Several years ago, routine laboratory tests showed that Susan Glickman Weinberg, then a 65-year-old clinical social worker in Los Angeles, had a hemoglobin A1C value of 5.8 percent, which was barely above normal.
“This is considered to be prediabetes,” said her internist. A1C measures how much sugar has circulated in the bloodstream over time. If her results hit 6 percent – still below the number that defines diabetes (6.5) – her doctor said he would recommend the widely used drug metformin.
“The thought that I might get diabetes was very annoying,” recalled Ms. Weinberg, who, as a child, had heard relatives talk about it as “this mysterious terrible thing”.
She was already on two blood pressure drugs, a statin for cholesterol and an osteoporosis drug. Did she really need a different recipe? She was also concerned about reports of tainted imported drugs. She wasn’t even sure what prediabetes meant or how quickly it could turn into diabetes.
“I felt like Patient Zero,” she said. “There were a lot of unknowns.”
Now there are fewer strangers. A longitudinal study of older adults, published online this month in the journal JAMA Internal Medicine, offers some answers to the very common intermediate disease known as prediabetes.
The researchers found that older people who were alleged to be prediabetic were more likely to have blood sugar levels return to normal over several years than they were with diabetes. And they were no more likely to die during the follow-up period than their counterparts with normal blood sugar.
“For most older adults, prediabetes should probably not be a priority,” said Elizabeth Selvin, epidemiologist at the Johns Hopkins Bloomberg School of Public Health in Baltimore and lead author on the study.
Prediabetes, a condition rarely discussed 15 years ago, refers to blood sugar levels that are higher than normal but have not exceeded 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; By midlife, it can indicate serious health problems.
A diagnosis of prediabetes means you are more likely to get diabetes and “that it leads to downstream disease,” said Dr. Kenneth Lam, a geriatrician at the University of California at San Francisco and author of an editorial to the study. “It damages your kidneys, your eyes and your nerves. It causes heart attacks and strokes, ”he said.
But for an older adult just reaching higher blood sugar levels, that’s a different story. It takes years for these dire consequences to develop, and many people in the 70s and 80s won’t live long enough to face them.
This fact generated Years of debate. Should older people with blood sugar levels slightly above average – a common occurrence as the pancreas produce less insulin later in life – take action, as the American Diabetes Association has called for?
Or does the prediabetic labeling merely “medicalize” a normal part of aging and create unnecessary anxiety for those already dealing with multiple health problems?
Dr. Selvin and her colleagues analyzed the results of an ongoing national cardiovascular risk study that began in the 1980s. When 3,412 of the participants showed up for their physical and laboratory tests between 2011 and 2013, they were 71 to 90 years old and did not have diabetes.
However, prediabetes was widespread. Almost three quarters qualified as prediabetic based on their A1C or fasting blood sugar levels.
These results were 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 is invoked doihaveprediabetes.orgwould consider almost anyone over 60 to be prediabetic.
In 2010 a CDC. Rating reported that 9 to 25 percent of patients with an A1C of 5.5 to 6 percent will develop diabetes over a five-year period; This also applies to 25 to 50 percent of those with A1C values of 6 to 6.5. However, these estimates were based on a middle-aged population.
When Dr. Selvin and her team five to six years later looked at what had actually happened to their older prediabetic cohort, 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 sugar – actually saw their readings return to normal blood sugar levels. (A Swedish study similar results found.)
16 to 19 percent had died, about as much as without prediabetes.
“We don’t see a great deal of risk in these people,” said Dr. Selvin. “Older adults can have complex health problems. Those that affect quality of life should be the focus, not the slightly elevated blood sugar. “
Dr. Saeid Shahraz, health researcher at Tufts Medical Center in Boston and lead author of the 2016 study, praised the new research. “The data is really strong,” he said. “The American Diabetes Association should do something about it.”
This could be the case, said Dr. Robert Gabbay, the scientific and medical director of the A.D.A. The organization currently recommends “at least annual monitoring” for people with prediabetes, a referral to the Lifestyle change programs shown to reduce health risks and possibly metformin for those who are obese and under 60.
Now the association’s Professional Practice Committee is going to review the study and “it could lead to some adjustments in the way we think about things,” said Dr. Gabbay. For older people who are considered to be prediabetic, “their risk may be lower than expected,” he added.
Defenders of the emphasis on the treatment of prediabetes, which allegedly affects a third of the US population, suggest that initial treatment should learn healthy behaviors that more Americans should be adopting anyway: weight loss, smoking cessation, exercise, and eating healthy .
“A number of patients have been diagnosed with prediabetes and that motivates them to change,” said Dr. Gabbay. “They know what to do, but they need something to get them going.”
Geriatrists tend to disagree. “It is unprofessional to mislead people and motivate them for fear of something that is not really true,” said Dr. Lam. “We’re all tired of having things to be afraid of.”
He and Dr. Sei Lee, co-author of the lead article on the new study and a fellow geriatrician at the University of California at San Francisco, advocates a case-by-case approach in older adults – especially if they are diagnosed with prediabetes and their children scold them at every crack.
For a frail and vulnerable patient, “you are likely to be dealing with a variety of other problems,” said Dr. Lam. “Don’t worry about that number.”
A very healthy 75-year-old who could live another 20 years is faced with a more differentiated decision. You can never progress to diabetes; She may also already be following recommended lifestyle changes.
Ms. Weinberg, now 69, sought help from a nutritionist, changed her diet to emphasize complex carbohydrates and proteins, and started walking and climbing stairs more instead of taking elevators. She lost 10 pounds that she didn’t have to lose. Over 18 months, her barely increased A1C value fell to 5.6.
Her friend Carol Jacobi, 71, who also lives in Los Angeles, received a similar warning around the same time. Her A1C was 5.7, the lowest number defined as prediabetic, but her internist immediately prescribed metformin.
Ms. Jacobi, a retired fundraiser with no family history of diabetes, did not feel concerned. She thought she could lose some weight, but she had normal blood pressure and an active life that included lots of walking and yoga. After trying the drug for a few months, she stopped.
Now no woman has prediabetes. Although Ms. Jacobi didn’t do much to lower her blood sugar and gained a few pounds during the pandemic, her A1C has also fallen to normal levels.