Increase in blood sugar as a function of age

[Roy Batty]

Or, perhaps more accurately, does insulin production decrease with age? If it does then might a diagnosis of prediabetes be erroneous and based on blood sugar levels for a younger population?

 

[EllieM]

Hi @Roy Batty what an interesting question.

HBa1c seems to increase with age

Preventing misdiagnosis of diabetes in the elderly: age-dependent HbA1c reference intervals derived from two population-based study cohorts - BMC Endocrine Disorders

Background Measurement of gylcated hemoglobin A1c (HbA1c) plays a central role in monitoring quality of antidiabetic therapy and in the diagnosis of diabetes. Several studies report increased levels of HbA1c in nondiabetic elderly. However, this observation did not reach incorporation into daily...

bmcendocrdisord.biomedcentral.com

The paper above reckons that this could lead to over diagnosis of diabetes in elderly patients... So I guess that means there may be an over diagnosis of prediabetes also.

But we don't know whether this reflects reduced cpeptide from elderly people with less efficient pancreases, increased insulin resistance, or a change in life span of the red blood cells? (Or some combination of these, or something else).

Interestingly, this very small study of 150 non diabetics who wore a cgm

Continuous Glucose Monitoring Profiles in Healthy Nondiabetic Participants: A Multicenter Prospective Study - PMC

Use of continuous glucose monitoring (CGM) is increasing for insulin-requiring patients with diabetes. Although data on glycemic profiles of healthy, nondiabetic individuals exist for older sensors, assessment of glycemic metrics with new-generation ...

www.ncbi.nlm.nih.gov

had slightly higher average glucose levels for the older participants, though it was a small increase and I'm not sure how significant it is with such a small sample. (Note that you need to divide by 18 to convert US mg/dL to UK mmol/L). Look at table 2. (The over 60s had an average bg of 5.8mmol/L whereas the 18-60s were at 5.5mmol/L , roughly corresponding to an increase in hba1c of 2mmol/mol according to my calculations)

As for insulin production, I can't find anything on studies of cpeptide levels by age in non diabetics, though I would be interested if someone else can. (There are lots of papers on declining cpeptide in T1s after diagnosis, but that is not the question that is being asked here.)


As regards the prediabetes (mis)diagnosis you also have to remember that the level at which prediabetes is diagnosed varies quite a bit from country to country.

 

[Roy Batty]

I found this

Hi @Roy Batty what an interesting question.

HBa1c seems to increase with age

Preventing misdiagnosis of diabetes in the elderly: age-dependent HbA1c reference intervals derived from two population-based study cohorts - BMC Endocrine Disorders

Background Measurement of gylcated hemoglobin A1c (HbA1c) plays a central role in monitoring quality of antidiabetic therapy and in the diagnosis of diabetes. Several studies report increased levels of HbA1c in nondiabetic elderly. However, this observation did not reach incorporation into daily...

bmcendocrdisord.biomedcentral.com

The paper above reckons that this could lead to over diagnosis of diabetes in elderly patients... So I guess that means there may be an over diagnosis of prediabetes also.

But we don't know whether this reflects reduced cpeptide from elderly people with less efficient pancreases, increased insulin resistance, or a change in life span of the red blood cells? (Or some combination of these, or something else).

Interestingly, this very small study of 150 non diabetics who wore a cgm

Continuous Glucose Monitoring Profiles in Healthy Nondiabetic Participants: A Multicenter Prospective Study - PMC

Use of continuous glucose monitoring (CGM) is increasing for insulin-requiring patients with diabetes. Although data on glycemic profiles of healthy, nondiabetic individuals exist for older sensors, assessment of glycemic metrics with new-generation ...

www.ncbi.nlm.nih.gov

had slightly higher average glucose levels for the older participants, though it was a small increase and I'm not sure how significant it is with such a small sample. (Note that you need to divide by 18 to convert US mg/dL to UK mmol/L). Look at table 2. (The over 60s had an average bg of 5.8mmol/L whereas the 18-60s were at 5.5mmol/L , roughly corresponding to an increase in hba1c of 2mmol/mol according to my calculations)

As for insulin production, I can't find anything on studies of cpeptide levels by age in non diabetics, though I would be interested if someone else can. (There are lots of papers on declining cpeptide in T1s after diagnosis, but that is not the question that is being asked here.)


