Understanding Type 2 Diabetes
Endocrinologist Deepashree Gupta, MD, UCLA Medical Center, simply defines diabetes as a disorder in which there is a mismatch between your insulin and blood sugar levels. “When you eat, your food is broken down into a sugar called glucose, which gives you energy,” she explains. “To use glucose as energy, your body needs insulin. With diabetes, the body does not make enough insulin or does not use it well.”
Type 1 diabetes results from a pancreas that does not make enough insulin, whereas type 2 diabetes occurs when cells resist what insulin is supposed to do—regulate blood sugar levels. Type 2 diabetes is by far the most common, and it may be possible to reverse it with healthy lifestyle choices.
Though a “prediabetes” diagnosis warns of probable disease, a growing body of evidence is questioning its relevance, especially for older adults, according to a new study published Feb 8, 2021, in JAMA Internal Medicine.
“Prediabetes” in Older Adults
The term “prediabetes” was introduced in 2001 when the American Diabetes Association began to call slightly elevated blood sugar prediabetes. Later adopted by the Centers for Disease Control and Prevention (CDC), this definition has led to farreaching consequences in medicine, such as more frequent office visits, lab tests, and more prescriptions for metformin (a common medication for diabetes). But how often does prediabetes actually progress into diabetes in older adults?
A 2018 review of 103 studies by the Cochrane Library in London reported that most people who qualify for prediabetes rarely go on to develop disease. Instead of prediabetes, UK researchers often use the term “intermediate hyperglycemia” (IH). The study authors concluded, “Taking into consideration the uncertainty of the available evidence, as well as the fluctuating stages of normoglycemia (normal blood sugar), intermediate hyperglycemia (IH) and type 2 diabetes mellitus, which may transition from one stage to another in both directions even after years of followup, practitioners should be careful about the potential implications of any active intervention for people ‘diagnosed’ with IH.”
This year, a study led by the John Hopkins Bloomberg School of Public Health looked into implications of a prediabetes diagnosis in older adults and suggests that the diagnosis may not be warranted or wise in this population. The hemoglobin A1C blood test summarizes a person’s average blood sugar level over a three month period. A normal level is below 5.7%; and 5.7% to 6.4% is considered prediabetes. The higher the level, the greater the risk for developing the disease. In the study, however, while many people over age 60 had prediabetes, most of the time it did progress into diabetes. It also did not place them at greater risk of death than their peers who did not have the prediabetes diagnosis.
To reach this conclusion, researchers analyzed data from 3,412 adults (average age 75.6 years). During the 6.5 years of follow-up, about 44% of participants had A1C levels that qualified as prediabetes, but only 9% progressed to diabetes, while 13% actually regressed to normal blood glucose levels. In addition, people with prediabetes were no more likely to die than those with normal
blood sugar.
And while healthy lifestyle habits are appropriate for everyone, medications for “pre” disease come with potentially worrisome side effects. Some geriatricians argue that this “pre” disease diagnosis creates unnecessary stress on older adults who already may be on multiple medications and/or challenged by more concerning conditions that deserve greater attention. This does not mean that elevated blood sugar should ignored, nor that medication should never be used. Rather, it’s a call to recognize that prediabetes and diabetes treatments have age-appropriate considerations.
Endocrinologists, Specialty Care
In some people, diabetes can become complicated and challenging to treat and manage. Therefore, some primary care physicians may refer patients to an endocrinologist. These internal medicine doctors specialize in the endocrine system, which is a system of hormone-making glands such as the thyroid, pituitary, adrenal, reproductive glands, and the pancreas. Endocrinologists can help people who are newly diagnosed with diabetes learn to effectively manage or possibly reverse the disease, and they also work with people whose diabetes has become difficult to manage or with those who have concerning complications. Uncontrolled diabetes can seriously damage the nervous system, eyes, kidneys, and lead to gangrene on the feet.
What you eat and your activity level can affect whether or not you get diabetes, and also may reduce medication need. But if medications are needed, it’s vital to consider older age, a person’s
preferences, and current health status. Guidelines are just a starting point; every person is unique and deserves personalized care.
Glucose, the Energizer
Foods typically contain a combination of what’s called macronutrients, which include carbohydrates, proteins, and fats. Each of these macronutrients is converted into glucose, but the amount of glucose varies as does where it may be stored. For example, although some protein is converted into glucose, most of it is stored in the liver and therefore has very little impact on blood sugar levels. Fat breaks down into glucose, but only about 10% of it does so. Also, fat is absorbed very slowly and so it does not spike blood sugar levels. In sharp contrast, 100% of carbohydrates are converted into glucose. High-carbohydrate and highly processed foods (e.g., white bread, white rice, cookies and cakes) quickly affect blood sugar levels, typically within an hour or two of consuming them.
Insulin, the Regulator
Insulin, a hormone made by the pancreas, constantly circulates through the bloodstream. When it sees glucose, it signals cells to absorb it. If there is too much glucose, insulin prompts cells to store it for use later. In these ways, insulin plays a key role in regulating proper blood glucose levels. But in people with type 2 diabetes, the pancreas makes insulin, but the cells resist its commands. That means glucose is not readily getting into cells and is instead piling up in blood vessels. “When blood glucose remains elevated over long periods of time, people feel sick,” explains endocrinologist Andrew Day, MD, UCLA Department of Medicine/Endocrinology. “They become very thirsty and they urinate more frequently. That’s because when the blood sugar is elevated, the body tries to get rid of it through urine.”
Other symptoms of high blood sugar include fatigue, reduced ability to concentrate, and tingling in hands and feet.
Regulating Blood Glucose with Medicine
Type 2 diabetes is typically treated with oral medications that normalize blood sugar levels. However, according to a recent Mayo Clinic study tight glucose control may not be ideal for older patients. Doing so could lead to low blood sugar levels (hypoglycemia), which places older adults at greater risk for dizziness and falls. Consider also that the benefits of tight glucose control may take years or decades to realize.
Endocrinologist Rozalina McCoy, lead author of the study and a primary care physician at Mayo clinic, said in the study’s conclusion, “We have a great opportunity to simplify and de-intensify the treatment regimens of our more elderly patients, which would reduce their risk of hypoglycemia (low blood sugar) and treatment burden without spilling over into hyperglycemia (high blood sugar).”
Dr. Gupta concurs that blood sugar targets and medications may need to be adjusted for changing needs of older adults. Metformin may be an appropriate medication for older adults with diabetes because it decreases glucose production from the liver, increases insulin sensitivity, and sometimes assists with weight loss. “It rarely causes low glucose levels, which is why it makes sense in this population,” she says.
Prevent and Manage Diabetes
According to research, diabetes in an older population is associated with reduced muscle strength, poor muscle quality, and accelerated loss of muscle mass. Diabetes is also an independent risk factor for frailty, which is characterized by diminished physical ability, psychosocial stress, and poor health outcomes. Recommendations that counteract those problems include consuming higher amounts of protein combined with aerobic and strength training exercises.
According to Dr. Day, if you have been diagnosed with prediabetes, exercising and eating healthfully can significantly reduce your risk of developing diabetes. He recommends setting small attainable
goals, keeping food and activity logs, and aiming for slow and steady weight loss rather than crash dieting. Recognizing that people often stress eat, he advises, “Write down situations when you are more likely to eat, and that can help you develop a plan to do something about it.”
He also advises slowing down while eating. When rushing, it’s very easy to overeat. Savor and try to enjoy the meal. A weekly meal plan can help you stay on track with nutritious dishes you enjoy. For inspiration, check out this website: http://tiny.cc/NIDDKRecipes.
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