According to the National Institute of Diabetes and Digestive and Kidney Diseases, more than 135 million people in the U.S. have diabetes or prediabetes. Of those adults, one in five did not even know they had the condition.
Diabetes is a chronic medical condition characterised by high levels of glucose (sugar) in the blood and can cause a heart attack, stroke, blindness, kidney failure, or loss of feet or legs.
Prediabetes, on the other hand, is when your blood sugar levels are higher than normal, but not quite at the diabetes level yet.
“It’s so important to understand the difference between prediabetes and diabetes,” said Alisha Natzke, APNP, a Family Nurse Practitioner at Aspirus Health. “Think of prediabetes as a warning sign; you don’t have diabetes yet but without making lifestyle changes people can progress into Type 2 diabetes.”
Diabetes risk factors include:
Being overweight
Having a parent or sibling who has Type 2 diabetes
Lack of physical activity (fewer than three times per week)
Some ethnic groups are at a higher risk for Type 2 diabetes
The good news is that Type 2 diabetes can be delayed or prevented in people with prediabetes or diabetes risk factors through effective lifestyle programs.
“Start by increasing your physical activity, it does not have to be perfect, start by increasing whatever you may have done in the past,” adds Natzke. “Focus on your meal choices and avoid things that are high in sugar, carbohydrates or made with processed foods because those all cause your blood sugar to spike.
Here is a checklist of recommendations to help reduce the risk of diabetes or prediabetes:
Increase your physical activity. Before you jump into a rigorous exercise routine, talk to your doctor about what physical activities are most beneficial for your body. Start slowly to avoid injury and work your way up to 30 minutes of exercise five days per week. Things like walking, swimming, and dancing could help keep your blood sugar from spiking.
Choose foods wisely. Carbohydrates like bread, grains, starches, milk, and fruits have the biggest effect on blood sugars. Focus heavily on controlling portion sizes of those foods and balance them with foods like vegetables, lean proteins, and heart healthy fats. A registered dietitian should help you customize a meal plan.
Check blood sugar regularly. Keep an eye on what you eat and how it affects you by testing your blood sugar. A fasting blood glucose level between 100 and 125 milligrams per deciliter (mg/dL) is considered prediabetes.
Get in the know. Talk to a certified diabetes educator to learn how to self-manage type 2 diabetes, including ongoing treatment. Diabetes educators provide information about how exercise and food choices affect blood sugar and prevent things like eye or kidney damage. The more you know, the easier it is to make healthy choices.
Check in with your primary care clinician regularly. Treatment needs to change depending on your blood sugar levels. Make appointments for regular check-ups to ensure you are up to date on your regimen.
“Complications from diabetes can range from numbness and tingling to the potential loss of limbs,” said Natzke. “We can also see damage to the kidneys and eyes or wherever there is small blood vessels, blood sugar when its elevated can cause damage to those areas.
As people with diabetes age, the glucose management strategies they’ve relied on for decades may need some adjustment.
Researchers at ATTD 2025 presented various strategies for simplifying treatment plans in older adults with diabetes.
Using advanced technologies like CGMs and AID systems can help older adults manage their diabetes more effectively, safely, and independently.
Several sessions at the 2025 Advanced Technologies and Treatments for Diabetes (ATTD) conference spotlighted diabetes management strategies for older adults living with diabetes.
According to the Centres for Disease Control (CDC), almost 30% of people aged 65 or older have diabetes, and this population is at higher risk for developing diabetes-related complications like low blood sugar (hypoglycaemia), kidney failure, and heart disease than younger people living with diabetes. And as the population continues to age, the number of older adults living with these conditions is expected to grow significantly in the coming years.
Joshua Neumiller, a pharmacist and certified diabetes care and education specialist (CDCES) at Washington State University highlighted the importance of individualized care in this population. Two 65-year-old individuals with diabetes can have different self-care abilities, living situations, levels of support, and goals. Their treatment regimen should be reflective of all these factors, and not just based on age, he said.
In addition, more than two-thirds of older adults have two or more chronic conditions, which may require multiple medications that can add additional burden to diabetes management. Researchers at ATTD emphasized that older adults may actually benefit from a simpler treatment regimen, especially when it comes to managing blood sugar.
“There is this paradox where overly intensive and complex treatment regimens are actually more common in those at highest risk of hypoglycaemia,” Neumiller stated.
Because older adults are commonly being overtreated for diabetes, the American Diabetes Association (ADA)’s 2025 Standards of Care recommends “de-intensifying,” or lowering the dose or frequency of medications that can cause hypoglycaemia (like insulin and sulfonylureas). Simplifying complex treatment plans can ensure that individualized blood sugar goals are met, and that the benefits of certain medication outweigh the harms.
