Due to the growing aging population, non-pharmacological interventions to prevent diabetes-related disability are critical if we want to reduce costly healthcare use and excess mortality. When reviewing existing preventive interventions, there are two things that need to be kept in mind.

First, only limited interventions have been developed to prevent disability among older adults with diabetes.^6-8 Several systematic reviews have shown that these interventions mostly focus on lifestyle interventions (physical activity and a healthy diet) and self-management interventions to promote metabolic control.^9-10 However, poor glycemic control is not necessarily associated with disability in older adults with diabetes.^1,3

Second, even though lifestyle interventions are widely acknowledged to promote muscle strength, physical function, and reduce premature disability in older adults,¹¹ little evidence supports the claim that lifestyle interventions may actually prevent disability. Keysor, Lorig, and Simonsick et al. all found that the benefits of physical activity in preventing disability are still poorly understood in late life.^4,11,12

This may be explained by three limitations in current lifestyle interventions. First, disability is less often chosen as a primary outcome in lifestyle interventions.⁵ Second, it is widely believed that managing physical activity, healthy diet, and medication can transfer and generalize to promote other daily activities and thereby prevent disability.⁹ However, we still need more evidence to confirm whether improved physical function actually prevents or delays disability in late life.

One may suggest that physical activity interventions can prevent mobility disability in late life. However, disability has been considered an umbrella concept that includes mobility disability (walking, climbing, or standing), ADL disability (eating and dressing), and IADL disability (shopping, driving, or preparing meals).^2,13-15 We therefore need to understand whether physical activity programs not only prevent mobility disability but also prevent ADL and IADL disability.

Third, some lifestyle interventions have successfully engaged older adults in exercise and healthy diets. But supporting continued engagement in physical activity and healthy diets is critical if we want to prevent disability in the long term.

After discussing the current gaps in interventions for preventing disability among older adults with diabetes, one may ask: what are the next steps for future research? In fact, there are three steps to consider when thinking about preventing disability in older adults with diabetes:

• Define and decide what kind of disability you want to prevent. Older adults with diabetes reported different types of disability (mobility; ADL; IADL) in daily lives.^1,2,16,17 For example, Maty et al. found that among 3570 non-institutionalized female older adults with diabetes, 51% of them have difficulties walking 2-3 blocks, 31% of them had difficulties shopping, and 30% of them had difficulties bathing and showing.¹⁷ If one wants to prevent disability for older adults with diabetes, strategies should target on preventing mobility, ADL, and IADL disability.
• Consider the type of prevention you are going to apply. Since older adults with diabetes are at high risk of developing risk factors of disability (depressive symptoms; cognitive impairment), one should apply the concept of indicative prevention: older adults who are experiencing early signs of disability or other risk factors associated with disability and treat them with special programs to reduce the risk factors.
• Identify specific active ingredients to maintain the effects of interventions. A systematic review of active ingredients in interventions had found that non-pharmacological interventions focused on behavioral changes rarely specified techniques to maintain the effects of interventions. Research has found that older adults with diabetes who maintained engagement in social activities had a better survival rate over a 2 year period.¹⁸ When one is developing interventions to prevent disability, there is a need to identify active ingredients for both initiating and continuing engagement of daily activities for older adults with diabetes.¹⁹

Diabetes-related disability is a problem that reduces older adults’ quality of life and health. Preventing disability among older adults with diabetes is important because it may reduce substantial healthcare costs in late life.

Because many medical, psychological, and social factors increase the risk of disability in older adults with diabetes, interventions that focus on diabetes diagnoses alone are not sufficient to explain the heterogeneity of disability in late life.²⁰ Medical management by itself is not sufficient to prevent disability.

Future interventions that aim to prevent disability should be individualized and tailored to older adults’ unique medical, psychological, and social situations. Indicated-prevention interventions should include strategies that address the interactions between risk factors, such as depressive symptoms and cognitive impairment, and disability in older adults with diabetes.

Without considering the active ingredients that address social and environmental factors, preventing disability in late life is much less likely to happen.