First-Line Recommendations for Managing Prediabetes
Patients with prediabetes should be referred to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program (DPP) to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity to at least 150 minutes per week. 1
Lifestyle Interventions as Foundation
Nutrition Recommendations
- Emphasize individualized medical nutrition therapy (MNT), preferably provided by a registered dietitian knowledgeable in diabetes care 1
- Focus on nutrient-dense foods in appropriate portions with an emphasis on:
- Minimally processed, high-fiber carbohydrate sources (at least 14g fiber per 1,000 kcal) 1
- Limiting sugar-sweetened beverages and foods with added sugars 1
- Heart-healthy eating patterns such as Mediterranean diet or DASH diet 1, 2
- Reducing total calorie intake by 500-1,000 calories/day for weight loss 1
Physical Activity Goals
- Aim for at least 150 minutes per week of moderate-intensity physical activity (such as brisk walking) 1
- Include resistance training as part of the exercise regimen 1
- Break up prolonged sedentary time, as it's associated with moderately lower postprandial glucose levels 1
- Distribute activity throughout the week with a minimum frequency of three times per week with at least 10-minute sessions 1
Weight Management
- Target a minimum weight loss of 5-7% of initial body weight 1
- Recommended pace of weight loss: 1-2 pounds per week 1
- Long-term data shows maximal prevention of diabetes observed at about 7-10% weight loss 1
Pharmacological Interventions
Metformin Therapy
- Consider metformin for prevention of type 2 diabetes in those with prediabetes, especially for:
- Monitor vitamin B12 levels periodically in metformin-treated patients, especially those with anemia or peripheral neuropathy 1
Other Pharmacological Options
- While other medications (α-glucosidase inhibitors, GLP-1 receptor agonists, thiazolidinediones) have shown efficacy in research studies, metformin has the strongest evidence base and demonstrated long-term safety 1, 4
- GLP-1 receptor agonist-based medications may be considered for those with obesity when ≥7% weight reduction is not achieved with lifestyle alone 1
Monitoring and Follow-up
- At least annual monitoring for the development of type 2 diabetes in those with prediabetes 1
- Regular assessment of cardiovascular risk factors (blood pressure, lipids) 1, 4
- Blood pressure goal: <130/80 mmHg 1
- LDL cholesterol goal: <100 mg/dL (2.60 mmol/L) 1
Implementation Approaches
- Technology-assisted interventions (smartphone apps, web-based applications, telehealth) may effectively deliver the DPP lifestyle intervention 1
- Group delivery of DPP content in community or primary care settings can reduce overall program costs while still producing effective outcomes 1
- Diabetes self-management education and support programs may be appropriate venues for people with prediabetes 1
- Text-based delivery with some interaction is preferred by many patients 5
Common Pitfalls and Caveats
- Using A1C alone to screen for prediabetes may be problematic in the presence of certain hemoglobinopathies or conditions that affect red blood cell turnover 1
- Years immediately following smoking cessation may represent a time of increased risk for diabetes, so patients should be monitored closely during this period 1
- Patients with food insecurity or unsupportive environments face unique barriers to lifestyle change and may require additional support 5
- For patients with fixed insulin doses, consistent patterns of carbohydrate intake with respect to time and amount is recommended 1
The evidence strongly supports that intensive lifestyle interventions can reduce the incidence of type 2 diabetes by 58% over 3 years, with sustained benefits seen in long-term follow-up studies 1, 3. When lifestyle intervention alone is insufficient, metformin offers the best evidence-based pharmacological option, particularly for higher-risk individuals 1, 3.