Type 2 diabetes often develops gradually, but prevention efforts tend to become more intensive only after blood sugar begins to rise. A group of international diabetes experts says that may be too late to capture some of the best opportunities to reduce risk.
In a commentary published in Nature Medicine, the experts propose a life-course approach to type 2 diabetes prevention, beginning before pregnancy and extending through childhood, adulthood and older age. Their 10-point framework draws on existing research rather than reporting results from a new clinical trial. Several authors reported financial relationships with pharmaceutical, diabetes technology and other health companies, including Novo Nordisk, Eli Lilly, Abbott, AstraZeneca and Boehringer Ingelheim.
“Type 2 diabetes does not develop overnight. The risk of disease often builds over decades and is shaped by biological, social, and behavioral factors at different stages of life,” said Andreas L. Birkenfeld, a senior author and diabetes researcher at University Hospital Tübingen and the German Center for Diabetes Research. “If we want to prevent diabetes effectively, preventive measures must therefore begin much earlier and take individual risks across the entire life course into account.”
For many adults, diabetes prevention becomes a priority after a doctor identifies elevated blood sugar, excess weight or another risk factor. The authors argue that the larger picture begins much earlier.
Metabolic health before and during pregnancy, childhood nutrition and growth, physical activity, weight changes and other health and social factors can all shape later diabetes risk. The framework calls for looking at those influences across a lifetime rather than treating prevention as a single diet-and-exercise intervention in middle age.
“Many people think of diabetes prevention mainly in terms of diet and exercise in adulthood,” said first author Yiying Wang, a medical doctoral researcher at University Hospital Tübingen. “However, the risk of developing the disease later in life is shaped much earlier.”
The authors point to the health of both parents before pregnancy as one potential influence on a child’s future metabolic health. Pregnancy, breastfeeding, childhood and adolescence may provide additional opportunities to support healthy development.
That does not mean a parent’s health determines whether a child will eventually develop type 2 diabetes. Genetics, environment, access to healthy food and health care, physical activity, socioeconomic conditions and many other factors can contribute to risk over time.
One of the framework’s more immediate recommendations focuses on people who already have prediabetes.
Prediabetes means blood glucose levels are higher than normal but have not reached the threshold for type 2 diabetes. Rather than viewing that stage only as something to keep from getting worse, the authors argue that returning blood sugar to the normal range should become a more prominent goal.
“Prediabetes is not an irreversible condition,” Birkenfeld said. “Prediabetes remission — meaning a return to normal blood glucose levels — should therefore become a central goal of prevention.”
Previous research has found that some people with prediabetes can return to normal blood glucose levels, particularly after lifestyle changes that may include dietary changes, greater physical activity and weight loss when appropriate. People who achieve normal blood sugar have also been found to have a lower subsequent risk of developing type 2 diabetes.
But remission is not guaranteed, and the framework should not be interpreted to mean that everyone with prediabetes can prevent type 2 diabetes through lifestyle changes alone.
Risk differs considerably from person to person. Genetics, age, medications, underlying health conditions and social circumstances can all affect both diabetes risk and how realistic particular prevention strategies may be.
That variability is one reason the authors are calling for more personalized approaches.
Their broader recommendations include identifying risk earlier, tailoring prevention to different stages of life, using digital and artificial intelligence tools where appropriate and addressing health inequities that can make diabetes prevention more difficult.
The framework also reflects a shift away from thinking of diabetes prevention as simply telling people to eat better, exercise more and lose weight.
Those behaviors remain important, but whether people can act on that advice depends partly on the environments in which they live. Food access, income, education, health care and opportunities for physical activity can all shape diabetes risk and a person’s ability to change it.
The authors are not proposing that every person follow the same prevention plan from childhood onward. Instead, they argue that opportunities to protect metabolic health appear at different stages of life and that health care systems could do more to recognize them before blood sugar reaches concerning levels.
For people who already have prediabetes, that could also mean changing the goal from simply delaying type 2 diabetes to helping more people return to normal blood glucose when possible.
The framework does not establish that starting prevention earlier will prevent type 2 diabetes in every individual. But it challenges the idea that diabetes prevention begins only when a blood test shows something has already started to go wrong.
The work was supported by the German Center for Diabetes Research through the German Federal Ministry of Research, Technology and Space; the Ministry of Science, Research and the Arts Baden-Württemberg; Helmholtz Munich; the Intramural Research Program of the National Institute of Diabetes and Digestive and Kidney Diseases within the National Institutes of Health; the China Scholarship Council; and the German Research Foundation.
Several authors reported financial relationships with pharmaceutical, diabetes technology and other health-related companies. These included research funding, consulting, advisory roles, speaking fees and trial leadership involving companies such as Novo Nordisk, Eli Lilly, Abbott, AstraZeneca, Boehringer Ingelheim, Sanofi, Bayer, Roche and others. One author founded a global public health consulting company, and other authors reported consulting or ownership interests in biotechnology and health companies.