Prediabetes may be reversible without weight loss through changes in body fat distribution. Digest
Prediabetes, a condition in which markers of blood sugar regulation are higher than normal but not yet in the diabetic range, is typically treated by focusing on weight loss. However, many people struggle to lose weight or keep it off. A new study examined whether people with prediabetes could return to normal blood sugar levels without losing weight, and whether this change affected their future risk of type 2 diabetes.
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The researchers analyzed data from a previous large German lifestyle intervention study, focusing on 234 adults with overweight or obesity (BMI around 30) who maintained or even gained a small amount of weight over one year. Participants underwent detailed metabolic testing, including oral glucose tolerance tests (OGTT, which tracks blood sugar and insulin levels over two hours after consuming a glucose drink) and MRI scans to track fat distribution, and were followed for up to 10 years to monitor whether they developed type 2 diabetes.
- About 22% of the participants who did not lose weight still returned to normal blood sugar levels after one year, showing that remission can occur without weight loss.
- Within this group, those who returned to normal blood sugar regulation had a 71% lower risk of developing type 2 diabetes over up to 10 years of follow-up.
- Participants who improved their blood sugar regulation showed better insulin sensitivity, meaning their bodies responded more effectively to insulin. Measures of how much insulin the body releases and how well the insulin-producing cells (called beta cells) work also moved in a healthier direction, but these changes were not strong enough to draw firm conclusions.
- Body weight, total body fat, muscle mass, fitness, diet adherence, physical activity, and circulating inflammatory markers showed similar patterns over time in participants who returned to normal blood sugar regulation and those who did not, suggesting that these factors alone did not explain the difference.
- Participants who improved their blood sugar regulation tended to store fat in a healthier way, with a higher proportion of subcutaneous fat (fat under the skin) compared to visceral fat (fat stored around internal organs), rather than clear differences in individual fat depots.
These results point to a weight-independent effect related to how fat is distributed in the body. Visceral fat is closely linked to metabolic dysfunction because it is more biologically active and releases fatty acids and inflammatory signals to key metabolic organs such as the liver. This can promote insulin resistance, increase blood sugar production, and strain the pancreas over time. In contrast, subcutaneous fat is better at safely storing excess energy and releases fewer harmful signals, making it less likely to interfere with normal blood sugar control.
The study was a post hoc analysis, meaning the subgroup was defined after the trial, which limits how confidently cause and effect can be established. In addition, key measures of insulin function were based on indirect calculations rather than gold-standard methods such as the hyperinsulinemic-euglycemic clamp. Overall, the findings suggest that strategies to prevent type 2 diabetes may need to focus not only on weight loss, but also on how the body stores fat. In episode #96, I explain how HIIT, circadian-timed eating, and quality sleep improve metabolic health and reduce chronic disease risk.