Diagnosing Diabetes Early and in the Elderly and the Prediabetes Label

The Book

The Book - Atmasvasth - A Guide to Ageing Healthfully

A 15-point guide to living long, healthy

AtmasvasthBhavin Jankharia

The Detailed 15-Point Guide to Live Long, Healthy

The 15-Point Guide - Detailed

The detailed 15-points guide to live long, healthy

AtmasvasthBhavin Jankharia

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In Dec 2024, I had written about the need to step up diabetes testing in all people over the age of 30, given the large number of undiagnosed diabetics in our country. The idea is that we can make a difference by getting those around us (workers, house-help, chauffeurs, people we know, relatives and friends) to test for diabetes with at least a fasting plasma glucose (FPG) level. This is cheap and can be done for under Rs. 100. Each of us could just budget Rs. 1000 per month and get 10 people around us tested and we would be saving lives each time we help identify a person previously undiagnosed to be diabetic.

The LASI (Longitudinal Aging Study of India) authorities have just released some more data [1]. They measured HbA1c levels and found that in those over age 45, 15% reported abnormal levels > 6.5%. Of these, 8% were undiagnosed, while 7% were diagnosed but under-treated. This data is from 2018, at which time approximately 330 million Indians were above the age of 45. This would mean 26.4 million undiagnosed and 23.1 million under-treated.

The 15% number also matches the NCRD data from 2022, which was published in 2024 [2] that I referenced in Dec 2024. 

I will come back to this in next week’s piece on what more we can do to create a major impact by helping to reduce cardiovascular risk in those around us. 

Things are a little more complex though when we look at a first-time diagnosis of borderline or mildly raised FPG or HbA1c levels in those over the age of 80. Recently, an aunt of mine was diagnosed to have “mild” diabetes with an FPG of 130 mg/dl and put on intensive treatment, which does not make sense. In otherwise healthy elderly people, it is fine to aim for an FPG of up to 130 mg/dl or an HbA1c of up to 7.5%. If they have other diseases, or cognitive impairment, then up to 150 mg/dl FPG and an HbA1c up to 8.0% is fine. If very sick, then an FPG up to 180 mg/dl is also acceptable and the HbA1c no longer matters [3].

There is a possibility of significant harm, if there is hypoglycemia and the FPG drops suddenly and tight glycemic control is not advocated in the elderly and frail the way it is in those between 18-75 years of age. 

And that brings us to an even more prickly problem…of the label “prediabetes”. I have seen relatives and friends and even doctors go into a tizzy when the FPG is between 110-125 mg/dl and HbA1c values are between 5.7-6.4%.

The “prediabetes” term is endorsed by the American Diabetes Association (ADA), but the International Diabetes Federation (IDF) just uses the term "intermediate hyperglycemia" while the WHO specifically does not endorse the term “prediabetes” because of the negative connotations of a label that may not ever turn into a disease. 

While there is data that suggests that early intervention may reduce the rate of progression to full-blown diabetes, a good number of people never progress and many reverse on their own. The paradox is that while testing can identify “at-risk” people, all decision making has to be individual. If you have other syndemic problems (high blood pressure, overweight/obesity, high LDL levels and smoke) that I wrote about last week, then perhaps the pre-diabetes label is a warning to get your act together. But if you have no other risk factors, then it could be a false alarm for which nothing further needs to be done. 

What does this mean for you and I?

1. If you are reading this, you would surely have tested yourself for diabetes. But please take some time out and get everyone around you tested. It is so inexpensive…for every 100 people you get tested (under Rs. 10,000), you will pick up 8 untreated full-blown diabetics, who will benefit from treatment and whose lives you will have improved for the better. 

2. If you or your family member above the age of 80 get diagnosed to have diabetes for the first time, do not rush into treatment, without having a detailed conversation about risks and benefits with an expert who understands not just diabetes care, but specifically, diabetes care in the geriatric population.

3. If you or your family member are given a label of prediabetes, do not rush into treatment without a detailed understanding of risks and benefits and the knowledge that a large number of so-called labeled prediabetics, never progress (i.e that FPG level is normal for them) or actually reverse on their own. If however, you have other syndemic issues, then you would need to take that label much more seriously.

Footnotes

1. LASI Wave 1 – Report on Biomarkers Based on DBS Assays

2. NCD Risk Factor Collaboration (NCD-RisC). Lancet. 2024 Nov 23;404(10467):2077-2093 

3. ElsSayed NA et al. Older Adult: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46:S216-S229