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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 progressing to diabetes?
Not much, say some experts. Prediabetes, a term that refers to blood sugar levels that are higher than normal but not extremely high, is not a disease and does not imply 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 high,” said Robert Lash, chief medical officer of the Endocrine Society. “However, labeling people with prediabetes can make them worried and anxious.”
Other experts believe it’s important to identify prediabetes, especially if doing so inspires older adults to add more physical activity, lose weight and eat healthier diets to help control blood sugar.
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“A diagnosis of prediabetes should always be taken seriously,” said Rodica Busui, president-elect of medicine and science for the American Diabetes Association, which recommends that adults age 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 course “Do I Have Diabetes?” campaign
Still, many older adults aren’t sure what to do if they’re told they have prediabetes. Nancy Selvin, 79, of Berkeley, California, is among them.
At 5-foot-1 and 106 pounds, Selvin, a ceramic artist, is slim and physically fit. He takes a rigorous hour-long exercise class three times a week and eats a Mediterranean-style diet. However, Selvin has been alarmed since learning last year that her blood sugar was slightly above normal.
“I’m scared of being diabetic,” she said.
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Two recent reports on 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 importance of this condition in older adults uncertain.
A new study by CDC researchers, published in April in JAMA Network Open, looked at data from more than 50,000 older patients with prediabetes between January 2010 and December 2018. Just over 5 percent of those patients they progressed to diabetes annually, he found.
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 not eaten anything for at least eight hours.)
Of note, the study results show that obese older adults with prediabetes had a significantly higher risk of developing diabetes. Also at risk were black seniors, those with a family history of diabetes, low-income seniors, and seniors at the high end (6 to 6.4 percent) of the prediabetes A1C range. Men had a slightly higher risk than women.
The findings may help providers personalize care for older adults, Busui said.
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They also confirm the importance of targeting older people with prediabetes, especially those who are most vulnerable, to lifestyle intervention programs, said Alain Koyama, lead study author and 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 older adults with prediabetes eat healthier, lose weight, and become more active . 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, puts prediabetes in further perspective. Over 6.5 years, it showed, fewer than 12 percent of older people with prediabetes progressed to full-blown diabetes. Conversely, a larger proportion died of other causes or returned to normal blood sugar levels during the study period.
“We know it’s common in older adults to have slightly elevated glucose levels, but that doesn’t mean the same as 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 no one develops the [diabetes] complications that we are very concerned about in younger people,” said Elizabeth Selvin.
“It’s OK to tell older adults 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 the Harvard Medical School. “But it’s important to educate patients 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. While this is considered in the diabetes clinical guidelines, it has not been incorporated into the prediabetes guidelines, he said.
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Aggressive treatments for prediabetes, such as the medication metformin, should be avoided, said Victor Montori, an endocrinologist and professor of medicine at the Mayo Clinic. “If you have diabetes, you will be prescribed metformin. But it is foolish to give you metformin now, because you may be at risk, to reduce the chance that you will need it 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, W.Va., who was alarmed last summer when she scored 5.8 percent on an A1C test. Hissam’s mother developed diabetes as an adult, and Hissam feared that it might happen to her too.
At the time, Hissam was going to exercise classes five days a week and also walking four to six miles a day. When his doctor advised him to “watch what you eat,” Hissam eliminated much of the sugar and carbohydrates from his diet and dropped nine pounds. But when she had another A1C test earlier this year, her number had dropped only slightly, to 5.6 percent.
“My doctor didn’t really have much to say when I asked, ‘Why weren’t there more changes?’ Hissam said.
Fluctuations in test results are common, especially around the lower and upper ends of the prediabetes range, experts said. According to the CDC study, 2.8 percent of prediabetic older adults with A1C levels of 5.7 to 5.9 percent develop diabetes each year.
Nancy Selvin, 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 the test results. tests Her doctor has told Selvin not to worry, but has prescribed a statin to reduce the potential for cardiovascular complications, because prediabetes is associated with a high risk of heart disease.
This is in line with one of the findings of the Johns Hopkins Prediabetes Study last year. “Taken together, 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.
Meanwhile, 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 my doctor said, ‘You’re prediabetic,’ I was shocked because I’ve always thought of myself as a very healthy person,” she said.
“If prediabetes is a kick in the ass to move people into 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 this is a new diagnosis, it’s not something I would worry about. I’m pretty sure diabetes won’t matter in your life.”
This article was produced by Kaiser Health News, a program of the Kaiser Family Foundation, a non-profit endowed organization that provides information on health issues to the nation.