Prediabetes prognosis poor predictor of illness development for older adults

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February 26, 2021

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Older adults with HbA1c in the prediabetes range were far more likely to return to normoglycemia or die during a 5-year follow-up period than they were to transition to overt type 2 diabetes, according to a community-based study.

The results suggest that prediabetes may not be a “robust diagnostic unit in old age,” the researchers wrote in a study published in JAMA Internal Medicine.

About 60% of older adults with prediabetes either returned to normoglycemia or died during a 5-year follow-up.

“Prediabetes is defined by elevated blood sugar levels below the threshold for diagnosing diabetes.” Mary R. Rooney, PhD, MPH, Healio said, a postdoctoral fellow at the Bloomberg School of Public Health at Johns Hopkins University. “Doctors look for prediabetes to identify patients at high risk of diabetes. Although we knew that slightly elevated levels of glucose or HbA1c were common in elderly patients, the question of whether these patients are more likely to develop diabetes remains unsolved. “

Incidence of disease low

Rooney and colleagues analyzed data from 3,412 baseline older adults without diabetes who participated in the Atherosclerosis Risk in Communities Study (ARIC) (baseline 2011-2013; mean age 76 years; 60% women; 17% blacks).

The participants were contacted every six months until December 2017 and took part in a follow-up visit between 2016 and 2017. The median follow-up was 5 years.

The researchers defined prediabetes as HbA1c between 5.7% and 6.4%, an impaired fasting glucose level between 100 mg / dl and 125 mg / dl, or both.

The primary endpoint was total diabetes, defined as a medical diagnosis, use of glucose-lowering drugs, an HbA1c of at least 6.5% or a fasting glucose of at least 26 mg / dl.

Mary R. Rooney

At the start of the study, 1,490 participants (44%) had HbA1c values ​​between 5.7% and 6.4%, 1,996 (59%) had IFG, 2,482 (73%) met the HbA1c or IFG criteria for prediabetes and 1,004 (29 %) both met the HbA1c and IFG criteria.

Within the cohort, 2,497 participants either attended the follow-up visit or died. During the follow-up, researchers observed 156 cases of diabetes (118 doctors diagnosed) and 434 deaths.

Among participants with baseline HbA1c levels of 5.7% to 6.4%, 97 (9%) developed type 2 diabetes, 148 (13%) regressed to normoglycemia, and 207 (19%) died. Of those with IFG at baseline, 112 (8%) developed type 2 diabetes, 647 (44%) regressed to normoglycemia, and 236 (16%) died.

Among participants with a baseline HbA1c of less than 5.7%, 239 (17%) developed HbA1c in the prediabetes range and 41 (3%) developed type 2 diabetes. Of those with a baseline fasting glucose level of less than 100 mg / dl, 80 (8%) developed IFG and 26 (3%) developed type 2 diabetes.

“In fact, in older adults with prediabetes, regression to normoglycemia or death was more common than progression to diabetes during the study period,” the researchers wrote.

An “optimal” definition of prediabetes

Depending on the definition, the prevalence of prediabetes in the study ranged from 29% to 73%, the researchers found. In secondary analyzes, the prediabetes prevalence according to international criteria was 15% lower, based on the criterion of the international committee of experts for an HbA1c level range of 6% to 6.4% and 23% based on the WHO criteria for fasting glucose levels of 110 mg / dl to 126 mg / dl.

“The various definitions and the wide range of prevalence estimates pose a challenge to understanding the burden of prediabetes in the population and its clinical and health relevance,” the researchers wrote. “The different definitions of prediabetes also have different benefits in assessing future diabetes.”

The researchers found that based on a confirmatory definition, the specificity for prediabetes was highest – both HbA1c levels of 5.7% to 6.4% and IFG – but the specificity was lowest when they were on either HbA1c – Levels from 5.7% to 6.4% or IFG based.

“Conversely, the sensitivity for association with complete or diagnosed diabetes was highest in prediabetes based on HbA1c levels of 5.7% to 6.4% or IFG and lowest on the confirmatory definition,” the researchers wrote. “The more stringent international definitions for prediabetes had a higher specificity for the association with both diabetes outcomes, but the sensitivity was lower. These differences in diagnostic performance have implications for screening strategies for diabetes. “

Rooney said that being diagnosed with prediabetes still offers an opportunity for lifestyle changes for an older adult.

“We found that HbA1c in the prediabetes range in older adults may not be a robust predictor of diabetes progression,” said Rooney. “This joint laboratory result can still provide an opportunity to encourage lifestyle improvements, including exercise and diet, if it is feasible and safe to do so. This approach has far-reaching benefits for patients. “

For more informations:

To damagey R. Rooney, PhD, MPH, can be reached at mroone12@jhu.edu.

perspective

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Kevin M. Pantalone, THU, ECNU, FACE)

Kevin M. Pantalone, DO, ECNU, FACE

It is estimated that approximately 35% of the US population has prediabetes, also commonly referred to as “an increased risk of type 2 diabetes.” It is important to note that the prevalence of prediabetes reported in the literature varies depending on the test used – HbA1c, fasting glucose, oral glucose tolerance test, or a combination of the three – and the diagnostic accuracy of the tests currently used to detect prediabetes has been reported to be in Screening programs is rather low.

Rooney and colleagues conducted a community-based cohort study of older adults with a median age of 75 and found that the prevalence of prediabetes was high. However, during follow-up, regression to normoglycemia or death was more common than progression to diabetes. The authors conclude that given the low rate of progression to diabetes in old age, prediabetes may not be a robust diagnostic unit.

However, it is important to note that prediabetes, like type 2 diabetes, is a spectrum disorder. The risk of progression is influenced by other factors beyond age. The report did not mention or take into account diabetes, BMI, weight changes, medication use such as metformin or comorbidity burden in the family history. These are important variables to consider when risk stratifying patients to determine who can make progress, who may need later assessment, and how often they should be reassessed. Many older patients with complex comorbidities can lose weight unintentionally, which often indicates an underlying disease. Such weight loss could be a significant disruptive factor that may, in part, affect or reduce the risk of prediabetes progressing to overt diabetes in this elderly population. Further studies on this subject are certainly in order.

Finally, it is important to realize that many prediabetes patients are also overweight or obese. When these are identified, formally diagnosed, and treated with lifestyle interventions with or without medication, it can reduce the risk of developing overt diabetes, as outlined in the Diabetes Prevention Program.

Kevin M. Pantalone, DO, ECNU, FACE

Employee endocrinologist

Director of Diabetes Initiatives

Department of Endocrinology

Cleveland Clinic

Disclosure: Pantalone reports that it has received speaker and consultancy fees from AstraZeneca, Bayer, Corcept Therapeutics, Eli Lilly, Merck, and Novo Nordisk, and research support from Bayer, Merck, and Novo Nordisk.

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