As regards the prediabetes (mis)diagnosis you also have to remember that the level at which prediabetes is diagnosed varies quite a bit from country to country.

I found this https://pubmed.ncbi.nlm.nih.gov/24698119/

 

[Roy Batty]

I found this

I found this https://pubmed.ncbi.nlm.nih.gov/24698119/

Aklso this https://hub.jhu.edu/2021/02/09/prediabetes-diagnosis-less-useful-for-older-patients/

 

[Roy Batty]

And thishttps://hub.jhu.edu/2021/02/09/prediabetes-diagnosis-less-useful-for-older-patients/

Older adults who are classified as having "prediabetes" due to moderately elevated measures of blood sugar usually don't go on to develop full-blown diabetes, according to a study led by researchers at Johns Hopkins Bloomberg School of Public Health.

Doctors still consider prediabetes a useful indicator of future diabetes risk in young and middle-aged adults. However, the study, which followed nearly 3,500 older adults, of median age 76, for about six and a half years, suggests that prediabetes is not a useful marker of diabetes risk in people of more advanced age.

 

[KennyA]

And thishttps://hub.jhu.edu/2021/02/09/prediabetes-diagnosis-less-useful-for-older-patients/

Older adults who are classified as having "prediabetes" due to moderately elevated measures of blood sugar usually don't go on to develop full-blown diabetes, according to a study led by researchers at Johns Hopkins Bloomberg School of Public Health.

Doctors still consider prediabetes a useful indicator of future diabetes risk in young and middle-aged adults. However, the study, which followed nearly 3,500 older adults, of median age 76, for about six and a half years, suggests that prediabetes is not a useful marker of diabetes risk in people of more advanced age.

I guess it depends. Bilous and Donnelly [Handbook of Diabetes] say

"There is a steep age-related increase in the prevalence of diabetes and impaired glucose tolerance which applies equally to both sexes";

"the presentation of diabetes in older people is often insidious and the diagnosis is often delayed";

and

"...in developed countries the majority of people with diabetes are aged>64."

The very short section on "Diabetes in Old Age" in the Handbook is [I meant to say - not encouraging for those of us who tick the >64 box]

Given that almost all non-diabetic people are strongly clustered around 38, with plus or minus three points (see graph), then taking the facts above into account you'd have to be looking to establish a different "normal" average for an older cohort.

But something would still be glycating the red blood cells to give that level of reading. And what about the experience of the individuals concerned? are they well? do they have symptoms? I'd find it hard to accept a BG level as "normal" or "acceptable" if it was causing problems.

If insulin resistance naturally increases with age, then you might well expect to find an increase in the "average" BG value for that older cohort. Given that the researchers were using a median age of 76, and following the cohort for six and a half years, you are inevitably going to see a higher proportion of deaths over that time and a higher proportion of other (possibly related or contributory) illnesses than you would in the general population. It could be that enough people in this age group simply don't live long enough to reach greatly elevated BG levels.

Of course, it could be that this research is aiming at establishing some sort of justification for letting a larger proportion of elderly people go without treatment. The advice in the Handbook would certainly back that line up.

Personally, I have doubts about the whole "pre-diabetes" thing being a useful marker for anything. If your blood glucose is no longer in normal range - that's an issue for me. I developed a large number of nasty diabetes symptoms when my BG was 43/44. I am far from being the only one. The level of 48 picked to be the cut-off back-stop for T2 diagnosis was chosen because "retinopathy is rare" at lower blood glucose levels. "Rare", but not unknown. I'd much prefer a diagnosis by a doctor who looked at all symptoms, including a BG out of normal range, made an early diagnosis on that basis, rather than waiting until things had got worse.

