Panicked over prediabetes? For older patients, more evidence to say: Not to worry

demeter-300x261It’s not an invitation to pile on the ice cream, cake, and candy. But older adults may get to say pshaw to the finger-wagging they may have endured from doctors and loved ones about their raised blood sugar levels and the condition that specialists ginned up to caution them about it: prediabetes.

As the New York Times reported, a newly published study by researchers at Johns Hopkins and elsewhere looked at data over six years on almost 3,500 older patients with elevated blood sugar measurements and found they “were far more likely to have their blood sugar levels return to normal than to progress to diabetes. And they were no more likely to die during the follow-up period than their peers with normal blood sugar.”

This is an important finding, the newspaper reported, quoting Elizabeth Selvin, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health in Baltimore and the senior author on the study:

“In most older adults, prediabetes probably shouldn’t be a priority,” she told the newspaper, which also explained:

“Prediabetes, a condition rarely discussed as recently as 15 years ago, refers to a blood sugar level that is higher than normal but that has not crossed the threshold into diabetes. It is commonly defined by a hemoglobin A1C reading of 5.7 to 6.4 percent or a fasting glucose level of 100 to 125 mg/dL; in midlife, it can portend serious health problems. A diagnosis of prediabetes means that you are more likely to develop diabetes, and ‘that leads to downstream illness,’ said Dr. Kenneth Lam, a geriatrician at the University of California, San Francisco … ‘It damages your kidneys, your eyes and your nerves. It causes heart attack and stroke,’ he said. But for an older adult just edging into higher blood sugar levels, it’s a different story. Those fearful consequences take years 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.”

The American Diabetes Association and other medical experts have pushed patients and their doctors to get seniors below an A1C reading of 6 and to stay clear of a 6.5 score, which would define them as diabetics. That has meant that doctors have prodded older patients about their diet and exercise, and, in some cases, put them on prescription drugs.

It still is a good idea for all adults to watch their consumption of excess sugar and carbohydrates, as well as to maintain their weight at appropriate levels, stay active and not smoke.

But the specialists and others may need to step back from their medicalization of blood sugar measurements as the formal condition of prediabetes and ease up on this worrisome diagnosis for older patients, experts told the New York Times. As Dr. Lam told the newspaper:

“It’s unprofessional to mislead people, to motivate them by fear of something that’s not actually true. We’re all tired of having things to be afraid of.”

In the Journal of the American Medical Association’s online Internal Medicine section, Lam and Dr. Sei Lee, a fellow geriatrician at the University of California, San Francisco, wrote an editorial calling for a “case-by-case approach in older adults — especially if a diagnosis of prediabetes will cause their children to berate them over every cookie,” the newspaper noted.

The latest research on seniors and prediabetes casts further doubts on prediabetes as a stand-alone condition. It is one of several diagnoses, as I have noted, that can buffalo patients into dubious medical herds.

The respected Centers for Disease Control and Prevention deems prediabetes to be a “serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes.”

The agency estimates that 84 million or so American adults—more than 1 out of 3—have reached this state, with 90% of them unaware of it. “Prediabetes,” the agency warns, “puts you at increased risk of developing type 2 diabetesheart disease, and stroke.” CDC experts have defended this characterization as a key way to raise consciousness to get patients to avert the increasing and real harms of actual diabetes, a disease diagnosed in 30 million Americans (9.4% of the population).

But how useful or meaningful is a condition if so many Americans share it? And how apt is it to call Americans pre-diabetic based on blood sugar readings?

As Dr. Victor Montori, an endocrinologist and diabetes specialist at the Mayo Clinic, explains, in older people, these numbers normally rise as the pancreas produces less insulin and the body becomes more insulin resistant.

An editorial in the respected medical journal JAMA Internal Medicine previously pointed out that before 2000, almost no one had even heard of “prediabetes,” a diagnosis that skeptics have denounced as so sweeping as to be an unhelpful “medicalization.”

As Ann Van den Bruel, a physician, researcher, and University of Oxford faculty member, has noted, studies have shown that 65% of younger patients diagnosed as prediabetic but left untreated do not advance to diabetes within a decade. Further, she has written:

“Treating people with prediabetes delays the development of diabetes by 2 years but provides no long-term benefits and has two important side effects: It increases the number of patients on diabetes drugs (many of whom would never develop diabetes), and it prolongs the duration of treatment in those who do develop diabetes since treatment for prediabetes and diabetes are the same.

In the meantime, insulin, a drug critical in the treatment of diabetes, has skyrocketed in price, and U.S. officials have failed to figure a way to get back in control the price of the life-changing and life-saving medication. And medical groups recently have disagreed among themselves on what ought to be an optimal blood sugar level for diabetics.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them by over testing, over diagnosing, misdiagnoses, and over treatment. Sure, a few simple tests in a doctor’s office may sound harmless. But they too often can lead to a cascade of more costly, painful, and invasive exams and procedures. Excesses in these treatment areas add $200 billion in unnecessary expenses to our care, with over treatment costing 30,000 lives a year of older (Medicare) patients alone. Every episode of care also increases the risks of medical error, which, in more normal times, was a leading cause of preventable death in this country, outpaced then only by respiratory disease, accidents, stroke and Alzheimer’s.

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