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October 25, 2016
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When Type 2 Shouldn't Matter

Yesterday, the 90-year-old Mother-Out-Law was scheduled for a mammogram. FOR REALZ.

The 56-year-old caregiver didn't see the irony:  "Ninety-year-olds can get breast cancer, too." Yes, but can most 90-year-olds survive radiation and chemo? Particularly 90-year-olds with severe joint degradation, who are blind from macular degeneration, and can't see or feel well enough to feed themselves properly?

When the standards of care for a younger, mostly healthy person are applied to someone whose natural life expectancy is shorter than the life expectancy of someone whose chronic or lethal medical condition is untreated, the result is a waste of time, energy, and (sometimes) limited medical resources. In those cases, a different standard needs be applied. Which is undoubtedly one of the reasons behind a recent UpToDate recommendation of 8.0% A1c as the standard of treatment for the extreme elderly.

For those of you old enough to remember having to "eat to your insulin", one of the difficulties in controlling blood glucose levels in children and the elderly becomes readily apparent. Neither group will eat if not hungry, or if they find their food unappetizing. Instead of losing weight because their bodies don't produce (or properly use) enough insulin to process the food they eat, many elderly lose weight simply because they aren't consuming sufficient calories to support their bodies' functions.

I've read that part of this is related to the natural process of dying: the body does not need nutrition when it is shutting down, much as a car does not need a full tank of gas when it is being hauled away to the scrap heap. But unlike that car, the human body can take months, years, or even decades to come to the point of that final shut-down. Between now and then, it needs food.

Which brings me to the 92-year-old Father-Out-Law, who has been living with type 2 diabetes for the past decade or so. Between confusion and caring for his wife, and the institutional nature of Meals-on-Wheels, he has lost a whole lot of weight since the last time I saw him, three years ago. (The Other Half says he'd put on a significant amount of weight since late May.) Restricting calories, carbs, fats, and cholesterol to control glucose levels that will not get high enough to threaten DKA, that would not cause complications for a decade or two, is counterproductive to keeping him alive for the next day, week, month, or year.

As The Other Half and I considered family meals that could be eaten without silverware (to help the MOL get food from plate to mouth) and which the parents would find tasty and palatable, it was more important to feed them foods which were calorie-dense than to find meals that would keep our numbers within target for the few days we were down South. While a PWD on exogenous insulin, and/or in danger of DKA, would need to be treated with more care, when it comes to an "extremely elderly" person like the FOL, all calories are "good" calories, and his pill-controlled type 2 shouldn't matter.

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