The Prediabetes Debate: Is It a Useful Diagnosis or Potentially Harmful?

If you’ve received this diagnosis, you may already feel as if you have diabetes. Your doctor has likely advised you to make diet and lifestyle changes, or perhaps they’ve prescribed medication to help lower your risk of developing type 2 diabetes.

However, some experts question how valuable the current definition of prediabetes is, and if having this diagnosis is in a patient’s best interests.

Here’s what you need to know about the current debate, and how to approach a prediabetes diagnosis from your doctor.

Prediabetes is not a disease itself, but rather a set of conditions that suggest a person is at a higher risk than normal to develop diabetes, which is a disease characterized by hyperglycemia, or high blood glucose (sugar).

“It measures the amount of sugar attached to hemoglobin, a protein found in your red blood cells,” explains Shiara Ortiz-Pujols, MD, obesity medicine specialist at Northwell Staten Island University Hospital in New York. “Because it is an average over three months, it is not affected by things that you may have eaten over the past week or 24 hours and therefore it can give you a better sense of how much glucose you have in your blood system,” she says. “In addition, this test does not require you to fast beforehand.”

• An A1C of 5.7 to 6.4 percent, or average blood glucose for the past two to three months
• Fasting plasma glucose (FPG) levels of 100 to 125 milligrams per deciliter (mg/dL), or blood glucose levels after fasting for at least eight hours
• Oral glucose tolerance test (OGTT) levels of 140 to 199 mg/dL, or your blood glucose levels before and two hours after you drink a special sweet drink

The History of the Term ‘Prediabetes’

In 2009, an International Expert Committee with members appointed by the ADA, the European Association for the Study of Diabetes (EASD), and the International Diabetes Federation (IDF) issued a report meant to recommend the use of the A1C test for the diagnosis of diabetes.

However, the committee did not embrace the term prediabetes, which they described as “problematic because it suggests that all individuals so classified will develop diabetes and that individuals who do not meet these glycemia-driven criteria (regardless of other risk factor values) are unlikely to develop diabetes — neither of which is the case.”

Risk Factors for Prediabetes

• Being a person who is overweight or who has obesity
• Being 45 years or older
• Having a family history of diabetes
• Having had gestational diabetes
• Being physically active fewer than three times a week
• Giving birth to a baby weighing more than 9 pounds
• Being of African American, Hispanic/Latino, American Indian, Alaska Native, Pacific Islander, or some Asian American ethnicities and races

One benefit of diagnosing people with prediabetes based on ADA criteria is the condition is easier to treat in its early stages, Dr. Ortiz-Pujols says.

“This is what you would see with any chronic disease. The earlier that it is caught, the more likely you will have successful treatment — the later a disease is identified the more likely that it will progress to more significant disease,” she explains.

Benefits of Lifestyle Changes

Intervening early opens a discussion about lifestyle changes, including nutrition, physical activity, and sleep, that can decrease a person’s risk of developing type 2 diabetes and other health problems, says Lisal Folsom, MD, medical director in the adult endocrinology division at the Wendy Novak Diabetes Institute at Norton Healthcare in Louisville, Kentucky.

“A diagnosis of prediabetes is a beautiful opportunity for somebody to assess their health and figure out ways that they can change what they're doing to ideally reverse prediabetes or to prevent the progression from prediabetes to diabetes,” she says. “But if you have the diagnosis, that's an impetus to make some changes, whereas if you didn't know, you wouldn't know that you needed to do anything differently.”

Benefits of Weight Loss and Metformin

Experts say there are several drawbacks to diagnosing prediabetes, including overdiagnosis, overtreatment, causing unnecessary anxiety and stress in patients, and the financial burden of tests and treatments.

Overdiagnosis of Prediabetes and Overtreatment

Overtreatment is also an issue. While addressing prediabetes is crucial for preventing type 2 diabetes and related health issues, intervening too much can lead to unnecessary stress and complications, says Maria Teresa Anton, MD, endocrinologist and educator at Pritikin Longevity Center in Miami.

“Overzealous intervention, such as excessive medication or overly restrictive diets, may not only diminish a patient's quality of life but also foster anxiety around food and health,” she says. “It’s important to focus on balanced, evidence-based lifestyle modifications that promote long-term well-being rather than solely aiming for clinical numbers. A thoughtful, individualized approach ensures that patients are supported in making sustainable changes without the risks associated with overtreatment.”

Weighing the Pros and Cons of Medication

However, while certain medications can reduce diabetes risk, they may not be necessary for everyone diagnosed with prediabetes, especially for those at a low risk of progression, says La’Tonzia Adams, MD, a clinical pathologist and representative for the College of American Pathologists (CAP) in Portland, Oregon.

