Beyond Glucose—Rethinking Prediabetes for Precision Prevention

What is it about?

Prediabetes—blood-sugar levels that are above normal yet not in the diabetic range—affects more than one in three adults, but recent work shows it is far from a single condition. In a large study, scientists measured how sensitive each participant’s body was to insulin, how much insulin the pancreas could still produce, how much fat had accumulated in the liver and around organs, and which genetic factors were present. Using computer-based clustering, they discovered six distinct biological profiles, or subtypes, within what we commonly call prediabetes. Three of these subtypes carry especially high risks. People with excess liver fat (“fatty-liver progressors”) see blood-sugar levels rise rapidly, yet they respond well to very intensive lifestyle programmes or bariatric surgery. Those whose pancreases struggle early to produce enough insulin (“beta-cell failure progressors”) may benefit most from medications that protect or stimulate the remaining insulin-producing cells. A third group maintains only slightly elevated blood sugar but displays high insulin levels and, surprisingly, a higher rate of kidney damage and early death, showing that complications can begin even before diabetes is officially diagnosed. Because the roots of high blood sugar differ so markedly, the traditional one-size-fits-all advice of weight loss and exercise may not be sufficient for everyone. Tailoring preventive care—so-called precision prevention—to a person’s subtype could stop or delay both diabetes and its complications more effectively. In practice this means doctors could focus the most intensive therapies on those who need them most, clinical trials could test whether modern drugs such as GLP-1 receptor agonists work better in certain subtypes, and researchers could track kidney, nerve, eye and heart health in addition to the simple question of whether someone “crosses the line” into diabetes. Recognising the different “flavors” of prediabetes therefore holds promise to match the right treatment to the right person at the right time, improving health and preventing serious complications.

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