For years, diabetes prevention has been closely associated with one main goal: losing weight. However, new research is challenging this long-held assumption. People diagnosed with prediabetes – a condition that affects up to one in three adults, depending on their age group – have always been advised to eat healthier and lose weight to reduce their risk. This message has remained largely unchanged for decades. However, the results are mixed. Diabetes rates continue to rise worldwide, and many people with prediabetes struggle to achieve their weight loss goals. As a result, they often feel discouraged while their risk remains high.
Remission of Prediabetes Without Weight Loss
Prediabetes refers to a pre-state of type 2 diabetes in which blood glucose levels are already elevated, but not yet high enough to fulfill the diagnosis of diabetes. At this stage, the body’s ability to regulate blood sugar is already impaired. Insulin resistance is often present, which means that the body’s cells no longer react sufficiently to the hormone insulin, which normally ensures that sugar is absorbed from the blood into the cells.
As a result, more glucose remains in the bloodstream, which can lead to long-term damage to blood vessels and organs, even if no clear symptoms are noticeable yet. In fact, prediabetes often goes unnoticed, as those affected usually feel healthy. Nevertheless, this condition is medically significant because it significantly increases the risk of developing type 2 diabetes later on. Cardiovascular diseases also occur more frequently in this context.
New findings published in Nature Medicine point in a different direction. The research shows that prediabetes can go into remission – meaning that blood sugar levels return to normal – even without weight loss. In fact, about one in four people who participated in lifestyle programs were able to normalize their blood sugar without losing weight. What is even more remarkable is that this type of remission offers the same protection against developing diabetes later on as a remission achieved through weight loss. These findings could significantly change the way doctors approach the treatment of overweight or obese people at high risk. But how can blood glucose improve without weight loss, or even with weight gain?
Why the Distribution of Adipose Tissue is More Important than Weight
The answer seems to lie in where fat is stored in the body. Not all fat has the same effect on health. Visceral fat, which surrounds the internal organs deep in the abdomen, is particularly harmful. It promotes chronic inflammation and interferes with insulin action – the hormone responsible for regulating blood sugar. If insulin does not work properly, the blood sugar level rises.
On the other hand, subcutaneous fat – the fat just under the skin – can actually support a healthier metabolism. This fatty tissue is much more “harmless” metabolically and can even have protective properties. To a certain extent, it serves as a safe store for excess energy. Importantly, subcutaneous fat releases certain hormones (adipokines) that have an anti-inflammatory effect and can improve insulin sensitivity. This supports, rather than disrupts, the processing of sugar in the body. This type of fat releases hormones that help insulin to work more efficiently.
The key point now is the distribution of fat, not just the amount. Two people of the same body weight can have a completely different risk of metabolic disease depending on whether they have more visceral or more subcutaneous fat. Research suggests that a kind of “redistribution” can occur as part of lifestyle changes: Fat is reduced from visceral depots and increasingly stored in subcutaneous tissue. Even if the body weight remains the same, the metabolism improves. The body becomes more sensitive to insulin again, inflammatory processes decrease and blood sugar can normalize. This could explain why some people improve their prediabetes or even bring it into remission without losing weight.
Fat quality also plays a role: how well fat cells can absorb and store new energy is crucial. If the subcutaneous fat tissue remains “receptive”, it can buffer excess energy and thus prevent fat from accumulating in unfavorable places such as organs or the abdomen. The study found that people who reversed their prediabetes without losing weight tended to shift fat away from their abdominal organs and into areas under the skin, even if their overall weight did not change.
Hormones that Help Regulate Blood Sugar
The researchers also identified a hormonal component. Natural hormones similar to those targeted by drugs such as Wegovy and Mounjaro (drugs used to treat obesity and type 2 diabetes) play an important role. These hormones, particularly GLP-1, help the beta cells of the pancreas to release insulin when blood glucose levels rise. People who achieved remission without weight loss seemed to naturally boost this hormone system while reducing the influence of other hormones that increase glucose levels.
