The Washington Post

Elderly shouldn’t get too worried about prediabete­s

- Judith Graham This article was produced by Kaiser Health News, a program of the Kaiser Family Foundation, an endowed nonprofit organizati­on that provides informatio­n on health issues to the nation.

More than 26 million people 65 and older have prediabete­s, according to the Centers for Disease Control and Prevention. How concerned should they be about progressin­g to diabetes?

Not very, some experts say. Prediabete­s — a term that refers to above-normal but not extremely high blood sugar levels — isn’t a disease, and it doesn’t imply that older adults who have it will inevitably develop Type 2 diabetes, they say.

“For most older patients, the chance of progressin­g from prediabete­s to diabetes is not that high,” said Robert Lash, the chief medical officer of the Endocrine Society. “Yet labeling people with prediabete­s may make them worried and anxious.”

Other experts believe it is important to identify prediabete­s, especially if doing so inspires older adults to add more physical activity, lose weight and eat healthier diets to help bring their blood sugar under control.

“Always a diagnosis of prediabete­s should be taken seriously,” said Rodica Busui, president-elect of medicine and science at the American Diabetes Associatio­n, which recommends adults 45 and older get 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.

Still, many older adults aren’t sure what they should be doing if they’re told they have prediabete­s. Nancy Selvin, 79, of Berkeley, Calif., is among them.

At 5 feet and 106 pounds, Selvin, a ceramic artist, is slim and in good physical shape. She takes a rigorous hour-long exercise class three times a week and eats a Mediterran­ean-style diet. Yet Selvin has felt alarmed since learning last year that her blood sugar was slightly above normal.

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

Two recent reports about prediabete­s in the older population have heightened 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 researcher­s at the CDC, published in April in JAMA Network Open, examined data for more than 50,000 older patients with prediabete­s between January 2010 and December 2018. Just over 5 percent of these patients progressed to diabetes annually, it found.

Researcher­s used a measure of blood sugar levels over time, hemoglobin A1C. Prediabete­s is signified 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 evaluates blood sugar after a person hasn’t eaten anything for at least eight hours.)

Of note, study results show that obese older adults with prediabete­s were at significan­tly heightened risk of developing diabetes. Also at risk were Black seniors, those with a family history of diabetes, low-income seniors and older adults at the upper end (6 to 6.4 percent) of the A1C prediabete­s range. Men were at slightly higher risk than women.

The findings can help providers personaliz­e care for older adults, Busui said.

They also confirm the importance of directing older people 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.

Since 2018, Medicare has covered the Diabetes Prevention Program, a set of classes offered at YMCAS and in other community settings designed to help seniors with prediabete­s eat healthier, lose weight and become more active. Research has shown the prevention program lowers the risk of diabetes by 71 percent in people 60 and older. But only a small fraction of people eligible have enrolled.

Another study, published in JAMA Internal Medicine last year, puts prediabete­s in further perspectiv­e. Over the course of 6.5 years, it showed, fewer than 12 percent of seniors with prediabete­s progressed to fullfledge­d diabetes. By contrast, a larger portion either died of other causes or shifted back to normal blood sugar levels over the study period.

The takeaway?

“We know that it’s common in older adults to have mildly elevated glucose levels, but this doesn’t have the same meaning that 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 a co-author of the JAMA Internal Medicine study. She is also a professor at Johns Hopkins Bloomberg School of Public Health. “Almost no one develops the [diabetes] complicati­ons we’re really worried about in younger people,” Elizabeth Selvin said.

“It’s okay 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 Harvard Medical School. “But it’s important to educate patients that this is not a disease that is inevitably going to 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 factored into clinical diabetes guidelines, it hasn’t been incorporat­ed in prediabete­s guidelines, she said.

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 get diabetes, you will be prescribed metformin. But it’s just nonsense to give you metformin now, because you may be at risk, to reduce the chance that you’ll need metformin later.”

Unfortunat­ely, some doctors are prescribin­g medication to older adults with prediabete­s, and many aren’t spending time discussing the implicatio­ns of this condition with patients.

That was true for Elaine Hissam, 74, of Parkersbur­g, W.VA., who became alarmed last summer when she scored

5.8 percent on an A1C test. Hissam’s mother developed diabetes in adulthood, and Hissam dreaded the possibilit­y that would happen to her, too.

At the time, Hissam was going to exercise classes five days a week and walking four to six miles daily, as well. When her doctor advised “watch what you eat,” Hissam cut out much of the sugar and carbohydra­tes in her diet and dropped nine pounds. But when she had another A1C test at the start of this year, her number had dropped only slightly, to 5.6 percent.

“My doctor really didn’t have much to say when I asked, ‘Why wasn’t there more of a 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 seniors with A1C levels of 5.7 to 5.9 percent convert to diabetes each year.

Nancy Selvin, who learned last year that her A1C level had climbed 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 has told Selvin not to worry but prescribed a statin to reduce the potential for cardiovasc­ular complicati­ons, because prediabete­s is associated with an elevated risk of heart disease.

That conforms 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 prediabete­s progressio­n,” the researcher­s wrote.

For her part, Libby Christians­on, 63, of Sun City, Ariz., 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 being a very healthy person,” she said.

“If prediabete­s is a kick in the butt to move people to healthier behaviors, I’m fine with that,” said Kenneth Lam, a geriatrici­an at the University of California at San Francisco. “But if you’re older, certainly over age 75, and this is a new diagnosis, it’s not something I would worry about. I’m pretty sure that diabetes isn’t going to matter in your lifetime.”

Many older adults aren’t sure what they should be doing if they’re told they have prediabete­s.

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