (n = 9) (1,3,6,8–13); cognitive capacity and/or age-related comorbidities (n = 9) (1,3,6,8,9,11–13,26); individualization of treatment plans (n = 9) (1,3,6,8–13); physical activity (n = 8) (1,3,6,8–11,13,26); insulin (n = 8) (1,3,6,8,10–13); malnutrition, restrictive dieting, and/or weight loss/gain (n = 8) (1,3,7–12); and education and counseling (n = 8) (1,3,6,8–12). Screening/assessment tools (n = 7) (3,6,8–12) and community resources (n = 5) (3,8,10,12,13) were also commonly discussed to promote optimal nutrition in older adults with diabetes. Additionally, specific recommendations were made for older adults with diabetes in long-term care (LTC) (n = 5) (1,3,6,10,11), hospitalized or receiving end-of-life care (n = 5) (1,6,8,9,12), or experiencing frailty and/or sarcopenia (n = 7) (1,3,6,9,11–13). Apart from the type 1 diabetes–specific guidelines (8), only five guidelines included guidance relevant to nutrition in the context of type 1 diabetes, which was predominantly focused on insulin therapy modifications for various conditions (e.g., functional and cognitive impairment) and settings (e.g., LTC, end-of-life care) as well as methods to improve glycemic control (1,6,8,11,13).

We conducted a rigorous review of the literature and found few experimental or observational studies explicitly focused on nutrition or diet in adults ≥65 years of age with type 1 diabetes. Further, recent clinical guidelines and consensus papers contained recommendations lacking specificity for nutrition-related guidance in this population.

A key strength of studies yielded by our search was the formulation of study samples with inclusion criteria across a range of comorbidities, which is fundamental to building an evidence base that is representative of the population of older adults with diabetes, many of whom have long duration of disease, as well as multiple diabetes-related and age-related comorbidities. Additionally, the studies that aimed to characterize nutrient intake used one or more dietary assessment instruments with evidence of validity.

Characteristics of existing studies that hamper the ability to draw insights from the experimental and observational evidence base include combination of adults ≥65 years of age with adults ≥18 years of age, combination of individuals with type 1 diabetes and type 2 diabetes, and combination of individuals with diverse durations of diabetes, despite well-recognized differences in physiological, behavioral, and psychosocial factors by these characteristics (1). Additional limitations that preclude drawing inferences from the extant evidence about the nutrition of older adults with type 1 diabetes and the strategies that may promote well-being through nutrition in this population include infrequent assessment of intervention adherence or use of self-report tools to assess intervention adherence, small sample sizes, clinic-based samples, limited racial/ethnic diversity, and power calculations that were either unreported or not conducted. Comparing findings across existing studies is also challenging due to variability in sample characteristics (e.g., comorbidities, diabetes duration, age).

Similarly, many recommendations in existing clinical guidelines and consensus papers predominantly draw on studies focused on type 2 diabetes and reference comparatively older primary literature. As a result, the applicability and relevance of these recommendations for contemporary older adults with type 1 diabetes remain unclear. Importantly, original research, clinical guidelines, and consensus papers may not generalize to lower-resource settings or non-Western countries (apart from IDF-DAR guidelines, focused on Ramadan) due to a lack of research conducted to date in those settings and limited inclusion of authors from those settings in guidelines or consensus papers.

Because the evidence demonstrates that medical nutrition therapy (MNT) measurably improves outcomes in adults with type 1 diabetes, the Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults states that it is imperative that all adults with type 1 diabetes be referred to a registered dietitian (RD) for MNT and individualization of the eating plan (27). However, apart from the Diabetes UK guidelines, there are no evidence-based clinical care guidelines specific to nutrition and older adults with type 1 diabetes, even though older adults have unique and multidimensional nutritional needs that often require adaptation of standard MNT care practices (27) (Table 4). Clinicians working with older adults have an understanding of these specific nutritional needs and challenges of older adults, yet the absence of specific clinical care guidelines requires the clinician to individually adapt dietary recommendations and behavioral approaches to improve clinical outcomes rather than follow evidence-based practices.

