Older adults with prediabetes, should they worry about diabetes?

Nearly half of older people — more than 26 million people age 65 and older — have prediabetes, according to the Centers for Disease Control and Prevention (CDC). How worried should they be?

Not much, some experts say. Prediabetes, a term that refers to above-normal but not extremely high blood sugar levels, is not a disease, and does not imply that older people with it will inevitably develop type 2 diabetes, they note.

“For most older patients, the chance of progressing from prediabetes to diabetes is not that high,” said Dr. Robert Lash, medical director of the Endocrine Society, commenting on recent research. “However, labeling people with prediabetes can cause concern and anxiety.”

Other experts believe it’s important to identify prediabetes, especially if it inspires older people to be more physically active, lose weight and eat healthier diets to help control blood sugar.

“A diagnosis of prediabetes should always be taken seriously,” said Dr. Rodica Busui, president-elect for medicine and science for the American Diabetes Association, which recommends that people over 45 get screened for prediabetes at least once. once every three years. The CDC and the American Medical Association make a similar point in their “Do I Have Diabetes?” campaign.

Still, many older people aren’t sure what they should do if told they have prediabetes. Nancy Selvin, 79, of Berkeley, California, is among them.

At 5 feet 106 pounds, Selvin, a ceramic artist, is slim and physically fit. She takes a rigorous one-hour exercise class three times a week and follows the Mediterranean diet. However, Ella Selvin has been worried since she learned last year that her blood sugar level was slightly above normal.

“I’m terrified of being diabetic,” she said.

Two recent reports on prediabetes in the elderly population have fueled increased interest in this topic. Until its publication, most studies focused on prediabetes in middle-aged adults, leaving the importance of this condition in older people in doubt.

The most recent study by CDC researchers, published in April in JAMA Network Open, examined data on more than 50,000 older patients with prediabetes between January 2010 and December 2018. It found that just over 5% of these patients developed diabetes annually.

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The researchers used a measure of blood sugar levels over time, hemoglobin A1C. Prediabetes is manifested by A1C levels of 5.7% to 6.4% or a fasting plasma glucose test reading of 100 to 125 milligrams per deciliter, according to the diabetes association. (This glucose test checks blood sugar after a person has not eaten anything for at least eight hours.)

Of note, the study results show that obese older people with prediabetes had a significantly increased risk of developing diabetes. Also at risk were black older people, those with a family history of diabetes, low-income older people, and older people at the high end (6%-6.4%) of the prediabetes A1C range. Men had a slightly higher risk than women.

The findings may help providers personalize care for older people, Busui said.

They also confirm the importance of referring older people with prediabetes, especially the most vulnerable, to lifestyle intervention programs, said Alain Koyama, the study’s lead author and a CDC epidemiologist.

Since 2018, Medicare has covered the Diabetes Prevention Program, a set of classes offered at YMCAs and other community settings designed to help seniors with prediabetes eat healthier diets, lose weight and get more exercise . Research has shown that the prevention program reduces the risk of diabetes by 71% in people age 60 and older. But only a small fraction of eligible people have signed up.

Another study, published in JAMA Internal Medicine last year, helps put prediabetes into a broader perspective. Over the course of 6.5 years, it showed that less than 12% of older people with prediabetes progressed to full-blown diabetes. By contrast, a larger portion died of other causes or returned to normal blood sugar levels during the study period.

The morale?. “We know it’s common for older people to have slightly elevated blood glucose levels, but this doesn’t have the same meaning as it would for younger people, it doesn’t mean you’re going to get diabetes, go blind or lose a leg,” said Elizabeth Selvin. , daughter of Nancy Selvin and co-author of the study. She is also a professor at the Johns Hopkins Bloomberg School of Public Health.

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“Hardly anyone develops the complications [de la diabetes] that we really care about in younger people.”

“It’s okay to tell older adults with prediabetes to exercise more and eat carbohydrates evenly throughout the day,” said Dr. Medha Munshi, director of the geriatric diabetes program at Joslin Diabetes Center, an affiliate of the School of Medicine. from Harvard. “But it’s important to educate patients that this is not a disease that will inevitably make them diabetic and stress them out.”

Many older people have slightly elevated blood sugar levels because they produce less insulin and process it less efficiently. While this is noted in diabetes clinical guidelines, it has not been incorporated into prediabetes guidelines, he noted.

Aggressive treatments for prediabetes, such as the drug metformin, should be avoided, according to Dr. Victor Montori, an endocrinologist and professor of medicine at the Mayo Clinic. “If you have diabetes, you will be prescribed metformin. But it doesn’t make sense to give you metformin now, because you could be at risk, reducing the chance that you’ll need metformin later.”

Unfortunately, some doctors prescribe medication for older people with prediabetes, and many don’t take the time to discuss the implications of this condition with patients.

That happened to Elaine Hissam, 74, of Parkersburg, West Virginia, who freaked out last summer when she scored 5.8% on an A1C test. Hissam’s mother developed diabetes in adulthood, and Hissam feared the possibility that it might happen to her as well.

At the time, Hissam was attending exercise classes five days a week and also walking 4 to 6 miles a day. When his doctor advised him to “watch what he eats,” Hissam cut much of the sugar and carbohydrates in his diet and lost 9 pounds. But when he had another A1C test earlier this year, he had dropped only slightly, to 5.6%.

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“My doctor really didn’t have much to say when I asked, ‘Why weren’t there more changes?’” Hissam said.

Experts consulted noted that fluctuations in test results are common, especially at the lower and upper ends of the prediabetes range. According to the CDC study, 2.8% of prediabetic seniors with A1C levels of 5.7% to 5.9% become diabetic each year.

Nancy Selvin, who learned last year that her A1C level had risen from 5.9% to 6.3%, said she has been trying to lose 6 pounds without success since getting her test results. Her doctor told Selvin not to worry, but she prescribed a statin to reduce the potential for cardiovascular complications, since prediabetes is associated with an elevated risk of heart disease.

That’s consistent with one of the conclusions of last year’s Johns Hopkins prediabetes study. “Taken together, current evidence suggests that cardiovascular disease and mortality should be the focus of disease prevention among older people rather than prediabetes progression,” the researchers wrote.

For her part, Libby Christianson, 63, of Sun City, Arizona, began walking more regularly and eating more protein after learning last summer that her A1C level was 5.7%. “When my doctor said, ‘You’re pre-diabetic,’ I was surprised because I’ve always considered myself a very healthy person,” she said.

“If prediabetes is a kick in the butt to get people into healthier behaviors, I agree with that,” said Dr. Kenneth Lam, a geriatrician at the University of California-San Francisco. “But if you’re older, certainly older than 75, and this is a new diagnosis, it’s not something I worry about. I’m pretty sure diabetes is not going to matter in your life.”

KHN (Kaiser Health News) is the newsroom of KFF (Kaiser Family Foundation), which produces in-depth health journalism. It is one of three major programs of KFF, a nonprofit organization that analyzes the nation’s health and public health issues.

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