Dynamics of Diabetes: Diabetes and cognitive decline.

This article will discuss the correlation between blood glucose levels and cognitive decline and what dietitians can do to help clients and patients preserve their cognitive health through lifestyle changes and nutrition intervention.

What Is Cognitive Decline? Impairments in cognitive function are common with advancing age and can range from mild cognitive impairment (MCI) to the more serious decline of dementia. Problems with memory, language, thinking, and judgment, beyond common age-related changes, are characterized as MCI. Cognitive decline is a precursor to dementia, a loss of mental capacity severe enough to interfere with a person's daily functioning. Alzheimer's disease and other neurological conditions can cause dementia, and diabetes is an independent risk factor for dementia.

Examining the Link It's well established in the literature that uncontrolled blood glucose in diabetes is a risk factor for microvascular diseases such as nephropathy and retinopathy. "We know that diabetes can cause damage to the small [blood] vessels in the body," says Elizabeth Selvin, PhD, MPH, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health. "High glucose levels cause damage to the small [blood] vessels, making the vessel walls weaker and less flexible. In the eye and kidney, holes can form, and the capillaries can leak."

In a study published in the December 2014 issue of the Annals of Internal Medicine, Selvin and colleagues examined the association between diabetes control in midlife with subsequent 20-year cognitive decline. For the study, researchers used data from the Atherosclerosis Risk in Communities Study (ARIC), which began following a group of 15,792 middle-aged adults in 1987. Participants were seen at four visits approximately three years apart beginning between 1987 and 1989, and were seen a fifth time between 2011 and 2013. Cognitive function was evaluated at visits two (1990 to 1992), four (1996 to 1998), and five.

The researchers compared the average amount of cognitive decline in the study participants with the amount of decline found in the ARIC participants. They determined there was a 19% increase in cognitive decline in subjects with poorly controlled diabetes. "The full underlying biology is still unclear, but this study adds to the growing evidence for a vascular basis for cognitive decline and dementia," Selvin says.

Impact of Cognitive Decline on Diabetes Self-Management Selvin and colleagues also found that diabetes appears to age the mind about five years faster than the normal effects of aging. For example, on average, a 60-year-old with diabetes will experience the same amount of cognitive decline as a healthy 65-year-old who's aging normally. Loss of memory, word recall, and executive function are strongly associated with progression to dementia.

These symptoms become problematic when people with diabetes try to take care of themselves, since diabetes self-management requires a moderately high level of cognitive function. Every day a patient with diabetes must make healthful food choices in the right amounts and at the right time, take medication as prescribed, monitor blood glucose levels, and solve problems. Older individuals with diabetes and cognitive decline may not be able to follow complicated treatment regimens requiring multiple daily insulin injections, multiple oral medications, or complex dietary regimens.5 In fact, people with low cognitive function are more likely to have difficulty and require assistance in performing these self-care tasks.

Counseling Patients While it's important to monitor the overall health of older patients with diabetes, dietitians should help middle-aged individuals with diabetes understand that blood sugar control during this stage of life may help protect against cognitive decline as they grow older.

Ruth Frechman, MA, RDN, CPT, owner of the nutrition consulting business On the Weigh in Burbank, California, and author of The Food Is My Friend Diet, suggests the following tips to help patients preserve cognition:

• Check blood levels of folate, vitamin B6, and vitamin B12 periodically. A study published in the January 2007 issue of the American Journal of Clinical Nutrition associated normal vitamin B12 and folate levels with protecting cognition. Long-term use of Metformin, a common diabetes drug, may cause a vitamin B12 and folate deficiency.

• Encourage more fatty fish intake and use of turmeric in cooking. Diabetes is an inflammatory condition, and eating anti-inflammatory foods, such as turmeric and fatty fish (eg, salmon, tuna, trout) may have positive effects on brain health.

• Manage the impact of vascular complications. Control blood sugar, keep blood cholesterol and blood pressure within normal limits, achieve a healthy weight by following a healthful diet, and encourage smoking cessation.

As the population ages and more elderly people live with diabetes, the importance of good blood glucose control can't be overemphasized. "[Moreover], if we can prevent diabetes and better control glucose in middle-aged people with diabetes, we may be able to prevent or delay cognitive decline in old age," Selvin says.

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