These findings offer practical guidance. Rather than just focusing on the number on the scale, people with prediabetes may benefit from strategies that influence the distribution of fat in the body. Certain dietary habits can help. Polyunsaturated fatty acids, found in the Mediterranean diet with its abundance of fish oil, olives and nuts, can reduce visceral fat. In addition to the quality of fat, the fiber content of the diet is also crucial. Fibre slows down the absorption of sugar into the blood, stabilizes blood sugar levels and has a positive effect on intestinal health. In turn, healthy intestinal function is closely linked to hormonal processes that regulate the metabolism. Adequate protein intake can also be helpful, as it promotes satiety, keeps blood sugar levels stable and helps to maintain or build muscle mass.
Physical activity further enhances these effects. Endurance training in particular, such as brisk walking, cycling or swimming, has been shown to be effective in reducing visceral fat – the metabolically active fat in the abdomen. This fat is closely linked to insulin resistance and elevated blood sugar levels. Even regular moderate exercise can bring about significant improvements here. In addition, strength training plays an important role, as muscle tissue can absorb glucose from the blood and therefore actively contributes to lowering blood sugar levels. More muscle mass therefore also means better blood sugar regulation. Interestingly, exercise not only influences energy consumption, but also hormonal processes. Regular physical activity can improve the natural GLP-1 secretion, increase insulin sensitivity and at the same time reduce stress hormones that would otherwise cause blood sugar levels to rise.
Overall, it has been shown that a combination of a balanced diet and regular exercise can achieve profound changes in metabolism. These relate in particular to the reduction of visceral fat, the improvement of insulin action and the regulation of important hormones. As a result, the blood sugar level can normalize – even if the body weight remains the same. This underlines the fact that it is not just the number on the scales that is decisive, but above all the internal metabolic processes, which can be specifically influenced by lifestyle factors.
A Change in the Strategy for Diabetes Prevention
This does not mean that weight loss should be ignored. Losing weight still promotes overall health and reduces the risk of diabetes. However, research suggests that normalizing blood sugar levels should be the primary goal, regardless of whether weight changes. For many people who have struggled with traditional weight loss programs, this opens up the possibility of making meaningful improvements through metabolic changes rather than a sole focus on weight. Healthcare providers may also need to broaden their approach. Monitoring improvements in blood glucose levels and promoting fat redistribution through targeted diet and exercise could offer alternative strategies for patients who are struggling to lose weight.
The implications of these findings extend far beyond individual patients. Diabetes is one of the fastest growing health problems worldwide, affecting hundreds of millions of people. The realization that prediabetes can improve without weight loss opens up new opportunities for prevention on a global scale. It also shifts the focus from body weight alone to metabolic health. This means that factors such as insulin sensitivity, fat distribution, inflammation levels and hormonal regulation are coming more to the fore. In practice, this means that people will no longer be judged solely on how much they weigh or how much weight they lose, but on how their internal metabolic processes develop.
This approach has several important consequences. Firstly, it can make prevention much more accessible. Many people fail on strict diets or find the focus on weight loss demotivating. If goals such as better blood sugar levels, more exercise or a more favorable fat distribution are emphasized instead, interventions are often more realistic and sustainable. This can lead to more people taking early action and thus preventing the progression of prediabetes. Secondly, this approach allows for greater individualization of treatment. Since different biological mechanisms – such as visceral fat, hormonal dysregulation or insulin resistance – can be at the forefront, measures can be selected more specifically. Some people benefit particularly from dietary changes, others more from exercise or stress reduction. This makes treatment more precise and potentially more effective.
Thirdly, this also has social and health policy implications. Prevention programs could be broader in scope, promoting not only weight loss but also healthy lifestyles in general – such as physical activity in everyday life, access to healthy food or stress management. This can make a big difference, especially in high-risk populations. Finally, this perspective also opens up new opportunities for research and development of therapies. With a clearer understanding of the mechanisms that contribute to the remission of prediabetes – such as changes in fat distribution or hormonal regulation – more targeted interventions can be developed, both in the area of lifestyle and medication.