How Meaningful Is Prediabetes for Older Adults?

How Meaningful Is Prediabetes for Older Adults?

2021-02-23 07:30:09
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A few years ago, routine lab tests showed that Susan Glickman Weinberg, then a 65-year-old clinical social worker in Los Angeles, had a hemoglobin A1C level of 5.8 percent, barely more than normal.

"This is considered prediabetes," her internist told her. A1C measures how much sugar is circulating in the bloodstream over time. If her results reached 6 percent – still below the number that defines diabetes, which is 6.5 – her doctor said he would recommend the commonly prescribed drug metformin.

"The thought that I might get diabetes was very disturbing," recalls Ms. Weinberg, who as a child had heard family members talk about it as "this mysteriously awful thing."

She was already on two blood pressure drugs, a cholesterol statin and an osteoporosis drug. Did she really need a different prescription? She was also concerned about the reports of contaminated imported drugs at the time. She didn't even know what prediabetes meant or how quickly it could turn into diabetes.

& # 39; I felt like Patient Zero, & # 39; she said. "There were many unknowns."

Now there are fewer unknowns. A Longitudinal Study of Older Adults, published online this month in the journal JAMA Internal Medicine, provides some answers about the common intermediate condition known as prediabetes.

The researchers found that older people who were supposedly prediabetic were much more likely to get their blood sugar levels back to normal than they were to develop diabetes. And they would die no more during the follow-up period than their peers with normal blood sugar.

"Prediabetes probably shouldn't be a priority in most older adults," said Elizabeth Selvin, an epidemiologist at Johns Hopkins Bloomberg School of Public Health in Baltimore and the study's senior author.

Prediabetes, a condition rarely discussed just 15 years ago, refers to a blood sugar level that is higher than normal but has not crossed the threshold for diabetes. It is usually defined by a hemoglobin A1C value of 5.7 to 6.4 percent or a fasting glucose level of 100 to 125 mg / dL; in middle age it can predict serious health problems.

A diagnosis of prediabetes means you are more likely to develop diabetes, and "that leads to downstream disease," said Dr. Kenneth Lam, a geriatrician at the University of California, San Francisco, and an author of an editorial accompanying the study& # 39; It damages your kidneys, your eyes and your nerves. It causes heart attack and stroke, ”he said.

But for an older adult just hitting higher blood sugar, it's a different story. It takes years for these frightening consequences to develop, and many people in their 70s and 80s will not live long enough to encounter them.

That fact has generated years of debate. Should older people with slightly above average blood sugar levels – which is common because the pancreas makes less insulin later in life – should take action, as the American Diabetes Association has urged?

Or does labeling prediabetic people just make a normal part of aging “medical,” creating unnecessary anxiety in those already dealing with multiple health conditions?

Dr. Selvin and her colleagues analyzed the findings of an ongoing national cardiovascular risk study that began in the 1980s. When 3,412 of the participants showed up for their physical and lab tests between 2011 and 2013, they were between 71 and 90 years old and did not have diabetes.

Prediabetes was rampant, however. Nearly three quarters qualified as prediabetic, based on their A1C or fasting blood glucose level.

These findings reflected a 2016 study noting that a popular online risk test created by the Centers for Disease Control and Prevention and the American Diabetes Association called doihaveprediabetes.org, almost anyone over the age of 60 would consider prediabetic.

In 2010, a CDC. review reported that 9 to 25 percent of those with an A1C of 5.5 to 6 percent will develop diabetes in five years; so are 25 to 50 percent of those with A1C levels of 6 to 6.5. But those estimates were based on a middle-aged population.

When Dr. Selvin and her team looked at what actually happened to their older prediabetic cohort five to six years later, only 8 or 9 percent had developed diabetes, depending on the definition used.

A much larger group – 13 percent of those whose A1C levels were elevated and 44 percent of those with prediabetic fasting blood glucose – actually saw their readings return to normal blood sugar levels.A Swedish study found similar results.]

Sixteen to 19 percent died, about the same as those without prediabetes.

"We don't see much risk in these individuals," said Dr. Selvin. “Older adults can have complex health problems. Those who harm quality of life should be the focus, not slightly elevated blood glucose. "

Dr. Saeid Shahraz, a health researcher at Tufts Medical Center in Boston and lead author of the 2016 study, praised the new research. "The data is very strong," he said. "The American Diabetes Association should do something about this."

You can, said Dr. Robert Gabbay, the A.D.A.'s chief scientific and medical officer. The organization currently recommends for people with prediabetes “minimum annual monitoring,” a reference to the lifestyle modification programs shown to reduce health risks and perhaps metformin for obese and under 60s.

Now the association's professional practices committee will review the study and "it could lead to some adjustments in the way we think about things," said Dr. Gabbay. In older people who are considered prediabetic, "their risk may be less than we thought," he added.

Advocates of the emphasis on treating prediabetes, which is said to affect one-third of the U.S. population, point out that first-line treatment involves learning healthy behaviors that more Americans should adopt anyway: weight loss, quitting smoking, exercise, and being healthy food .

"I've been diagnosed with prediabetes in a number of patients, and that's what motivates them to change," said Dr. Gabbay. "They know what to do, but they need something to put them in gear."

Geriatricians usually disagree. "It's unprofessional to mislead people, motivate them for fear of something that isn't really true," said Dr. Lamb. "We are all tired of having things to fear."

He and Dr. Sei Lee, a co-author of the editorial on the new study and a fellow geriatrician at the University of California, San Francisco, advocate a case-by-case approach in older adults – especially as a diagnosis of prediabetes their children to scold them about every cookie.

For a patient who is frail and frail, "you are likely to be dealing with lots of other problems," said Dr. Lamb. "Don't worry about this number."

A very healthy 75-year-old who could live for 20 more years faces a more nuanced decision. She may never develop diabetes; she may also be following the recommended lifestyle changes.

Mrs. Weinberg, now 69, sought help from a nutritionist, changed her diet to emphasize complex carbohydrates and proteins, and began walking and climbing stairs more than taking elevators. She's lost ten pounds that she didn't need to lose. After 18 months, her barely elevated A1C level dropped to 5.6.

Her friend Carol Jacobi, 71, who also lives in Los Angeles, received a similar warning about the same time. Her A1C was 5.7, the lowest number defined as prediabetic, but her internist immediately prescribed metformin.

Mrs. Jacobi, a retired fundraiser with no family history of diabetes, was not concerned. She thought she could lose some weight, but she had normal blood pressure and an active life with lots of walking and yoga. After trying the drug for a few months, she stopped.

Now neither woman has prediabetes. Although Mrs. Jacobi did not do much to lower her blood sugar and gained a few pounds during the pandemic, her A1C has also dropped to normal levels.


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