Deprescribing and de-intensifying
Dr. Anna Kahkoska, an Assistant Professor in Nutrition at UNC Chapel Hill, defined deprescribing as the process of stopping an inappropriate medication with the supervision of a healthcare professional. Deprescribing comes with many challenges, as there is no universal definition for “overtreatment,” and existing guidelines rely on A1C, which is not always accurate or predictive of experiencing low blood sugar.
“Just because someone has an A1C of 8 or above does not mean that they’re not at risk of experiencing hypoglycaemia,” Neumiller explained.
De-intensifying, on the other hand, means reducing the dose, frequency, or strength of a medication rather than stopping it altogether. Treatment regimens can also be simplified by making dosing schedules easier, reducing blood glucose checks, and consolidating medications. The ADA recommends that de-intensifying diabetes medications for older adults should be considered when the harms and/or burdens of treatment may be greater than the benefits.
Realignment
While deprescribing and de-intensifying can help manage the burden of taking multiple medications, realignment is a more dynamic and individualized approach that integrates data from CGMs to identify patterns in blood sugar, reduce hypoglycaemia, and simplify care.
Dr. Medha Munshi presenting at ATTD 2025
Dr. Medha Munshi, a geriatrician and endocrinologist that directs the Joslin Geriatric Diabetes Program, authored a recent paper that guides healthcare providers to follow a four-step process that can ensure changes to treatment regimens are individualized, simplified, and safer.
Step 1: Seek triggers
The first step is to investigate signs, symptoms, or factors that may impact treatment goals or strategies. Examples of this include medical events, such as a fall or accidental injury, as well as emergency room visits or hospitalisations. Life-altering events, including a change in living situation or loss of a spouse or care partner can also signal a need for realignment. New or worsening cognitive impairment can also be a sign of unrecognized hypoglycemia.
Once these triggers are identified, it’s important to determine if the cause or contributing factors are diabetes-related. For example, an overly complex diabetes regimen could contribute to missing doses, which could then cause symptoms such as confusion and interrupted sleep.
Step 2: Shared decision-making
To take action, providers should review medications for any side effects or interactions, and check with the care partners and pharmacy to see if medications are being adhered to. A two-week CGM can help to evaluate more specific patterns in blood sugar changes.
Consulting with the older adult with diabetes and/or their care partner is crucial to ensuring that any decisions made to change a treatment regimen align with the patient’s goals and preferences.
Step 3: Set or reset goals
Once the need for realignment is established, providers can work with their patients and caregivers to revise management goals based on both changes in clinical, psychosocial, or environmental factors and the individual’s preferences for their diabetes management.
Step 4: Simpler and safer treatment
The treatment strategy should be based on individual-specific and disease-specific considerations, with an emphasis on safety.
Realignment of treatment strategies includes multiple processes, all of which work towards reducing the burden of managing blood sugar levels with other chronic conditions, improving outcomes and quality of life, and providing older adults with a sense of autonomy and independence in their diabetes management.
Using advanced technology to support older adults with diabetes
Technology is key for realignment, said Munshi, as CGMs can identify patterns that are not seen by fingersticks or A1C testing. Munshi’s recent study in adults over the age of 65 with type 1 diabetes and hypoglycaemia found that CGM use combined with realignment strategies reduced the amount of time participants spent with their blood sugar below 70 mg/dL (hypoglycaemia), and lowered the number of hypoglycaemic episodes.
Recent clinical trials have also shown that using automated insulin delivery (AID) systems in older adults with type 1 diabetes can improve time in range and A1C, as well as decrease hypoglycaemia.
“Ten years ago, I would have said that AID is not meant for this population. Now, you see two things happening – aging people are becoming more technologically savvy, and the technology itself is becoming more user-friendly,” explained Munshi.
Research on the use of advanced technologies in older adults is growing, but a recent review found that there’s a significant gap in studies that measure the effectiveness of these technologies in diverse populations of these older adults. More work needs to be done to understand what the barriers are to adopting this technology in this population.
“Older age itself should not be a limiting factor for using advanced technologies in diabetes,” stated Tomasz Klupa, a professor at Jagiellonian University Medical College in Poland.
Klupa presented preliminary results from a study on the MiniMed 780G system in adults over 65 with type 1 diabetes, mentioning that older adults may need a more personalized approach and more time to adapt to new technologies, but it should never be assumed that the patient’s age will be a limitation.
Dr. Anna Kahkoska presenting at ATTD 2025
In a presentation on the use of CGMs in older insulin-dependent individuals with cognitive or functional impairment, Kahkoska also emphasized that learning how to use this technology is a dynamic process, but it can have benefits that go beyond reducing the risk of hypoglycaemia.
Studies have shown that using advanced diabetes technology can also improve the safety and well-being of people with diabetes by preventing the worry associated with hypoglycaemia, and increasing feelings of security, confidence, and freedom in daily activities.
The session at ATTD concluded with a final powerful message from Dr. Munshi: “Don’t take your eyes off of the final goal, which is aging successfully,” she said. “Most of us, and our older patients, want to be independent and cognitively healthy. Let’s not do anything that interferes with that ultimate goal.”