Table 4

Adaptations to standard nutrition guidelines for older adults with type 1 diabetes based on physiological and socioenvironmental considerations

Nutrition-related adaptationsPhysiological considerationsSocioenvironmental considerations
Optimizing macronutrient intakes, especially protein recommendations, considering the need to balance glycemic control, preservation of lean muscle mass, and weight management; older adults have an increased need for protein, especially in the setting of malnutrition, frailty, or sarcopenia (51). Adapting menus for changes in dentition and swallowing, reducing ability and desire to consume staples of a balanced diet (such as lean protein, whole grains, vegetables, nuts, and seeds). Problem-solving for lack of control over meals when living in retirement community or independent/assisted-living home that provides meals or when cohabitating with family members who provide meals but will not adapt menus to fit nutritional needs. 
Adapting macronutrient recommendations due to the increasing burden of comorbidities, such as hypertension, dyslipidemia, cancer, kidney disease, and overweight/obesity. Problem-solving and planning for reduced ability to prepare/cook foods (which increases reliance on prepared foods, often high in simple carbohydrates and low in fiber) related to 1) mobility and dexterity changes, 2) neuropathy, and 3) retinopathy. Planning for changes in access to food related to loss of transportation, financial struggles, or changing living situation (such as losing access to cooking appliances in circumstances of memory care or transitioning to living alone after the loss of a partner). 
Shifting insulin-dosing recommendations in the setting of reduced caloric needs and changed dietary patterns as a result of aging. Shifting meal timing and insulin dosing to adapt to increasing polypharmacy and challenging medication requirements, such as those regarding timing of meals before/during/after dose. Problem-solving for reduced ability to access and afford medications and insulin related to loss of transportation or financial struggles. 
Planning dietary interventions to overcome poorer digestion and absorption of macro- and micronutrients, which can lead to deficiencies impacting glucose and muscle metabolism. Adapting meal plans and food choices to maintain nutritional adequacy to cope with GI complications such as gastroparesis.  
Nutrition-related adaptationsPhysiological considerationsSocioenvironmental considerations
Optimizing macronutrient intakes, especially protein recommendations, considering the need to balance glycemic control, preservation of lean muscle mass, and weight management; older adults have an increased need for protein, especially in the setting of malnutrition, frailty, or sarcopenia (51). Adapting menus for changes in dentition and swallowing, reducing ability and desire to consume staples of a balanced diet (such as lean protein, whole grains, vegetables, nuts, and seeds). Problem-solving for lack of control over meals when living in retirement community or independent/assisted-living home that provides meals or when cohabitating with family members who provide meals but will not adapt menus to fit nutritional needs. 
Adapting macronutrient recommendations due to the increasing burden of comorbidities, such as hypertension, dyslipidemia, cancer, kidney disease, and overweight/obesity. Problem-solving and planning for reduced ability to prepare/cook foods (which increases reliance on prepared foods, often high in simple carbohydrates and low in fiber) related to 1) mobility and dexterity changes, 2) neuropathy, and 3) retinopathy. Planning for changes in access to food related to loss of transportation, financial struggles, or changing living situation (such as losing access to cooking appliances in circumstances of memory care or transitioning to living alone after the loss of a partner). 
Shifting insulin-dosing recommendations in the setting of reduced caloric needs and changed dietary patterns as a result of aging. Shifting meal timing and insulin dosing to adapt to increasing polypharmacy and challenging medication requirements, such as those regarding timing of meals before/during/after dose. Problem-solving for reduced ability to access and afford medications and insulin related to loss of transportation or financial struggles. 
Planning dietary interventions to overcome poorer digestion and absorption of macro- and micronutrients, which can lead to deficiencies impacting glucose and muscle metabolism. Adapting meal plans and food choices to maintain nutritional adequacy to cope with GI complications such as gastroparesis.  

GI, gastrointestinal.

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Looking Ahead

Although our review demonstrates limited evidence to guide nutrition recommendations and strategies in this emerging patient population of older adults with type 1 diabetes, these results offer guidance about the research that should be prioritized in efforts to fill the identified gaps (Fig. 2).

