In Reply: Dr Dubowitz and colleagues note that, compared with middle-aged adults, older adults require different management and goals in the treatment of diabetes. Nevertheless, blood glucose control remains the main means for monitoring response to treatment. It has been suggested that frail older persons should have less-stringent HbA1c targets than the 7% recommended by the American Diabetes Association for most adults.1- 2 In older frail patients, 8.0% may be appropriate. Tight glycemic control may cause problems related to dietary restriction, frequent finger sticks, insulin injections, polypharmacy, and increased risk of hypoglycemia, with limited benefit in the prevention of microvascular complications in populations with limited life expectancy. No such concerns have been raised for exercise and physical activity. In fact, the Guidelines for Improving the Care of the Older Person with Diabetes Mellitus of the American Geriatrics Society specifically recommend exercise and physical activity, which in combination with nutrition education, can significantly improve weight, blood pressure, lipid levels, and blood glucose control.2 These recommendations, along with the meta-analysis by Mr Umpierre and colleagues3 and the totality of available scientific evidence, further strengthen the view that structured exercise and physical activity programs ought to be considered for insurance reimbursement to promote health, especially in high-risk populations.