Ashlee Williams, MD (Host): More than one in three American adults has prediabetes, but most don't even know that they have it. The good news, prediabetes doesn't have to progress to type 2 diabetes. In many cases, making the right changes at the right time can lower blood sugar levels and return them to a healthy range. But with so much conflicting advice about diets, exercise, weight loss, and blood sugar, it can be hard to know where to start.

Welcome to the Healthier You podcast. I'm Dr. Ashlee Williams. And today, I'm talking with Dr. Vernesha Montgomery, a board-certified family medicine physician here at Kaiser Permanente. Today, we'll discuss pre-diabetes, who's at risk, and whether it can truly be reversed. Dr. Montgomery, thank you so much for joining us today.

Vernesha Montgomery, MD: Thank you, Dr. Williams, for allowing me an opportunity to talk about this very, very important topic.

Host: Yes, it's such an important topic. So, we always like to start with the basics. First, what is prediabetes and how can we prevent it from progressing to diabetes?

Vernesha Montgomery, MD: That's a great question that many of my patients have. So ,what is prediabetes? Prediabetes means that your blood sugar levels are higher than normal, but not yet high enough to meet the criteria for type 2 diabetes. You can kind of look at it like a warning sign that your body is beginning to have trouble regulating blood sugar.

And normally, the hormone insulin will help move glucose, or we also call it sugar, from your blood into your cells where it's used for energy. But with prediabetes, your body starts to become a little more resistant to insulin, meaning it doesn't work as effectively. So in response, your pancreas, an abdominal organ, produces more insulin to compensate. And over time, it may not be able to keep up. So, it allows the blood sugar levels to continue to rise.

You will hear certain tests called A1cs. You may have seen it on your lab work. And an A1c level between 5.7 and 6.4 is considered prediabetes. If you have a fasting blood sugar between 100 and 125, that is also considered prediabetes. Or a two-hour glucose tolerance test that results between 140 and 199 is also considered prediabetes. But the most concerning part of prediabetes is that it causes no symptoms. So, many folks are walking around and have no clue that they have this prediabetes. But the great news that I want to share is that this stage is often reversible. So, it's unlike type 2 diabetes, where permanent damage may already be occurring. Prediabetes offers an opportunity to intervene before any complications develop.

Host: That is great news. So, can you talk a little bit about who is most at risk for developing pre-diabetes and who you think should be screened?

Vernesha Montgomery, MD: Another really, really great question. So, Dr. Williams, there are several factors, as you know, that will increase your risk of developing prediabetes. For example, being 35 years or older, being overweight or having excess weight around the abdomen. If you have a family history of type 2 diabetes, then you're a little bit more at risk for developing prediabetes. If you're physically inactive, if you have high blood pressure or unhealthy cholesterol levels, so other things that need to be monitored regularly. Also, if you have a history of gestational diabetes, which is diabetes during pregnancy.

Another important risk factor is smoking. You also know that certain racial and ethnic groups, including African Americans, Hispanic Latinos, Native Americans, Asian Americans, and Pacific Islander populations also have a higher risk of developing type 2 diabetes.

The American Diabetes Association recommends screening all adults starting at age 35, specifically if they have any of the risk factors that I just previously mentioned. As we mentioned before, prediabetes usually has no symptoms, so it's important that you're screened in order to detect it.

Screening is simple. An A1c is a blood test. It will measure your average blood sugars over the past two to three months. You often do not have to fast because of this fact. And it's also the preferred screening test. And then, you can also have a fasting blood glucose test, which will measure your blood sugar after you haven't eaten for at least about eight hours, usually overnight. I have my patients come in first thing in the morning before breakfast, before their to have fasting blood glucose tests.

Sometimes a provider may order an oral glucose tolerance test. Usually, that's done during pregnancy. You remember drinking that very, very sweet sugary beverage and then having your blood sugars checked two hours afterwards. If your results are normal, screening is typically repeated about every three years, although your doctor may recommend more frequent testing if you have some of those risk factors that I mentioned before.

