Why aren’t more people treated for prediabetes?

Roughly 98 million adults in the United States—or more than 1 in 3—have prediabetes. It's a condition in which your blood sugar level is abnormally high but not high enough to be considered diabetes. Prediabetes is a warning sign that diabetes may be in your future, and it’s also a risk factor for heart disease and stroke.

But shockingly, of those Americans who have prediabetes, more than 80 percent don’t even know it. Why is that, and what role do healthcare providers (HCP) play in this apparent disconnect?

Understanding the extent of prediabetes

In search of answers, a group of researchers at the University of Florida analyzed data from a 2012 government survey of HCPs. They looked at patients aged 45 and older who'd had an A1C blood test within 90 days of their healthcare visit. (A1C is used to measure average blood sugar levels over a period of several months.)

The scientists found that 34 percent of the patients had blood sugar levels in the prediabetes range. Of these, only 23 percent were in treatment, either by way of being prescribed medication or making lifestyle changes. The findings were published in Journal of the American Board of Family Medicine in 2016.

These findings have been confirmed in more recent research, as well.

One 2022 study published in the Journal of General Internal Medicine looked at 3,888 patients who had been diagnosed with prediabetes. Follow-up monitoring is essential to help patients with prediabetes avoid developing diabetes. But in the study, only 63.4 percent had repeat testing within the year, 5.4 percent received a prescription for metformin (a medicine that can help control the condition), and only 1 percent were prescribed nutritional consultation to help improve their diet.

A 2021 study, also published in the Journal of General Internal Medicine, found similar results. Among 16,713 patients analyzed, only 20.4 percent received treatment for prediabetes and much smaller numbers actually completed their follow-up visits.

Why do so few prediabetes patients receive and pursue treatment?

Breaking bad habits

One issue may be that many HCPs don’t see prediabetes as an immediate cause for concern and don’t provide recommendations that can begin helping right away, says Jack Merendino, MD, an assistant clinical professor at George Washington University School of Medicine in Washington, DC and chief of the endocrine section at Suburban Hospital, Johns Hopkins Medicine, in Bethesda, Maryland.

The main treatments for prediabetes are lifestyle modifications, which often require a detailed conversation with one’s HCP. That can present a problem, according to Dr. Merendino, who is also a member of Sharecare’s Advisory Board.

“There’s a lot of evidence that doctors are not good at recommending lifestyle changes,” Merendino says. These changes may include eating a healthy diet and exercising regularly. “In the physician’s mind, what’s going on is that there’s an impending problem, but it’s not yet bad enough to need medication. Doctors tend to look at treatment as medication.”

One reason HCPs don’t often recommend lifestyle changes is the perception that patients don’t follow their orders. Even so, Merendino thinks HCPs often underestimate the influence they have with their patients.

“A fair number of patients do make changes when recommended by doctors,” he says.

A lack of a sense of urgency

Another reason for the low numbers of diagnoses of prediabetes, Merendino says, is that some HCPs don’t see prediabetes as urgent. Controlling diabetes often means getting A1C levels down to under 7 percent, which is still above the level considered to be prediabetes.

“Physicians are saying it’s not as much of a big deal, rather than thinking that if the patient has prediabetes then they might develop diabetes,” Merendino says.

Meanwhile, progressing from prediabetes to diabetes usually takes years. “It’s seen as an issue, but an issue for the future,” Merendino explains.

Prediabtes should be taken seriously

Still, a diagnosis of prediabetes should be taken seriously. It is not a benign (or harmless) condition. For example, by the time many people are diagnosed with diabetes, they already have neuropathy, or nerve damage. That means at least some patients developed neuropathy while they were in the prediabetes stage, Merendino explains.

“It’s not like you’re fine with prediabetes and then you get complications when you reach diabetes levels,” he notes.

The truth is that a diagnosis of prediabetes is an excellent opportunity to try to avoid diabetes. If patients know they have it, they can take action.

Should you be tested?

Prediabetes usually has no obvious symptoms, so it’s important to look for it. If you’re 45 or older (the age when risk increases), think about getting tested, especially if you’re considered overweight or obese. You should also consider being tested if you’re under 45, overweight or obese, and have additional risk factors such as family history of diabetes, physical inactivity, high blood pressure, low HDL (aka “good” cholesterol), or polyendocrine metabolic ovarian syndrome (PMOS), a condition previously known as polycystic ovary syndrome (PCOS) that involves imbalances in hormone levels and irregular menstrual periods.

Reversing prediabetes

If you are diagnosed with prediabetes, there’s no need to panic. Having prediabetes doesn’t mean diabetes is your destiny. Still, according to some estimates, as many as 70 percent of people with prediabetes will eventually develop diabetes if they don’t make lifestyle changes. The longer you have elevated blood sugar levels, the more likely diabetes becomes, Merendino says. So think of a prediabetes diagnosis as a warning sign.

“Patients should be asking, ‘How do I prevent myself from progressing to diabetes?’” Merendino says. “Doctors’ recommendations should be lifestyle modifications: weight loss and physical activity.” According to the Centers for Disease Control and Prevention, eating healthy and being active can cut the risk of type 2 diabetes in half.

The Diabetes Prevention Program is a major study sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases that followed more than 3,200 people in 27 clinical centers for about three years. The study showed that lifestyle changes were about twice as effective as taking medication at preventing the development of diabetes. People in the landmark study, which was published in the New England Journal of Medicine in 2002, saw success even at low levels of weight loss.

Exercise has a lot of important benefits: Not only does it help you manage your weight, but it also helps the body use insulin more efficiently. (Insulin is a hormone that helps the body convert blood sugar into energy.) Following a lifestyle change program recognized by the CDC can cut your risk for diabetes by more than half. (Find a program in your area.)

“For exercise to do twice as good as drugs—that was really major,” says Merendino. “If there’s a failure here, it’s a failure on the part of physicians to internalize the powerful effect that lifestyle intervention can have.”