Diabetes prevention should chase normal glucose, not slower decline

Clinical takeaway: When prediabetes turns up, consider setting the goal as documented return to normal glucose regulation and rechecking to confirm it, rather than tracking gradual drift.

Glucose thresholds for type 2 diabetes were drawn to mark where retinal and kidney damage becomes likely, not where risk starts. Prediabetes sits below that line by design, which is why it reads as a heads-up instead of a condition with a goal attached.

But the category still carries real risk, and it also carries the promise of reversibility. Restoring normal glucose regulation is achievable for a meaningful share of patients, and doing so tracks with lower long-term risk than slower progression does.

Still, most US prevention effort is aimed at postponement: program referral, metformin in higher-risk patients, a repeat test in a year. None of it defines success for an individual patient, so prediabetes tends to sit in the chart unresolved for years. An international expert panel spanning basic science, clinical medicine, and prevention research sets out a life-course framework, consensus covering the stages from before conception to older adulthood.

The authors want prediabetes remission recognized as a prevention endpoint in its own right, on the argument that it is achievable, measurable with tests already in use, and pragmatic enough to act on. Targeted lifestyle intervention often brings glucose regulation back within range, and patients who get there carry substantially lower long-term risk than those who stay dysglycemic.

Behind that target sits a risk architecture that begins earlier than prevention usually does. The authors map developmental, transitional, and contextual determinants across the life course, marking windows where metabolic vulnerability is amplified and where normal regulation can still be recovered. Parental metabolic health before conception, pregnancy and breastfeeding, early childhood weight trajectory, and the insulin resistance of puberty all enter as potential intervention points.

"Prediabetes is not an irreversible condition. The aim is not merely to stop disease progression, but to restore metabolic health as early and as durably as possible," said Andreas Birkenfeld, MD, senior author and medical director of diabetology, endocrinology and nephrology at University Hospital Tübingen.

Source: Wang Y, et al. (2026 Aug 10) Nat Med. Type 2 diabetes prevention across the life course