My conclusion is that some of this seems to be about the merits of attaching (or not) a particular label, when the label isn't all that much use in the first place.

[Edited to restore something that I deleted and didn't mean to.]

 

[Melgar]

Or, perhaps more accurately, does insulin production decrease with age? If it does then might a diagnosis of prediabetes be erroneous and based on blood sugar levels for a younger population?

One can say that many other age related heath issues, Hypothyroidism for instance. Many older folks feel the cold because their thyroid is no longer efficient, but it's not normal and they still need medication to control it.

 

[Roy Batty]

A link to another paper popped up in a feed I follow, very interesting conclusions.

Effect of Aging on A1C Levels in Individuals Without Diabetes: Evidence from the Framingham Offspring Study and the National Health and Nutrition Examination Survey 2001–2004 - PMC

OBJECTIVE—Although glycemic levels are known to rise with normal aging, the nondiabetic A1C range is not age specific. We examined whether A1C was associated with age in nondiabetic subjects and in subjects with normal glucose tolerance (NGT) in two ...

www.ncbi.nlm.nih.gov

 

[Melgar]

I agree with @KennyA on this. High blood sugars are high blood sugars regardless of age. The fact that pancreas' may become less efficient as we age doesn't detract from the fact that being in a diabetic state is not a healthy place to be for our bodies. It's not healthy and can shorten our lives, period. I'm being cynical here, but it just gives healthcare professionals a reason to say well you are old so it doesn't matter (we can save some money by not putting you on blood sugar reducing meds). It does matter. Same if you had cancer, older people are statistically more likely to get cancer. Do we say that's okay because the older you get the more likely you are to get some form of cancer. It still needs to be treated regardless whether you are statistically likely to get it. Just because people age doesn't mean we can simply put it down to age and not treat it. I find these types of studies disturbing. Elderly patients are often dismissed because they are older, especially in social health care systems. My father was brushed aside by the NHS and not treated for bladder cancer and he died at 65. To this day my stomach turns over because we let it happen when we should have pushed for his treatment. Back then I still had this respect for Dr's and didn't question them, now, I'm all over them, doing my own research and challenging them.

 

[Roy Batty]

I agree with @KennyA on this. High blood sugars are high blood sugars regardless of age. The fact that pancreas' may become less efficient as we age doesn't detract from the fact that being in a diabetic state is not a healthy place to be for our bodies. It's not healthy and can shorten our lives, period. I'm being cynical here, but it just gives healthcare professionals a reason to say well you are old so it doesn't matter (we can save some money by not putting you on blood sugar reducing meds). It does matter. Same if you had cancer, older people are statistically more likely to get cancer. Do we say that's okay because the older you get the more likely you are to get some form of cancer. It still needs to be treated regardless whether you are statistically likely to get it. Just because people age doesn't mean we can simply put it down to age and not treat it. I find these types of studies disturbing. Elderly patients are often dismissed because they are older, especially in social health care systems. My father was brushed aside by the NHS and not treated for bladder cancer and he died at 65. To this day my stomach turns over because we let it happen when we should have pushed for his treatment. Back then I still had this respect for Dr's and didn't question them, now, I'm all over them, doing my own research and challenging them.

Does everything need treating though? It's not uncommon for men to have prostate cancer that doesn't need treatment and they die from something unrelated.

Is it possible to have elevated blood sugar and be prediabetic without developing T2D before death?

It's not unknown to be prescribed drugs unnecessarily.

 

[Melgar]

Does everything need treating though? It's not uncommon for men to have prostate cancer that doesn't need treatment and they die from something unrelated.

Is it possible to have elevated blood sugar and be pre-diabetic without developing T2D before death?

It's not unknown to be prescribed drugs unnecessarily.

Yes. A life is a life, regardless of age, especially when the medical situation is treatable. Some people are not able to advocate for themselves so we must trust the healthcare system to treat us all without prejudice; To get the best medical care regardless of our personal worth. Maybe I have spent too long in North America and I don't accept inept Drs and nurses or getting pushed aside because of my age. I'm 62 I expect to live, hopefully another 25-30 years. I want to know that I am not being pushed aside because of my age with the excuse that I am old and I should expect my body to fail, therefore we will not treat you.

