Older people with prediabetes should eat better, move, but not worry too much about diabetes

Nearly half of seniors — more than 26 million people 65 and older – have prediabetes, according to the Centers for Disease Control and Prevention. How concerned should they be?

Not very, say some experts. Prediabetes – a term that refers to higher than normal but not extremely high blood sugar levels – is not a disease, and it does not imply that older people who have it will inevitably develop type 2 diabetes, they note. .

“For most older patients, the risk of going from prediabetes to diabetes is not that high,” said Dr. Robert Lash, chief medical officer of the Endocrine Society, commenting on recent research. “Yet labeling people with prediabetes can make them feel worried and anxious.”

Other experts believe identifying prediabetes is important, especially if it causes older people to do more physical activity, lose weight and eat healthier to help control blood sugar.

“A diagnosis of prediabetes should always be taken seriously,” said Dr. Rodica Busui, president-elect of medicine and science at the American Diabetes Association, who 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 theirAm I diabetic? » country.

Yet many seniors don’t know what they should do if they are told they have prediabetes. Nancy Selvin, 79, of Berkeley, Calif., is one of them.

At 5 feet and 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 a Mediterranean-style diet. Still, Selvin has felt alarmed since learning last year that her blood sugar was slightly above normal.

“I’m afraid I’m diabetic,” she said.

Two recent reports on prediabetes in the elderly are generating increased interest in this topic. Until publication, most studies focused on prediabetes in middle-aged adults, leaving the significance of this condition in older adults unclear.

The most recent study by CDC researchers, published in April in JAMA Network Open, examined data from more than 50,000 elderly patients with prediabetes between January 2010 and December 2018. Just over 5% of these patients progressed to diabetes each year, he noted.

The researchers used a measurement of blood glucose over time, hemoglobin a1c. Prediabetes is signified by A1C levels from 5.7% to 6.4% or a fasting blood sugar test reading of 100 to 125 milligrams per deciliter, according to the Diabetes Association. (This blood glucose test assesses blood sugar after a person has not eaten anything for at least eight hours.)

It should be noted that the results of the study show that obese older people with prediabetes were at a significantly increased risk of developing diabetes. Black seniors, people with a family history of diabetes, low-income seniors, and seniors on the upper end (6% to 6.4%) of the prediabetes A1C range were also at risk. Men were slightly more at risk than women.

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

They also confirm the importance of referring older people with prediabetes — especially the 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 do more. ‘physical activity. Research has shown that the prevention program reduces the risk of diabetes by 71% in people aged 60 and over. But only a small fraction of eligible people signed up.

Libby Christianson, of Sun City, Arizona, is walking more regularly and paying more attention to her diet after learning last summer that her blood sugar was high. “When my doctor said to me, ‘You’re pre-diabetic,’ I was shocked because I’ve always considered myself a very healthy person,” she says. (Libby Christianson)

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

Take-out? “We know it’s common in older people to have slightly elevated glucose levels, but that doesn’t have the same meaning as in younger people – it doesn’t mean you’re going to get diabetes, become blind or lose your leg, say 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.

“Hardly anyone develops the [diabetes] complications that really worry us in young people.

“There’s nothing wrong with telling older people with prediabetes to exercise more and eat carbohydrates evenly throughout the day,” says Dr AS 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 will inevitably make you diabetic and stress you out.”

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

Nancy Selvin, from Berkeley, Calif., takes a rigorous one-hour exercise class three times a week and follows a Mediterranean-style diet. Still, Selvin was alarmed last year when she learned that her blood sugar was slightly above normal. “I’m afraid of being diabetic,” she says. (Kristie Chang)

Aggressive treatments for prediabetes, such as the drug metformin, should be avoided, according to Dr. Victor Montori, endocrinologist and professor of medicine at the Mayo Clinic. “If you have diabetes, you will be prescribed metformin. But it’s just plain nonsense to give you metformin now, because you might be at risk, to reduce the risk of needing metformin later.

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

Such was the case with Elaine Hissam, 74, of Parkersburg, West Virginia, who was alarmed last summer when she scored 5.8% on an A1C test. Hissam’s mother developed diabetes as an adult, and Hissam dreaded the possibility of it happening to her too.

At the time, Hissam was taking exercise classes five days a week and also walking 4-6 miles a day. When advised by her doctor to “watch what you eat,” Hissam cut a lot of sugar and carbs from her diet and lost 9 pounds. But when she took another A1C test earlier this year, it had only dropped slightly, to 5.6%.

“My doctor really didn’t have much to say when I asked, ‘Why hasn’t there been more change?’ said Hissam.

Experts I spoke with 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% of prediabetic older adults with A1C levels of 5.7% to 5.9% become diabetic each year.

Nancy Selvin, who learned last year that her A1C had dropped from 5.9% to 6.3%, said she had been trying to lose 6 pounds without success since getting the results from these tests. His doctor told Selvin not to worry but prescribed him a statin to reduce the risk of cardiovascular complications, as 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 central to disease prevention in 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%. “When my doctor said to me, ‘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 butt to get people to adopt healthier behaviors, that’s fine with me,” said Dr Kenneth Lam, a geriatrician at the University of California-San Francisco. “But if you’re older, definitely over 75, and it’s a new diagnosis, that’s not something I would worry about. I’m pretty sure diabetes isn’t won’t matter in your life.

We look forward to hearing from readers about the questions you’d like answered, the issues you’ve had with your care, and the advice you need for dealing with the health care system. Visit khn.org/columnists to submit your requests or advice.

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