Figure 2
Challenges for nutrition research in older adults with type 1 diabetes, next steps for evidence generation, and considerations for clinical nutrition guidelines.
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Challenges for nutrition research in older adults with type 1 diabetes, next steps for evidence generation, and considerations for clinical nutrition guidelines.

Figure 2
Challenges for nutrition research in older adults with type 1 diabetes, next steps for evidence generation, and considerations for clinical nutrition guidelines.
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Challenges for nutrition research in older adults with type 1 diabetes, next steps for evidence generation, and considerations for clinical nutrition guidelines.

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Challenges of Nutrition Research for Older Adults With Type 1 Diabetes

Nutrition is central to type 1 diabetes management, and as individuals with type 1 diabetes age, so too must their diabetes management strategies and nutritional practices evolve. For example, formulation of older adults’ diabetes regimens must include consideration of changes to lifestyle and living arrangements, functional status or frailty, cognition, geriatric syndromes, multimorbidity (e.g., obesity and sarcopenia), evolving attitudes surrounding aging and self-care, and changes in individual preferences and values (2,28). People with type 1 diabetes experience these changes in different combinations and in different sequences throughout older adulthood (29). Moreover, although many older adults may have been diagnosed at a younger age, age of diagnosis varies widely (30). As a result, the population of individuals with type 1 diabetes who are growing older vary in their experiences and needs as they learn to manage their condition alongside the physiologic and psychosocial changes related to aging (29). It is therefore important for these individuals to be supported with evidence-based strategies in an ongoing fashion, especially because the approaches to diabetes self-care on which they rely may be rendered less effective or relevant by the significant physiological and psychosocial changes that define older adulthood (2,3).

Because of marked changes in physiological, behavioral, and social factors that occur at multiple points throughout older adulthood, ongoing assessment of the factors that drive nutritional status and eating behavior is foundational to achieving the vision of effectively and continuously matching older adults with strategies that support their well-being across this life stage. Research to develop valid assessment measures or to establish validity of existing measures among subgroups of older adults is needed. Such research efforts will ensure the validity of experimental studies where these measures are used to assess intervention outcomes, which in turn promotes translation of effective interventions into clinical guidelines and practice.

Next Step for Evidence Generation and Clinical Nutrition Guideline Development

A foundational step in the development of health-promoting eating strategies for older adults with type 1 diabetes is research that enables accurate understanding of existing nutritional status and its drivers in this population, which requires population-based samples that represent the wide range of comorbidities and social circumstances experienced by older adults with type 1 diabetes. Qualitative research is well positioned to help researchers leverage the “lived expertise” of older adults with type 1 diabetes and incorporate into intervention development research the best practices of navigating eating and diabetes management of older adults incurred through decades of experience (29). Study samples should be curated to ensure strategies are tested and developed to promote well-being across the diverse subgroups within the broader population of older adults with type 1 diabetes. Incorporating implementation metrics (i.e., process evaluation) into efficacy and effectiveness trials will promote replication and help increase the efficiency with which researchers identify health-promoting and feasible eating strategies for this population (31). In the future, evidence-based nutrition guidelines may offer new tools to address the evolving health-related needs of older adults with type 1 diabetes and optimize their well-being through diet and diabetes-related eating practices.

This article contains supplementary material online at https://doi.org/10.2337/figshare.25371583.

Funding. Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award no. P30DK056350. A.R.K. is supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant K12TR004416. A.R.K. also reports receiving research grants from Diabetes Research Connection and the ADA, and a prize from the National Academy of Medicine, outside the submitted work.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

Author Contributions. A.C.S., G.E., and A.R.K. determined search criteria and designed search extraction tables. G.E. extracted the articles after search calibration with A.C.S., R.M., and A.R.K. A.C.S. wrote the first draft of the manuscript. G.E., R.M., A.F., and A.R.K. contributed to discussion. All authors reviewed and edited the manuscript. All authors approved the final version of the manuscript.

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