Pre-diabetes is generally not treated in any country, it's a wake up call for us to do something about it. And it is firmly in most people's grasp to give it their best shot at reducing blood sugars with the help of sites like this one. I am also a firm believer that we should work with our medical practitioners for our own health not rely on a Dr or nurse to look after us. It's our life at stake not there's. So there is a degree of personal responsibility if we are mentally fit and able. The Canadian healthcare system is failing. 1 out of every 5 people do not have access to a first line Dr or nurse. Without that access, people are dying needlessly. I didn't have a Dr for over 6 years. That is when I learnt to research and read medical papers to know what is going on. I am nerdy, but many people just accept what Dr's tell them, just like we did when my father wasn't treated for his early bladder cancer - a very treatable cancer. I fell strongly about people getting the right advice and meds.

 

[Roy Batty]

My argument isn't about the value of a life, but whether or not treatment is always desirable, appropriate and necessary.

I have almost no contact with the NHS in the UK, only because I have no need. In the rare instances I do I feel that I'm not treated as an individual, or holistically.

Last year because my blood sugar was on the pre-diabetic range the practice"s diabetes nurse called me and said you need to lose weight and change your lifestyle with more exercise. I was angry as she has no idea about my lifestyle, diet and my body composition and distribution. If she did then she might have recognised a different approach would have been better.

Also, I'm not interested extending my life span regardlessly. By which I mean I would refuse treatment for cancer as an example, if that gave me an extra 6-12 months and required aggressive, invasive, painful procedures that left me requiring extended hospitalisation, nursing care and living in pain.

I'm older than you and I plan to live my remaining time as fullly as possible, whether that's months or years.

 

[Melgar]

Don't get me wrong I totally get what you are saying, and your life choices are yours to make. My own personal view is that all life is precious and as long as you are given the correct medical information, the correct medical advice, and importantly access to proper medical care, then you are in a position to make choices about your own health. If I had terminal cancer I would very likely opt for no treatment myself. Others may think differently. My beef is when you are not given a choice because you are deemed too old or you don't have access to treatment and you don't even know that you are being denied medical options. Diabetes is treatable regardless of age. Now if you are 75 years old, your Ac1 is at 10% those high blood sugars are damaging your vascular system, your organs and whatever else. You are told of the consequences, offered advice and the options for meds but choose to ignore that medical advice then, as long as you are compos mentis, you have the right not to take that advice.

 

[MimT]

My beef is when you are not given a choice because you are deemed too old or you don't have access to treatment and you don't even know that you are being denied medical options. Diabetes is treatable regardless of age. Now if you are 75 years old, your Ac1 is at 10% those high blood sugars are damaging your vascular system, your organs and whatever else. You are told of the consequences, offered advice and the options for meds but choose to ignore that medical advice then, as long as you are compos mentis, you have the right not to take that advice.

Agree with this. When you reach 75 your life expectancy is another 14 1/2 years on average (in Australia), with a wide margin of error. (Plenty of people live till they are 90 or 100 these days.) That might not seem much when you're 30 years old, but for a 75 year old, it often means having a few years to enjoy life (relatively) free from responsibilities and pressures, such as work and raising a family.

Prediabetes can involve large fluctuations in blood glucose, damaging organs and the circulatory system etc. It may be treated with drugs and/or lifestyle/diet changes.

The Harvard study mentioned above had lots of people dying before the end of the study (from what?). It also went for only 5 or 6 years. I've seen elsewhere that prediabetes may lead to diabetes in 5 years, for 25% of people. I don't know if that is with or without drug treatment/lifestyle and diet changes or not. (If you live long enough, lots of things start going haywire. That doesn't mean you can't prevent or slow down those harmful things if you take the appropriate action. It's usually worth a shot.)