“Unnecessary medication introduces the potential for side effects, which can lower patients’ quality of life and adherence to treatment plans,” she says, noting that glucose levels are only one of several factors that can indicate a person’s risk of disease progression.

Variations in Prediabetes Diagnosis

Another criticism of diagnosing prediabetes is that variations in diagnostic criteria and inconsistencies in A1C levels and fasting glucose measurements can create confusion among clinicians and patients, Dr. Anton says.

As mentioned above, criteria for diagnosing prediabetes can differ from organization to organization, such as from the ADA to the WHO.

The test results can also be problematic. Discrepancies in A1C and fasting glucose results may arise due to variations in red blood cell turnover (as seen in people with anemia or other blood conditions), changes in red blood cell production, or certain genetic variants, Anton explains.

Additionally, she says, A1C test results may not fully reflect glucose level fluctuations that happen after eating or during periods of hypoglycemia (low blood sugar).

Another downside of the A1C test is that levels can vary among people of different ethnicities and races, Ortiz-Pujols notes. In particular, non-Hispanic Black people tend to have higher A1C levels than white people.

“These discrepancies may lead to misdiagnosis, inappropriate treatment strategies, and a lack of standardized care,” says Anton, pointing to the need for "more unified guidelines and better education for both healthcare providers and patients.”

Ethical Considerations

While “medicalization” of a non-disease like prediabetes can be controversial, a prediabetes diagnosis can help equip patients with the tools they need to stave off not only type 2 diabetes but also associated long-term health risks like kidney disease and heart disease.

“Without the medicalization of [prediabetes], the onus of action is left on the person affected by the condition, which we know does not necessarily activate nor empower the person to do something to reverse the course of the condition,” Ortiz-Pujols says. Medicalization can facilitate more research on the issue as well as effective prevention strategies, she adds.

Deciding whether to diagnose a patient with prediabetes requires careful ethical consideration, Dr. Adams says. If the diagnosis leads to unnecessary anxiety, expense, and interventions without clear evidence of benefit, it could arguably harm patients more than it helps them, and raise questions about whether the diagnosis primarily serves the patient or other interests.

“The question of whether the ‘pre-disease’ state should be treated, and how aggressively, raises important ethical issues,” she explains. “Addressing these issues involves balancing prevention with the risks of overtreatment, ensuring that healthcare practices are not primarily driven by pharmaceutical or medical industry incentives but are genuinely aimed at promoting long-term health and well-being.“

The Business of Prediabetes

Adams draws a parallel to other conditions that may be overdiagnosed and overmedicated. For example, recommending medication for people with borderline high blood pressure can be controversial, since lifestyle changes may be equally effective.

“Treating mild hypertension pharmacologically can create a dependency on medication while sometimes failing to address underlying health behaviors, raising similar questions about whether this approach best serves patients’ health,” she says.

However, intervention can be critical for those who are truly at risk of developing diabetes.

“This debate boils down to finding a balanced approach — one that doesn't underplay the risks for those truly on the path to diabetes while avoiding unnecessary treatment for those unlikely to progress,” Adams says.

If you have test results that come back in the range for prediabetes, remember that it’s an indication of risk, and most of what happens next is under your control. “Knowledge is power,” Dr. Folsom says.

• Ask your primary care doctor about what you can do to lower your risk of progressing to diabetes, including eating a healthier diet, exercising more, losing weight, and possibly taking medication.
• Seek a referral to a registered dietitian-nutritionist in case you may benefit from changing your eating habits.

“If somebody has prediabetes, the first thing I'm going to recommend is look at your nutrition, include more fruits and vegetables, switch over to whole grains, make sure you're eating good, clean whole foods and lean proteins, adding in plant foods like beans and nuts and seeds and limiting processed foods, sugary beverages, and desserts, and then increasing physical activity,” Folsom says.

Above all, keep your diagnosis in perspective. Having prediabetes doesn’t mean you’re definitely going to develop diabetes. It’s simply a warning sign to make changes.

The Takeaway

• The current protocol for diagnosing prediabetes isn’t perfect, and standards can differ from one organization to another, but most experts agree the diagnosis can help encourage healthy lifestyle changes and prevent disease when administered responsibly.
• A prediabetes diagnosis can be anxiety-provoking, but some people diagnosed with prediabetes never develop diabetes, and lifestyle changes can help you avoid it.
• If you’ve been diagnosed with prediabetes, talk to your doctor for personalized guidance.