Host: Got it. Yes. One of my favorites is the A1c test. I love it because you don't have to fast prior to coming to the lab, because it is testing your blood sugar over the last three months. Okay. So, let's say we have the diagnosis of pre-diabetes. Is it reversible? And are there any lifestyle changes that you suggest to your patients to make if it is reversible?

Vernesha Montgomery, MD: Absolutely. Another wonderful question. Many of my patients, they get scared, they get nervous. What does this mean for me? Is this a permanent diagnosis? In many cases, prediabetes can be reversed, and research actually shows that a healthy lifestyle can significantly lower blood sugar levels and reduce the risk of progressing to type 2 diabetes.

And so, some people are able to return their blood sugar to the normal range, and others are able to keep it stable for many years without even progressing to the diagnosis of type 2 diabetes. So, most people want to know, like, what are the things that I can do to prevent this progression into type 2 diabetes, and there are several things that can be done.

The most important is to lose a modest amount of weight. Even losing 5% to 10% of your body weight can make a drastic difference. For example, someone who is 200 pounds, that's just about, you know, 10 to 20 pounds of excess weight that can be lost around the abdomen, and that weight around the abdomen is contributing to insulin resistance. So, just losing just a small amount of weight will help improve your insulin sensitivity.

The next one, my favorite one, is to be physically active. So, I always tell my patients, aim for at least 150 minutes of moderate intensity exercise each week, and you can choose what you like as your form of exercise. For example, you can go walking, cycling, swimming. My favorite is dancing. You just turn on some music in your home, grab your kids, grab your grandchildren, grab your pets, and just move, and that doesn't even need a gym membership.

Another important one is strength training at least twice a week. And the reason why exercise is so important that we sometimes don't talk about is, one, because your muscles actually will use glucose for energy while you're active and will lower your blood sugar. And second, exercise makes your muscles more sensitive to insulin. So, they can absorb glucose more efficiently even after your workout is over. So, imagine that. You're not even working out, and your muscles are helping you. So, building muscles through resistance training is especially beneficial, because our muscles are one of the body's largest users of glucose.

Another thing, Dr. Williams, is I encourage my patients to choose foods that support steady blood sugars. So rather than restricting your diet, focusing more on eating more vegetables, fruits, whole grains, beans, lean proteins, nuts, seeds, and healthy fats while limiting sugary drinks, sweets, refined carbs, and heavily processed foods.

Another important type of food is high fiber. High fiber foods will slow down digestion and the absorption of glucose into the bloodstream. So, it prevents large blood sugar spikes after meals. Always remember, pair your carbohydrates with a protein or healthy fat to help stabilize your blood sugar. And it also keeps you feeling full longer.

One that we always forget about is prioritizing quality sleep. So, aiming for seven to nine hours of quality sleep every night. As you know, poor sleep can increase stress hormones like cortisol and can just ruin your day. It disrupts the hormones that will regulate hunger, and it increases your cravings for high-calorie foods. So, do not ever forget the importance of quality sleep.

Lastly, managing chronic stress. So when we're stressed and we're under chronic constant stress, our body produces cortisol and adrenaline, and these are hormones that signal the liver to release more glucose into the bloodstream. Chronically elevated stress hormones can contribute to higher blood sugar levels and worsen insulin resistance.

So, remember activities like walking, meditation, yoga, mindfulness, praying, spending time outdoors, or just simply taking time for hobbies and social connections that bring you joy can reduce stress and support healthier blood sugar.

We also can't forget the importance of avoiding smoking and limiting alcohol. Smoking can actually increase inflammation and insulin resistance. And if you drink alcohol, we recommend that you do so in moderation, as excessive alcohol intake can also affect blood sugar regulation and contribute to weight gain. Remember, this is not about being perfect, but small and consistent changes can, over time, be beneficial.

Host: So, we've changed our diet, we're exercising, we're sleeping, there's no stress, we don't smoke or drink, we still have an elevated A1c, considered prediabetes. Are there any medications that you recommend to treat prediabetes?

