Diabetes Management in Older Adults

From diatribe.org

Key takeaways:

• 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.

https://diatribe.org/diabetes-management/diabetes-management-older-adults 

What WWII data tells us about children, added sugar and chronic disease

From washingtonpost.com

By Alexandra Frost

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.

“With today’s children, including toddlers, consuming excessive sugar, concerns are naturally growing about its long-term impact,” says Tadeja Gracner, a senior economist at the Center for Economic and Social Research at the University of Southern California and the study’s lead author.

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.
• The National Dietary Guidelines for Americans recommend minimizing added sugar intake at any age, limiting it to less than 10 percent of calories per day.

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.”

https://www.washingtonpost.com/wellness/2025/03/24/pregnancy-early-childhood-sugar-diabetes/

Is Type 2 Diabetes an Autoimmune Disease?

From verywellhealth.com

Type 2 diabetes is not an autoimmune condition, while type 1 diabetes is. Though new research suggests the immune system may be involved in type 2 diabetes, its causes are more closely linked to other factors such as family history and lifestyle habits.

MoMo Productions / Getty Images

How Type 2 Diabetes Differs From Type 1 

Diabetes is a disease characterized by high blood glucose (sugar) levels. Blood sugar is regulated by insulin, a hormone produced by the pancreas. Though they share some characteristics, type 1 diabetes and type 2 diabetes are not the same. They have different causes and the treatment plans are often very different, as well.

Type 1 Diabetes

• Onset usually in childhood, adolescence, or young adulthood

• Can come on suddenly

• Insulin required for survival (body no longer produces insulin)

• Autoimmune disease; pancreatic cells damaged

• Risk factors that include family history, genetics, potential environmental triggers, and being young

Type 2 Diabetes

• Onset typically in adulthood
  

• Usually develops gradually over time

• Treatments that can include lifestyle changes, oral medication, or injectable medication (including insulin)

• Not an autoimmune disease; may be delayed or prevented with lifestyle changes

• Risk factors that include family history, ethnicity, overweight/obesity, lack of physical activity, age

Type 1 Diabetes

Type 1 diabetes is an autoimmune condition. It is usually diagnosed in children, adolescents, and young adults, though people of any age can develop it.

In type 1 diabetes, the body mistakenly attacks cells in the pancreas that produce insulin. Because of this, people with type 1 diabetes produce very little or no insulin, thus requiring insulin for survival.

This reaction is due to autoantibodies, which are proteins produced by the immune system that are mistakenly directed to healthy cells in the pancreas that produce insulin as foreign.

Risk factors for type 1 diabetes include:

• Genetics or having a family history of type 1 diabetes
• Being young
• Potential environmental triggers, such as a virus

There is no cure for type 1 diabetes, though it can be treated.

Type 2 Diabetes

Type 2 diabetes is when the body doesn’t respond to or cannot properly use insulin (insulin resistance).  It is usually diagnosed in adults, but people of any age, including children, can be diagnosed with type 2 diabetes. Type 2 diabetes usually develops gradually over time.

Risk factors include:

• Having a family history of type 2 diabetes
• Being overweight
• Being over 45 years of age
• Being physically inactive

U.S. populations with a higher prevalence of type 2 diabetes are:

• African American
• Latinx
• Native American
• Alaska Native
• Pacific Islander
• Asian American

Lifestyle interventions, such as losing weight, participating in regular physical activity, and following a healthy diet, can prevent or delay type 2 diabetes.

Along with self-monitoring of blood glucose, treatment may include lifestyle changes, oral (by mouth) medication, and/or injectable medication.

Research on Immune System Involvement

While some research suggests potential immune system involvement in type 2 diabetes, it is not considered a classic autoimmune disease in which the body attacks its own cells (as is seen with type 1 diabetes). Type 2 diabetes is considered a multifactorial disease (having many contributing factors).

Researchers have documented that type 2 diabetes is characterized by chronic (long-term) low-grade inflammation.

Inflammation occurs as a result of the immune response to high blood glucose levels and the presence of inflammatory mediators (chemicals) produced by adipocytes (cells that store energy as fat) and macrophages (white blood cells that play an important role in the immune system). 

A 2019 study found that some people with type 2 diabetes have altered immune cells, which cause inflammation that is attributable to an autoimmune response. The study revealed that reactive autoantibodies against insulin-producing cells could be detected in some people.

The researchers also noted that upcoming data suggest a modified function of regulatory T cells (a type of white blood cell involved in the immune system) in some people. Experts hypothesize that unhealthy lifestyle choices and advanced age may act as possible “triggers” for these inflammatory responses.

What Is an Autoimmune Disorder?

