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More than 26 million people age 65 and older have prediabetes, according to the Centers for Disease Control and Prevention. How worried should they be about diabetes progression?
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 mean that older adults who have it will inevitably develop type 2 diabetes, they say.
“For most older patients, the chance of progression from prediabetes to diabetes is not that great,” said Robert Lash, chief medical officer of the Endocrine Society. “Yet labeling people with prediabetes can make them anxious and worried.”
Other experts believe it’s important to identify prediabetes, especially if it inspires older people to add more physical activity, lose weight and eat healthier to control their blood sugar.
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“A diagnosis of prediabetes should always be taken seriously,” said Rodica Busui, president-elect of medicine and science at the American Diabetes Association, which recommends adults 45 and older be screened for prediabetes at least once every three years. The CDC and the American Medical Association make a similar point in their ongoing “Do I Have Diabetes?” campaign.
However, many older people are not sure what to do if they are told they have prediabetes. Nancy Selwyn, 79, of Berkeley, California, is among them.
At 5-foot-1 and 106 pounds, Selwyn, a ceramic artist, is lean and in good physical shape. She attends rigorous one-hour workouts three times a week and eats a Mediterranean diet. Still, Selwyn has been worried since she learned last year that her blood sugar was slightly above normal.
“I’m terrified of being diabetic,” she said.
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Two recent reports of prediabetes in the elderly population have increased interest in this topic. Until their publication, most studies focused on prediabetes in middle-aged adults, leaving the significance of this condition in older adults uncertain.
A new 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. Just over 5 percent of these patients progress to diabetes annually. established.
The researchers used a measure of blood sugar levels over time, hemoglobin A1C. Prediabetes is indicated by A1C levels of 5.7 to 6.4 percent or a fasting plasma glucose test reading of 100 to 125 milligrams per deciliter, according to the diabetes association. (This glucose test assesses blood sugar after a person has eaten nothing for at least eight hours.)
Of note, the study results showed that obese adults with prediabetes were at a significantly increased risk of developing diabetes. Also at risk were black seniors, those with a family history of diabetes, low-income seniors and seniors at the upper end (6 to 6.4 percent) of the prediabetes A1C range. Men are at slightly higher risk than women.
The findings could help providers personalize care for the elderly, Busui said.
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They also confirm the importance of targeting older adults with prediabetes — especially those who are most vulnerable — to lifestyle intervention programs, said Alain Koyama, the study’s lead author and an epidemiologist at the CDC.
Starting in 2018, Medicare covered the Diabetes Prevention Program, a set of classes offered at YMCAs and other community settings designed to help seniors with prediabetes eat healthier, lose weight and become more active. Research shows that the prevention program reduces the risk of diabetes by 71 percent in people 60 and older. But only a small fraction of eligible people enrolled.
Another study published in JAMA Internal Medicine last year puts prediabetes in greater perspective. Over 6.5 years, it showed that fewer than 12 percent of older adults with prediabetes progressed to full-blown diabetes. In contrast, a greater proportion either died of other causes or returned to normal blood sugar levels during the study period.
“We know that it’s common for older people to have slightly elevated glucose levels, but it doesn’t have the same significance as it would in younger individuals – it doesn’t mean you’re going to get diabetes, go blind or lose your leg said Elizabeth Selvin, daughter of Nancy Selvin and co-author of the JAMA Internal Medicine study. She is also a professor at the Johns Hopkins Bloomberg School of Public Health. “Almost nobody develops [diabetes] complications that we really worry about in younger people,” said Elizabeth Selwyn.
“It’s good to tell older people with prediabetes to exercise more and eat carbohydrates evenly throughout the day,” said Medha Munshi, director of the Geriatric Diabetes Program at the Joslin Diabetes Center, an affiliate of Harvard Medical School. “However, it is important that patients are educated that this is not a disease that will inevitably make you diabetic and stress you out.”
Many older people have slightly elevated blood sugar because they produce less insulin and process it less efficiently. Although this is included in the clinical guidelines for diabetes, it is not included in the guidelines for prediabetes, she said.
For those with prediabetes, losing four to six pounds can reduce the risk of diabetes
Aggressive treatments for prediabetes, such as the drug metformin, should be avoided, said Victor Montori, an endocrinologist and professor of medicine at the Mayo Clinic. “If you get diabetes, you will be prescribed metformin. But it’s just stupid to give you metformin now because you may be at risk to reduce the chance of needing metformin later.
Unfortunately, some doctors prescribe medications to older people with prediabetes, and many do not take the time to discuss the implications of this condition with patients.
That was true for Elaine Hissam, 74, of Parkersburg, West Virginia, who became alarmed last summer when she scored 5.8 percent on an A1C test. Hisam’s mother develops diabetes as an adult, and Hisam fears the possibility of it happening to her as well.
At the time, Hissam would go to exercise classes five days a week and also walk four to six miles each day. When her doctor advised her to “watch what you eat,” Hissam eliminated much of the sugar and carbohydrates in her diet and lost nine pounds. But when she had another A1C test earlier this year, her number had dropped only slightly, to 5.6 percent.
“My doctor really had nothing to say when I asked, ‘Why wasn’t there more change?'” Hissam said.
Experts said fluctuations in test results are common, especially around the lower and upper ends of the prediabetes range. According to the CDC study, 2.8 percent of prediabetic adults with A1C levels of 5.7 to 5.9 percent become diabetic each year.
Nancy Selwyn, who learned last year that her A1C level had risen to 6.3 percent from 5.9 percent, said she has been trying to lose six pounds without success since getting those test results. Her doctor told Selwyn not to worry, but prescribed a statin to reduce the potential for cardiovascular complications because prediabetes is associated with an increased risk of heart disease.
This is consistent with one of the conclusions of the Johns Hopkins Prediabetes Study last year. “Taken as a whole, the current evidence suggests that cardiovascular disease and mortality should be the focus of disease prevention among older adults, rather than the progression of prediabetes,” the researchers wrote.
For her part, Libby Christianson, 63, of Sun City, Arizona, started walking more regularly and eating more protein after learning last summer that her A1C level was 5.7 percent.
“When the doctor said, ‘You’re pre-diabetic,’ I was shocked because I’ve always considered myself a very healthy person,” she said.
“If prediabetes is a kick in the ass to encourage people to adopt healthier behaviors, I’m fine with that,” said Kenneth Lam, a geriatrician at the University of California, San Francisco. “But if you’re older, certainly over 75, and it’s a new diagnosis, it’s not something I would worry about. I’m pretty sure diabetes won’t matter in your lifetime.
This article was created by Kaiser Health News, a program of the Kaiser Family Foundation, a nonprofit charitable organization that provides information on the nation’s health issues.
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