Welcome back, health champions!👋

Last time, we drew a line that doesn't get talked about enough: lowering your blood sugar numbers isn't the same as fixing the biology that pushed them up. One approach helps keep glucose levels in range; the other aims to improve the underlying biology so normal glucose regulation becomes easier to maintain. Both are legitimate goals that need different plans, and much of the frustration with prediabetes is following one plan while hoping for the other's results.

In today's guide:

• A quick refresher on managing glucose levels vs. reversing prediabetes

• The six most common prediabetes approaches, viewed through one simple lens

• Which tools lower the numbers and which shift the underlying biology

• How to combine them into a plan that fits your goal

BEST FINDS

We're revamping recipes. Tell us what you want!

No recipe this week; something better instead.

Based on your feedback, the recipe section is getting a full revamp and a dedicated home. What's new:

• Reviewed by a Registered Dietitian (RD)

• A consistent, prediabetes-friendly structure with complete nutrition info: carbs, net carbs, protein, and more

• Tagged by the plan each recipe fits: complex-carb, Mediterranean, plant-based, low-carb, keto, or several at once

• All gathered in one browsable home

Help us make it better for you: we put together a 2-minute survey on what you'd like to see.

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Prediabetes Approaches Decoded: Which Manage Glucose Levels vs. Help Reverse Prediabetes?

First, a quick refresher: managing glucose levels vs. reversing prediabetes: Managing glucose levels keeps your numbers in a safer range - smaller post-meal spikes, a lower fasting reading, a lower A1c. Real, worthwhile, often very sustainable. Read: Part 1 - managing vs. reversing prediabetes.

Reversing prediabetes (returning to normal glucose regulation) goes deeper. It works on the underlying biology of prediabetes — especially insulin resistance, excess fat stored in the liver and pancreas (ectopic fat), and growing strain on the beta cells that make insulin. Improve those, and your body often handles glucose more effectively on its own, making healthy glucose levels easier to maintain over time (which typically leads to lower A1c, lower fasting glucose, and smaller post-meal spikes as well).

We'll hold each approach up to one question: is it mainly lowering glucose levels, or mainly improving the underlying biology? Most do a little of both. What matters is where the primary effect lands.

1. Cutting out bread, pasta, sugary drinks, and sweets

What it does

Shrinks post-meal glucose spikes. Less refined carbohydrate means less glucose entering the bloodstream at once, leading to smaller spikes, lower average glucose levels, and often a lower A1c.

Mainly: managing glucose levels

By itself, cutting refined carbohydrates mainly reduces the amount of glucose entering the bloodstream. If it also leads to weight loss or lower liver fat, it can improve insulin sensitivity too.

2. Cutting carbs more broadly (low-carb or keto)

What it does

A more aggressive version of #1. Fewer carbohydrates throughout the day means less glucose to process. Keto goes further by shifting the body's primary fuel source from glucose toward fat and ketones

Mainly: managing glucose levels, with a twist

Compared with simply cutting refined carbohydrates, keto often produces lower, steadier glucose levels, largely because far fewer carbohydrates are entering the system. It may also improve insulin sensitivity indirectly through weight loss and reductions in liver fat.

A useful test: if your numbers hold only while carbs stay very low, much of the benefit is probably coming from carbohydrate restriction itself. If you can add moderate amounts of carbohydrates back and still maintain healthy glucose levels, deeper metabolic improvements have likely occurred.

3. Adding walks and exercise

What it does

Exercise works on both sides of the equation.

In the moment (managing glucose levels): A walk after a meal pulls glucose into working muscle through a contraction-driven pathway that doesn't require insulin. That's why even a short post-meal walk can reduce a glucose spike.

Over time (improving the underlying biology): Regular exercise (including walking, aerobic exercise, and strength training) increases muscle GLUT4 (the protein that helps move glucose into cells), builds insulin-sensitive muscle, and improves insulin sensitivity for up to 24–48 hours after a session.

Mainly: both

Occasional walks help manage glucose levels; regular exercise improves the insulin resistance behind prediabetes.

4. Losing weight

What it does

Probably the most consistently proven underlying-biology lever for prediabetes, especially for people carrying excess weight around the middle.

For many people, losing weight helps reduce excess fat stored in places it doesn't belong, especially the liver and pancreas. As that fat decreases, insulin sensitivity often improves and the insulin-producing beta cells get some relief.

An important nuance: the benefits don't always wait for major weight loss. Some people see improvements in blood sugar control before substantial weight comes off, particularly with intensive dietary changes or metabolic surgery. But over the long run, larger and more sustained improvements in metabolic health usually go hand-in-hand with larger and more sustained weight loss.

In the DiRECT trial (type 2 diabetes), participants who achieved remission saw liver fat fall, pancreatic fat decline, and beta-cell function recover. The same biology appears to apply in prediabetes.

The catches

How you lose weight matters. The goal isn't just losing weight, it's losing it in a way that preserves muscle, supports good nutrition, and doesn't worsen other markers of metabolic health such as blood lipids. Just as important, keeping the weight off matters: weight regain often brings ectopic fat back, reducing many of the metabolic benefits that came with the loss.

5. Structured programs (DPP-style)

What it does

The CDC-recognized National Diabetes Prevention Program combines modest weight loss (~5–7%), increased physical activity (150 minutes per week), and a year of behavior support.

Mainly: both, but focused on prevention

The original Diabetes Prevention Program reduced progression to type 2 diabetes by 58% over about three years.

Return to normal glucose regulation, the clinical outcome most closely aligned with what many people mean by "reversing prediabetes" occurred in a substantial minority of participants.

Participants who returned to normal glucose regulation had substantially lower long-term diabetes risk than those who remained prediabetic.

The 5–7% weight-loss target is designed to lower diabetes risk, not necessarily to normalize glucose regulation. So remaining in the prediabetes range after a DPP-style program does not mean the program failed.

6. Medications — metformin and GLP-1s

Metformin

Metformin mainly lowers how much glucose your liver releases and modestly improves insulin sensitivity, partly through effects on liver metabolism and liver fat.

In the Diabetes Prevention Program, it reduced progression to type 2 diabetes by 31%.

Mainly: an underlying-biology pathway (but drug-dependent)

Much of metformin's benefit depends on continued use, although lifestyle changes made during treatment can continue providing benefit afterward.

GLP-1 receptor agonists (semaglutide, tirzepatide)

These medications work several ways: slowing gastric emptying, increasing satiety, improving mealtime insulin responses, and, most importantly here, driving substantial weight loss.

Mainly: a mix

The direct drug effect primarily improves glucose levels. The weight loss they produce can improve the underlying biology of prediabetes through reductions in ectopic fat and insulin resistance.

The catch is durability. Weight regain after stopping GLP-1 therapy is common, and many of the metabolic benefits fade in proportion to the regained weight. The durability of benefit depends largely on maintaining the weight loss achieved.

At a glance: which approach does what?

Build a plan that fits your goal

No single approach does everything. Some strategies mainly improve glucose levels, while others directly improve the underlying biology of prediabetes. The most durable plans usually combine both.

If your goal is to stay stable, glucose-management strategies may be enough. If your goal is to reverse prediabetes (return to normal glucose regulation), make sure your plan includes at least one strong underlying-biology lever such as regular exercise, sustained weight loss (ectopic fat loss), or both.

Medications can be useful tools, but the changes most likely to last are the ones that improve your body's ability to handle glucose on its own.

Ask yourself: which part of the problem is your plan actually solving?

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