An autoimmune disorder or disease, is a condition in which the body mistakes its own healthy cells, tissues, or organs as foreign substances and attacks them.

Normally, the immune system is able to tell the difference between your cells and foreign substances. A flaw in the immune system can make the body unable to tell the difference between the two.

When this happens, the body mistakenly makes autoantibodies that attack the body’s normal cells, tissues, or organs. Simultaneously, regulatory T cells fail to keep the immune system functioning properly.

Autoimmune diseases can affect any part of the body. Experts know of more than 80 autoimmune diseases. Some common autoimmune diseases are type 1 diabetes, multiple sclerosis (MS), lupus, and rheumatoid arthritis (RA).

Studies suggest these diseases may be caused by interactions between certain genes and the environment. Risk factors for developing an autoimmune disease include sex, race, and certain ethnic characteristics.

Immunosuppressant Medications

Researchers have developed medications called immunosuppressants to help treat such conditions as autoimmune diseases. These drugs weaken the immune system response in an effort to reduce the body's reaction to substances it mistakes as harmful.

For example, a specific class of immunosuppressants called anti-CD20 antibodies is designed to target and destroy the immune cells that are attacking healthy tissue. These drugs treat some autoimmune diseases, such as RA and MS.

Some research indicates that immunosuppressive medications may benefit people with type 2 diabetes. More studies are needed before immunosuppressant drugs are used in the treatment of type 2 diabetes, but early research is encouraging.

Reasons for Lower Immunity With Type 2 Diabetes

Chronic low-grade inflammation, as described earlier, damages the cells in the pancreas that produce insulin. This leads to lower insulin production, which causes high blood glucose levels. High blood glucose levels in diabetes are thought to disrupt the immune system. 

When the immune system is altered, it is not able to properly ward off invading pathogens (disease-causing "germs"). Because of this, people with diabetes—especially those with poorly managed blood glucose levels—are known to be more susceptible to infections. 

Ways to Boost Immune Health

A healthy lifestyle can strengthen your immune system. The following healthy lifestyle habits  can help boost your immune system naturally:

• Follow a healthy eating pattern, including plenty of fruits and vegetables.
• Engage in regular physical activity.
• Maintain a healthy weight.
• Get seven to nine hours of quality sleep each night.
• Don’t smoke.
• Limit alcohol consumption.
• Reduce stress.
• Practice good hygiene and safe food handling practices.

How to Reduce Inflammation and Support Insulin Sensitivity

Inflammation is a very complicated process affecting many different inflammatory cells and pathways. Chronic low-grade inflammation has been shown to contribute to insulin resistance.

Several animal studies have demonstrated the benefit of reducing inflammation for obesity-linked insulin resistance and metabolic disease (conditions that affect the body's ability to process and use energy from food). However, human clinical studies testing specific therapies targeting inflammation and their impact on metabolic disease have had promising but substandard results.

 Nevertheless, reducing inflammation in the body has been shown to maintain or improve insulin sensitivity. There are several ways to help reduce inflammation, such as using using complementary therapies and healthy lifestyle habits. These include:

• Following an anti-inflammatory diet that includes fruits, leafy green vegetables (e.g., kale, spinach, romaine lettuce), fatty fish (e.g., salmon and tuna), whole grains, nuts, and olive oil
• Cooking with herbs and spices, such as clove, coriander, garlic, ginger, onion, pepper, and turmeric
• Reducing stress
• Avoiding or quitting smoking
• Limiting alcohol consumption
• Exercising regularly
• Getting enough sleep
• Drinking green tea or coffee

When to See a Provider

Contact a healthcare provider if you experience symptoms of diabetes or high blood glucose, such as:

• Blurred vision
• Fatigue or weakness
• Increased thirst
• Increased hunger
• Numbness or tingling in hands or feet
• Sores that heal slowly
• Urinating (peeing) often

Summary

Type 2 diabetes is not considered an autoimmune disease, while type 1 diabetes is. An autoimmune disease is when the body mistakes its own healthy cells, tissues, or organs for foreign substances and attacks them.

People with type 1 diabetes make little to no insulin because their bodies mistakenly attack cells in the pancreas that produce insulin. People with type 2 diabetes may still produce insulin, but their bodies don’t respond to or use it properly. 

Type 2 diabetes is considered a multifactorial disease. Chronic low-grade inflammation damages pancreatic cells that produce insulin, lowering insulin production and causing high blood glucose levels.

High blood glucose levels in diabetes are thought to disrupt the immune system. Experts hypothesize that unhealthy lifestyle choices and advanced age may act as possible “triggers” for these inflammatory responses.

https://www.verywellhealth.com/is-type-2-diabetes-an-autoimmune-disease-11694524