Vernesha Montgomery, MD: Sure, you're right. For most people, these lifestyle changes, over time are the first and most effective treatment. However, for some folks, medication can be appropriate, and that's a decision you have to speak one-on-one with your physician about.

The most common prescribed medication is metformin, and many people have heard of that one. This particular medication works by improving the body's response to insulin, and it reduces the glucose production by the liver.

So metformin, I often consider metformin in my patients that have a body mass index of 35 or higher, are younger than age 60 with multiple risk factors, have a history of gestational diabetes, which is diabetes during pregnancy, and if they continue to have rising blood sugar despite all of their hard work with healthy lifestyle changes. So usually, metformin is a preferred option.

There are newer medications that many people have heard of, such as the GLP-1s, that have also been shown to promote weight loss and improve blood sugar control. While they're primarily approved for diabetes or obesity treatment, they may be appropriate for some patients that are very high risk, particularly when obesity is a major contributing factor.

But again, that's a discussion that you should have with your primary care provider. One thing I do want to stress is that medications should never be viewed as a substitute for healthy habits. I like to tell my patients they can be a tool to help you reach your goals. And even if medication is prescribed, nutrition, physical activity, and weight management remain the foundation of treatment of prediabetes.

Host: Yes. Lifestyle changes are equally important to medication, should always be combined. So, let's give advice to the person who's been diagnosed with prediabetes today. What is the first action they should take, and how should they stay motivated?

Vernesha Montgomery, MD: Yes. So, I always tell my patients, prediabetes, you are not a failure. It does not mean that you're a failure. It should be viewed as an opportunity. The first step is to schedule a conversation with your healthcare provider. I know it's really easy to go on Google or ChatGPT, but really having a one-on-one conversation with your provider, with your physician about your personal risk factors, your family history is the first step.

And then, rather than trying to overhaul your entire lifestyle overnight, because that's not sustainable, focus on one or two sustainable changes. For example, take a 20-minute walk after dinner on most evenings. Replace your sugary beverages, juices, soda with water or unsweetened tea.

Another small change you can make is to fill your plate, half of your plate with vegetables. They add the fiber we talked about earlier, they make you feel full, and they stabilize your blood sugars. Again, we talk about adding that strength training, building those muscles, and then again, aiming for your seven to nine hours of sleep.

Other options that patients can use, we have resources with Kaiser Permanente. We have registered dieticians. We have diabetes prevention programs where you can receive education, coaching, and ongoing support during this prediabetes stage.

Just remember, the most important takeaway point is early action can truly change the outcome. Every healthy choice you make today can help protect your long-term health and significantly reduce your risk of developing type 2 diabetes.

Host: I will say the Kaiser Permanente Diabetes Prevention Program has been a game-changer for a lot of my patients, so highly recommend. And I do agree, if you have to Google it or ask ChatGPT, always great to check in with your primary care doctor. Dr. Montgomery, thank you so much for all this amazing information. We learned a lot about prediabetes and what we can do to prevent progression to type 2 diabetes.

Here are the top takeaways: one, prediabetes is a warning sign, not a life sentence. Early action can prevent or even reverse progression to type 2 diabetes. Because prediabetes actually has no symptoms, regular screening with a simple blood test is the best way to detect it before complications develop.

Losing just five to seven percent of your body weight and getting at least 150 minutes of exercise each week can dramatically improve insulin sensitivity and lower your risk of developing type 2 diabetes.

Eating a balanced diet rich in vegetables, whole grains, lean proteins, and healthy fats while limiting sugary drinks and processed foods helps keep blood sugar levels steady and supports long-term metabolic health.

And lastly, small, consistent lifestyle changes are more effective than drastic short-term efforts. And every healthy choice you make today can have a lasting impact on your future health

For more information from our experts, visit kp.org/doctor and listen to more episodes of Healthier You wherever you get your podcasts. If you enjoyed this episode, be sure to subscribe and share it with others. Have questions or health topics you'd like for us to address in future episodes? Let us know in the comments. Thank you. And from all of us at Kaiser Permanente, be well.