Diabetes mellitus is a highly prevalent metabolic condition in ageing societies associated with high levels of morbidity, multiple therapies, and functional deterioration that challenges even the best of health care systems to deliver high-quality, individualized care. Most international clinical guidelines have ignored the often-unique issues of frailty, functional limitation, changes in mental health, and increasing dependency that characterize many aged patients with diabetes. A collaborative Expert Group of the IAGG and EDWPOP and an International Task Force have explored the key issues that affect diabetes in older people using a robust method comprising a Delphi process and an evidence-based review of the literature. Eight domains of interest were initially agreed and discussed: hypoglycemia, therapy, care home diabetes, influence of comorbidities, glucose targets, family/carer perspectives, diabetes education, and patient safety. A set of "consensus" statements was produced in each domain of interest. These form a foundation for future policy development in this area and should influence the clinical behavior and approach of all health professionals engaged in delivering diabetes care to older people.

The gastrointestinal effects of intraluminal fats may be critically dependent on the chain length of fatty acids released during lipolysis. We postulated that intraduodenal administration of lauric acid (12 carbon atoms; C12) would suppress appetite, modulate antropyloroduodenal pressure waves (PWs), and stimulate the release of cholecystokinin (CCK) and glucagon-like peptide-1 (GLP-1) more than an identical dose of decanoic acid (10 carbon atoms; C10). Eight healthy males (19-47 yr old) were studied on three occasions in a double-blind, randomized fashion. Appetite perceptions, antropyloroduodenal PWs, and plasma CCK and GLP-1 concentrations were measured during a 90-min intraduodenal infusion of 1) C12, 2) C10, or 3) control (rate: 2 ml/min, 0.375 kcal/min for C12/C10). Energy intake at a buffet meal, immediately after completion of the infusion, was also quantified. C12, but not C10, suppressed appetite perceptions (P < 0.001) and energy intake (control: 4,604 +/- 464 kJ, C10: 4,109 +/- 588 kJ, and C12: 1,747 +/- 632 kJ; P < 0.001, C12 vs. control/C10). C12, but not C10, also induced nausea (P < 0.001). C12 stimulated basal pyloric pressures and isolated pyloric PWs and suppressed antral and duodenal PWs compared with control (P < 0.05 for all). C10 transiently stimulated isolated pyloric PWs (P = 0.001) and had no effect on antral PWs but markedly stimulated duodenal PWs (P = 0.004). C12 and C10 increased plasma CCK (P < 0.001), but the effect of C12 was substantially greater (P = 0.001); C12 stimulated GLP-1 (P < 0.05), whereas C10 did not. In conclusion, there are major differences in the effects of intraduodenal C12 and C10, administered at 0.375 kcal/min, on appetite, energy intake, antropyloroduodenal PWs, and gut hormone release in humans.

Oral testosterone administration to older relatively hypogonadal men results in an increase in muscle mass and a decrease in body fat.

Objective: Visual analogue scales are widely used in appetite research, yet the validity of these scales to evaluate appetite and mood has not been assessed in older subjects. The aim of this study was to determine the relations between food intake and visual analogue scale (VAS) ratings of appetite and nonappetite sensations in healthy older and young subjects. Design: Retrospective combined analysis of four single-blind, randomised, controlled appetite studies. Setting: All studies were conducted in the University of Adelaide, Department of Medicine, Adelaide, Australia. Subjects: A total of 45 healthy young men (n ¼ 24) and women (n ¼ 21) aged 18-35 y and 45 healthy older men (n ¼ 24) and women (n ¼ 21) aged 65-85 y were recruited by advertisement. Interventions: Oral, intraduodenal or intravenous administration of treatments which suppressed food intake were compared to control. Up to 90 min after treatment, a test meal was offered and subjects ate freely for between 30 and 60 min. Perceptions were assessed by 100-mm visual analogue scales administered at regular intervals. Results: Food intake at the test meal was positively related to perceptions of hunger, drowsiness, and calmness at both baseline and premeal (r 40.16, Po0.05), and inversely related to premeal ratings of fullness (r4 0.2, Po0.05) in both older and young subjects. Food intake was related to VAS ratings at least as strongly, if not more so, in older as in young subjects. Conclusions: These observations (i) confirm that food intake is related to perceptions of hunger and fullness as assessed by VAS in healthy older and young subjects, and (ii) suggest that sensations, not obviously associated with appetite, including 'drowsiness' and 'calmness', are also associated with food intake.

The presence of nutrients in the small intestine slows gastric emptying and suppresses appetite and food intake; these effects are partly mediated by the release of gut hormones, including CCK. We investigated the hypothesis that the modulation of antropyloroduodenal motility, suppression of appetite, and stimulation of CCK and glucagon-like peptide-1 secretion by intraduodenal fat are dependent on triglyceride hydrolysis by lipase. Sixteen healthy, young, lean men were studied twice in double-blind, randomized, crossover fashion. Ratings for appetite-related sensations, antropyloroduodenal motility, and plasma CCK and glucagon-like peptide-1 concentrations were measured during a 120-min duodenal infusion of a triglyceride emulsion (2.8 kcal/min) on one day with, on the other day without, 120 mg tetrahydrolipstatin, a potent lipase inhibitor. Immediately after the duodenal fat infusion, food intake at a buffet lunch was quantified. Lipase inhibition with tetrahydrolipstatin was associated with reductions in tonic and phasic pyloric pressures, increased numbers of isolated antral and duodenal pressure waves, and stimulation of antropyloroduodenal pressure-wave sequences (all P < 0.05). Scores for prospective consumption and food intake at lunch were greater, and nausea scores were slightly less, and the rises in plasma CCK and glucagon-like peptide-1 were abolished (all P < 0.05). In conclusion, lipase inhibition attenuates the effects of duodenal fat on antropyloroduodenal motility, appetite, and CCK and glucagon-like peptide-1 secretion.

