Risk factors

Is prediabetes now an irrelevant concept that can be ignored?


The concept of prediabetes may be irrelevant, according to findings from a study that found older adults with prediabetes were more likely to regress to normoglycaemia than progress to diabetes.

The study, published in JAMA Internal Medicine, comprised 3,412 adults 71-90 years of age. None had diabetes at baseline however 73% met either HbA1c criteria for prediabetes or had impaired fasting glucose (IFG).

After a median follow up of five years, most patients (59%) with baseline prediabetes remained in the HbA1c 5.7% – 6.4% range, 19% had died, 13% regressed to normoglycaemia, and 9% progressed to diabetes.

In patients with baseline IFG, 32% had no change in status by the follow-up visit, 16% had died, 44% regressed to normoglycaemia and 8% had progressed to diabetes.

The study found however that prediabetes at baseline – by any definition – was associated with incident total diabetes and incident diagnosed diabetes.

“For diagnosed diabetes, the highest absolute risk was observed among those with HbA1c levels of 5.7% to 6.4% and FG levels of 100 to 125 mg/dL (incidence rate, 79.3),” the study said.

“The findings of the current study support a focus on lifestyle improvement when feasible and safe, especially given the broader benefits of lifestyle modification beyond diabetes prevention.”

“Given the low risk of diabetes progression in this study (especially relative to mortality risk), it is unlikely that pharmacologic intervention or other aggressive approaches to diabetes prevention in older age will provide large benefits and could have unintended harmful effects (eg, overdiagnosis, anxiety, and implications for insurance coverage).”

An Invited Commentary in the journal went further and said prediabetes was irrelevant and can safely be ignored in older adults.

It said the concept of prediabetes should be reserved for healthier, middle-aged adults as it appeared to be a weaker risk factor for diabetes in older adults.

“For most patients, it is the end-organ vascular complications that results from years of poorly controlled diabetes that cause symptoms. Therefore, the modern definition of diabetes is conceptually closer to being a risk factor itself (eg, something that portends future disease) than an illness (eg, something that patients experience).”

“Prediabetes, then, is a risk factor twice removed; it is a risk factor for diabetes, which itself may be most accurately described as a risk factor for end-organ vascular disease.”

“Because the benefits of prediabetes management are most likely accrued 10 or more years in the future, older adults with frailty and limited life expectancy are unlikely to benefit from prediabetes management.”

Australian perspective

However Professor Jonathan Shaw told the limbic that it was a defined population that couldn’t be ignored.

“Whilst more people either stayed the same or went backwards [to normoglycaemia] than progressed to diabetes, the majority of people who ended up developing diabetes did so from the status of prediabetes. There is only one way to get from normal to diabetes and that is through prediabetes.”

And there were really only two ways of preventing diabetes.

“One is to make the whole population healthier and the other is to target those people at higher risk and one of the most obvious groups – even if the risk isn’t stratospherically high – is people with prediabetes.”

Professor Shaw, Deputy Director (Clinical and Population Health) at the Baker Heart and Diabetes Institute, said the results were however somewhat reassuring.

“The relatively smaller number of people progressing to diabetes is important. A small part of the report also tells us that mortality wasn’t increased in people with prediabetes. To me that is another reassurance that prediabetes may not be such a serious target in older people.”

He said there had already been a relaxation of HbA1c treatment targets over the last 10-15 years for older adults or people with multiple comorbidities.

“It’s not a surprise really that if we are less aggressive with diabetes itself in older adults, then similarly the same should apply to prediabetes.”

He said, consistent with the Australian consensus-based position statement on the management of prediabetes, there wasn’t much of a role for glucose-lowering medications.

“The ADS position statement noted that medication is probably only valuable in younger patients,” he said.

“It’s still a condition which requires some attention – mainly to the general tenets of a healthy lifestyle. I probably wouldn’t be putting them into an intensive lifestyle program unless there were other reasons, for example, obesity and a need to lose a lot of weight.”

He added that balance and muscle strength become more important targets in the elderly.

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