It can be confusing to hear that you’re at risk for a serious health condition when you feel fine. Take prediabetes—a condition where your blood sugar (also referred to as glucose) levels are higher than normal, but not high enough to be classified as diabetes.
“People can be shocked when they learn they have higher blood sugars, because prediabetes typically has no symptoms,” says UNC Health endocrinologist Delfin “Dale” Iglesia, MD.
Over time, high blood sugar not only causes diabetes; it increases your risk for issues with your heart, kidneys, brain, liver, eyes and nerves. That’s why learning you have prediabetes can be a valuable wake-up call.
“Prediabetes can be an opportunity to reset and address what’s going on,” Dr. Iglesia says. “There is time to improve your numbers and prevent or delay the disease from progressing.”
Understanding Prediabetes and Diabetes
Your body uses sugar, or glucose, as one of its main sources of energy. When you eat something sweet or containing carbohydrates, sugar enters the blood stream via the gut. A hormone from the pancreas called insulin moves it from the blood into the cells, where it can be used as fuel.
“If the body doesn’t make enough insulin, or doesn’t use insulin properly, there will be higher than normal blood sugar,” Dr. Iglesia says.
In type 1 diabetes, an autoimmune disease, your immune cells attack the cells in the pancreas that make insulin, so not enough insulin is made.
With type 2 diabetes, a combination of genetic and lifestyle factors can lead to insulin resistance, a state when you still have some insulin in your body but your cells don’t respond to it. That means the blood sugar accumulates in the blood and the body becomes less efficient at using glucose for fuel.
Prediabetes, typically associated with type 2 diabetes, is a sign that this process is starting. Your doctor can use three different tests to diagnose it:
- An A1C test is a blood test of average glucose over the past two to three months. A normal A1C level is below 5.7 percent. Prediabetic range is 5.7 to 6.4 percent, and diabetic range is 6.5 percent or higher.
- A fasting plasma glucose test is a blood test that requires abstaining from food and sweetened drinks beforehand. If your fasting blood sugar is 100 to 125 milligrams per deciliter, this is considered prediabetes; over 125 mg/dL is considered diabetes.
- An oral glucose tolerance test requires blood draws before and after you consume a sugary drink to show how your body responds to glucose. A blood sugar level of less than 140 mg/dL is considered normal, levels of 140 to 199 mg/dL are considered prediabetic range, and a level 200 mg/dL or higher is considered diabetes range.
It takes more than one test to officially diagnose prediabetes.
“High blood sugar levels have to be confirmed on two separate tests,” Dr. Iglesia says. “That could be two separate tests on one occasion, like an A1C and then a fasting plasma glucose test, or the same test repeated at another visit.”
Once you know these numbers, there’s an opportunity to control them. Prediabetes doesn’t always progress to diabetes.
Your Next Steps When You Have Prediabetes
- Understand the risk factors you can control.
There are many risk factors for diabetes, and some you can’t control. You’re at higher risk for diabetes if you have a family history of the disease. If you’re Black, Native American, Latino or Asian, you’re at higher risk of insulin resistance. Risk increases with age.
But there are plenty of risk factors that can be changed.
“Diabetes has different contributing factors for everyone, so educate yourself on your specific risk factors and focus on the ones you can control,” Dr. Iglesia says.
Chronic stress, smoking, excessive alcohol use and lack of sleep are common lifestyle factors that increase diabetes risk. Some medications can put you at risk for higher blood sugar, including steroids and antipsychotics; your doctor can help you identify alternatives if needed.
For most people, the biggest modifiable risk factor is weight.
“Losing weight and maintaining the weight loss has been proven to help delay or prevent type 2 diabetes,” Dr. Iglesia says, noting that a 7 percent weight loss can lower your risk by 58 percent in three years.
- Make dietary changes.
When it comes to losing weight, “diet is the biggest part of the equation,” Dr. Iglesia says.
The Mediterranean diet, which emphasizes fruits and vegetables, fish, legumes and whole grains, and limits red meat and ultraprocessed foods, has been associated with a 20 percent reduced risk of type 2 diabetes. Plant-based, low-carb diets also can reduce the risk.
Dr. Iglesia says it’s important to recognize that these diets aren’t possible for everyone—certain diets might be tied to your cultural background, or the cost of some food items may not be in your budget. If you can’t change your entire diet, start with reasonable changes, such as reducing the number of times you get fast food or drink soda in a week.
“Small changes can make a big difference,” Dr. Iglesia says. “A nutritionist or your doctor can help target specific changes that you’ll feel motivated to do, that are feasible and measurable, that you’ll feel confident making.”
Making changes to your diet also can address two other major risk factors for diabetes—high blood pressure and high cholesterol.
- Get moving.
Exercise, when paired with dietary changes, can help you lose weight, but it provides benefits beyond that.
“Even if you don’t lose weight, adding physical activity helps with blood sugar management,” Dr. Iglesia says. “Aim for 150 minutes per week of moderate physical activity, like brisk walking. Even if you don’t meet that guideline, something is better than nothing.”
Exercise also helps to reduce stress and help with sleep, addressing two other risk factors for diabetes.
If you’re getting regular exercise, Dr. Iglesia recommends also adding strength training.
“Building and preserving muscle mass is important too, because muscle is like a sponge for blood sugar,” he says. “There are people at risk for type 2 diabetes who aren’t overweight, but they lack significant muscle mass.”
- Ask your doctor about medication.
Currently, there are no Food and Drug Administration-approved medications specifically for prediabetes, but there are specific circumstances where you might start a medication before a diabetes diagnosis.
“The emphasis is always on diet and lifestyle, but patients who are at higher risk, because of family history or another condition, may benefit from medication at this point,” Dr. Iglesia says.
One option is metformin, used in type 2 diabetes to reduce blood sugar and improve insulin resistance. For patients with kidney disease, sodium-glucose cotransporter-2 (SGLT2) inhibitors, which limit how much blood sugar the kidneys absorb, may be used.
If you have struggled to lose weight in the past or have several other weight-related complications, weight loss medications such as semaglutide (brand names Ozempic and Wegovy) and tirzepatide (brand names Mounjaro and Zepbound) may be an option.
- Ask for help with making sustainable, long-term changes.
You may have tried to make these lifestyle changes before. If they haven’t stuck, don’t give up.
“These aren’t always easy changes,” Dr. Iglesia says. “When we talk about lifestyle changes, the emphasis on ‘life’ is important. You have to identify a healthy weight that you can maintain for the long-term.”
It might be helpful to ask your provider about local or online resources, such as nutritionists who can help with eating plans or trainers who can help you find exercise you’ll want to do. You may also benefit from a diabetes education program, which can help you set long-term goals in all of these areas and offer accountability; some of these programs may be covered by insurance.
“You might be more motivated to make changes in a structured program,” Dr. Iglesia says.
It’s also important to see your primary care provider regularly; don’t avoid an appointment because you’re worried that your blood sugar numbers have gone up.
“Prediabetes and diabetes are a team game,” Dr. Iglesia says. “You have physicians, diabetes educators, nutritionists, pharmacists, and ultimately your friends and family—people on your team who will be there to help you. You’re not alone in this.”
If you’re concerned about your risk for prediabetes or diabetes, talk to your doctor. If you need a doctor, find one near you.