Background: Aging is associated with a decrease in appetite and a slowing of gastric emptying. The gastrointestinal hormones cholecystokinin (CCK), glucagon-like peptide 1 (GLP-1), and peptide YY (PYY) may mediate these changes. Objective: We investigated whether aging influenced the secretion of CCK, GLP-1, and PYY and their effects on appetite and pyloric motility. Design: Eight healthy older (65-80 y) and 7 younger (20-34 y) men received isoenergetic (12.1 kJ/min) intraduodenal infusions of lipid and glucose for 120 min on separate days. Plasma CCK, GLP-1, and PYY concentrations were measured. Results: Plasma CCK concentrations were higher in older than in younger subjects (P = 0.004) as a result of higher baseline values (4.7 ± 0.2 compared with 3.2 ± 0.2 pmol/L; P < 0.0001) and a greater rise during lipid infusion (increase from baseline: 7.1 ± 0.5 compared with 5.3 ± 0.6 pmol/L; P = 0.048). Plasma GLP-1 and PYY concentrations were not significantly different between groups. The decrease in hunger during intraduodenal lipid infusion was inversely related to the increase in CCK, GLP-1, and PYY in younger but not older subjects. During intraduodenal lipid infusion, the increase in isolated pyloric pressure wave (IPPW) frequency was positively related to GLP-1 and PYY and the increase in IPPW amplitude was positively related to CCK in older but not younger subjects, whereas the increase in IPPW amplitude and pyloric tone was negatively related to GLP-1 and PYY in younger subjects. Conclusions: Human aging is associated with increased CCK concentrations, which may contribute to the slowing of gastric emptying, mediated by increased pyloric motility. The role of increased plasma CCK concentrations in mediating the agerelated decrease in appetite remains to be established.Am J Clin Nutr 1999;69:999-1006. KEY WORDSCholecystokinin, CCK, glucagon-like peptide 1, GLP-1, peptide YY, PYY, appetite, pylorus, gastric emptying, small intestine, elderly, men, aging INTRODUCTIONAging is associated with a decrease in appetite and food intake (1, 2); additionally, body weight tends to decrease from 65 to 70 y of age (1). This anorexia of aging may predispose the elderly to pathologic weight loss and increased morbidity and mortality (3). The causes of the anorexia of aging are unknown but are likely to be multifactorial.Appetite is controlled by a central system that is responsible for the initiation of eating and that is held in check by a peripheral satiety system, which is activated by the presence of food in the gastrointestinal tract (3). An important mediator of gastrointestinal satiety signals is thought to be the release of gastrointestinal satiety hormones, including cholecystokinin (CCK) (4, 5), bombesin, glucagon, and glucagon-like peptide 1 (GLP-1) (6), induced by interaction of nutrients with receptors in the small intestine (4).Gastric emptying of nutrients is slightly slower in healthy elderly than in young adults (7,8) and there is evidence that this may contribute to increased satiation, perhaps by p...

Aims/hypothesis: Long-term trials in insulintreated subjects with type 2 diabetes have shown that adjunctive treatment with the amylin analogue pramlintide reduces HbA 1 c levels and elicits weight loss. While amylin reduces food intake in rodents, pramlintide's effect on satiety and food intake in humans has not yet been assessed. Methods: In this randomised, double-blind, placebo-controlled crossover study, 11 insulin-treated men with type 2 diabetes (age 60±9 years, BMI 28.9±4.8 kg/m 2 ) and 15 nondiabetic obese men (age 41±21 years, BMI 34.4±4.5 kg/m 2 ) underwent two standardised meal tests. After fasting overnight, subjects received single subcutaneous injections of either pramlintide (120 μg) or placebo, followed by a preload meal. After 1 h, subjects ate an ad libitum buffet meal. Energy intake and meal duration were measured, as were hunger ratings (using visual analogue scales), and plasma cholecystokinin, glucagon-like peptide-1 and peptide YY concentrations over time. Results: Compared with placebo, pramlintide reduced energy intake in both the type 2 diabetes (Δ−202±64 kcal, −23±8%, p<0.01) and obese (Δ−170±68 kcal, −16±6%, p<0.02) groups, without affecting meal duration. Hunger and hormonal analyte profiles provided evidence that pramlintide may exert a primary satiogenic effect, independently of other anorexigenic gut peptides. Conclusions/interpretation: The results indicate that enhanced satiety and reduced food intake may explain the weight loss observed in long-term pramlintide trials.

The MNA identified a large number of subjects with impaired nutrition who did significantly worse than well-nourished subjects during the following year. Studies are needed to determine whether nutritional or other interventions in people with low MNA scores can improve clinical outcomes.