The bottom line
Older adults with diabetes often require more individualized and simplified treatment regimens to manage their condition safely. Realigning treatment regimens and using advanced technologies like CGMs can help reduce hypoglycaemia and improve overall well-being, allowing for greater independence and quality of life. Ultimately, the goal should be to support aging successfully, keeping personal preferences and health priorities at the forefront of their care.
Health data from people raised during sugar rationing offers insights on chronic disease
It’s hard to escape the fruit snacks-juice box culture many parents and children live in. But a growing body of research supports limiting children’s sugar intake for the first 1,000 days of life — starting at conception — or until age 2.
A study released last year based on World War II-era data highlights the importance of eating well, particularly during pregnancy, says Robert Siegel, a paediatrician and paediatric obesity specialist at Cincinnati Children’s Hospital and Medical Centre. Siegel, who was not involved in the study, is also the director of the hospital’s Centre for Better Health and Nutrition.
“You are not only what you eat, you are what your mom eats,” Siegel says. “In utero and afterward, you’re definitely developing these food preferences.”
World War II-era data offered a window into life with and without sugar rationing. (iStock)
Diabetes risk
Published in Science last year, the World War II-based research points to an increased risk of some chronic diseases, including Type 2 diabetes and hypertension, for pregnant women and young children who consume higher levels of sugar.
She says health data collected during and after World War II-era sugar rationing in Britain offers unique insights. It allowed her team to compare long-term health trends among those who had extremely limited access to sugar in their early years with those who had more traditional sugar intake.
Using data from the UK Biobank, the researchers examined records of more than 60,000 people born between October 1951 and March 1956 (ages 51-66 at the time of the survey). Britain rationed sugar and other foods from January 1940, early in World War II, until the mid-1950s, years after the war’s end.
Early-life sugar rationing was associated with reduced Type 2 diabetes by 35 percent and delayed disease onset by four years, and a 20 percent lower hypertension rate and delayed disease onset by two years, the study found.
“We find that the end of rationing increased the adult prevalence of chronic inflammation, an important marker of chronic disease. We also find increases in poor metabolic health; particularly diabetes, cholesterol and arthritis,” Gracner and her co-author, Paul Gertler, wrote in a working paper accompanying the study.
In an interview, Gracner says more research is needed on the underlying reasons for this, but “our findings suggest that early-life sugar restrictions set individuals on a healthier trajectory.” One possible reason, she says, “is a reduced preference for sweetness — a hypothesis supported by our working paper and other studies showing that taste preferences form early and persist into adulthood.”
Researchers are investigating the role epigenetics — changes in gene expression that can be inherited — and metabolism play during pregnancy, and want to learn more about just how much sugar is “okay” during critical periods of foetal development, Gracner says.
“It means that we need to continue to work on the ideal nutritional intake from the moment of conception onward,” adds Mark R. Corkins, chair of the American Academy of Paediatrics’ Committee on Nutrition and division chief of paediatric gastroenterology at the University of Tennessee Health Science Centre.
Guidelines for parents
The American Academy of Paediatrics (AAP) says maternal prenatal nutrition and the first two years of life (starting with conception) may “program” childhood and adult health risks. The Mayo Clinic recommends avoiding “added sugars.” These are the sugars added to food products, including pasta sauces, crackers and drinks. Typically, they’re processed and not naturally occurring; they include corn syrup, fructose, sucrose and glucose.
The AAP says sugar makes up 17 percent of kids’ diets, and half of that comes from sugary drinks. Among the AAP’s recommendations:
Children under 2 years should consume no added sugar.
Children 2 and older should take in less than 25 grams (about 6 teaspoons) of added sugar per day. For reference, 1 cup of Honey Nut Cheerios has 12 grams of added sugar.
Steven Abelowitz, medical director and paediatrician at Ocean Paediatrics in Orange County, California, says parents don’t need to strive for perfection but for reducing sugar as much as possible.
“Today, in almost all food products, there’s a breakdown of all ingredients including sugar,” Abelowitz says. “When there’s an option, choose the product that is lower in sugar.”
For parents who need a starting place or goal, he recommends a concept called “95210,” developed by Pittsburgh-based paediatrician Alicia Hartung:
9 hours of sleep
5 servings of fruits and vegetables per day
2 hours or less of screens
1 hour of movement
0 sugary drinks
Abelowitz says there are lower-sugar swaps that can help during pregnancy. “Looking at and being aware of the total carbohydrates and total sugar contents in products will help make a positive impact for both the mother and baby,” he says.
Gracner says manufacturers should also play a role. “While improving nutritional literacy is important, food companies also need to be part of the solution — whether through reformulating healthier options or reconsidering how sugary foods are marketed and priced.”
She adds that the study “isn’t about banning sugar — a birthday cake, candy or cookies in moderation are treats we can all enjoy from time to time.”