Many people who are 70, 80 or 90 years old would be happy to change their diet and get more exercise if it meant living longer and having a better quality of life. Whether they want to also take a drug or not would depend on the risk - e.g. of getting hypoglycemia or other unwanted side effects that they may or may not be able to cope with. Most people would still want to know if their glucose levels are in prediabetic range, just as they'd want to know if their lipids are at harmful levels, or if they have a cancer (treatable or not). If a person is given good and complete information, they can make a judgement about what to do about it, taking advice from their doctors and choosing which advice they want to follow.

 

[AloeSvea]

When my mother was diagnosed with prediabetes in her 80s she and I had lots of discussion about what she wanted to do about it, if anything.

Rather than avoid or cut down the high carb food in her diet (principally bread and weetbix, and cookies and cake, rice, pasta and potatoes) she chose to live with it. I was more distressed than she was, so I went online and looked at the mortality rates of the elderly with elevated blood glucose/prediabetes diagnosed much later life, in terms of going on to diabetes proper and dying of a diabetes complication. I was very happy to find a study that said basically that little time alive as lost to an elderly person developing prediabetes and diabetes proper so late in life. (I think it was pitched in between days and a few weeks.) She was happy to hear it, and as we watch her ever increasing girth getting on to 8 years later, she is more concerned about her appearance than developing the usual range of diabetes complications. (Heart failure being the obvious one to die from, at a ripe old age does not seem tragic? Not to my mother now at any rate....)

The biggie for her, and consequently a worry for me, re diabetes complications, is dementia. Of the vascular variety. It wasn't an issue for her back when we originally discussed it, and now, when it is, it is too late. She lives on a dementia ward now in a rest home. The food is non negotiable. (And she forgets she has dementia, of course, let alone prediabetes.)

 

[Outlier]

There is also the need to take over-medication into account. Some old people I know are in double figures with various drugs that, if one actually reads the accompanying leaflets, may cause problems interacting with each other. Or else the drug(s) for Condition A have a dismal effect on Condition B. Knowledge is power - then we and our loved ones can make better decisions, as we are seldom treated holistically.

 

[Resurgam]

I have found that eating low carb has resulted in needing lower amounts of Thyroxine, which is not something anyone expected, but I stick to my 40gm of carbs maximum fairly rigidly - my blood glucose isn't elevated by a little over indulgence, but it also is not lowered by reducing - I used to set the maximum at 50gm, wanted to lower my HbA1c so reduced to 40 gm and it was exactly the same a year later and at least 3650 gm of carbs less, all carefully counted, HbA1c still 42.
In the last couple of years, still with low blood glucose after eating, my HbA1c has increased by one at each test. I can only put it down to the lower replacement rate of cells, so they are more elderly when tested. I will be 73 soon.

 

[Omar51]

I agree with @KennyA on this. High blood sugars are high blood sugars regardless of age. The fact that pancreas' may become less efficient as we age doesn't detract from the fact that being in a diabetic state is not a healthy place to be for our bodies. It's not healthy and can shorten our lives, period. I'm being cynical here, but it just gives healthcare professionals a reason to say well you are old so it doesn't matter (we can save some money by not putting you on blood sugar reducing meds). It does matter. Same if you had cancer, older people are statistically more likely to get cancer. Do we say that's okay because the older you get the more likely you are to get some form of cancer. It still needs to be treated regardless whether you are statistically likely to get it. Just because people age doesn't mean we can simply put it down to age and not treat it. I find these types of studies disturbing. Elderly patients are often dismissed because they are older, especially in social health care systems. My father was brushed aside by the NHS and not treated for bladder cancer and he died at 65. To this day my stomach turns over because we let it happen when we should have pushed for his treatment. Back then I still had this respect for Dr's and didn't question them, now, I'm all over them, doing my own research and challenging them.

Last month I turned 73, I have been pre w/o meds for over 14 years. Obviously I started off with high BG and high A1c. After years of low carbs, I lost 70/75 pounds. Now my BG is well controlled compared to 14 years ago. I check my A1c quarterly. For the last 3 times my A1c was 34.4 (5.3). Omar