Welcome back, health champions!👋

If you've ever finished a meal and wondered whether the walk you took after it actually did anything or felt frustrated that despite years of careful choices, your A1c hasn't really budged, today's issue is for you.

In today's guide:

• What the three prediabetes tests are actually telling you about your biology

• Why most prediabetes plans aim lower than you think

• Symptom management vs. true remission — and how to tell which one your current plan is built for

• A simple way to figure out where you are on the spectrum, and what to do about it

Prediabetes: Are You Managing the Symptoms or Fixing the Cause?

You're already doing more than most

Here's the good news: if you've been prediabetic for a while, you've probably built real habits: skipping the bread basket, walking after dinner; or maybe starting metformin. Many of you have held off diabetes for years, and that's no small feat.

In fact, pat yourself on the back. About 1 in 3 U.S. adults has prediabetes, only 1 in 5 of them know it, and fewer still act on it. You're in that last group, a small, serious circle of health champions. That matters, your efforts genuinely lowers your cardiovascular risk.

But here's the question worth sitting with: are those habits managing your blood sugar, or actually changing the biology that pushed it up in the first place?

The standard of care rarely makes this distinction and it's the single best lens for understanding why some people stay stuck in prediabetes for a decade while others get back to normal and stay there.

This is Part 1 of two. Today: how your blood sugar numbers hint at what's happening underneath at a biological level, and the difference between managing prediabetes symptoms and going after the deeper causes for true remission. Next time, we'll go approach-by-approach — carbs, exercise, weight loss, metformin, GLP-1s — to see which ones manage symptoms and which ones shift the underlying biology.

What the three prediabetes tests are really telling you

Prediabetes is diagnosed using any one of three blood tests (per the ADA Standards of Care). You've likely seen these numbers before, but here they are quickly:

• HbA1c: 5.7–6.4% (normal: below 5.7%)

• Fasting plasma glucose: 100–125 mg/dL (normal: below 100 mg/dL)

• 2-hour glucose during an oral glucose tolerance test (OGTT): 140–199 mg/dL (normal: below 140 mg/dL)

What's less commonly discussed is that each test is a window into a different underlying problem. In simplified terms:

• A1c reflects your average blood glucose exposure over the past ~3 months — it's the cumulative result of everything happening in your metabolism over past 3 months.

• Fasting glucose reflects what your body is doing overnight, when no food is coming in. When that number runs high, it's often a sign the liver is releasing more glucose than it should — something commonly linked to hepatic insulin resistance.

• The OGTT reflects how effectively your body handles a large glucose load. It gives insight into both how well the pancreas responds with insulin and how efficiently tissues like muscle pull glucose back out of the bloodstream.

It's common to be normal on one test and prediabetic on another. And which one is holding you back gives you a real clue about which underlying driver is most active in your case.

The goal almost everyone is given: "don't get diabetes"

Prediabetes is defined as a risk state, an in-between zone on the way to diabetes, so the default treatment goal has always been simple: keep you from crossing that line. The most influential evidence behind that goal is the Diabetes Prevention Program (DPP), a landmark NIH trial showing that intensive lifestyle change cut 3-year progression to type 2 diabetes by 58%, and metformin by 31%. The ADA's prevention recommendations are largely built on it.

But notice what the goal was: not getting diabetes. Not getting back to normal. The entire framework is oriented around preventing progression, not reversing the condition.

Real-world translations of the DPP make this even more apparent. In community-based National DPP programs, average weight loss is about half what participants achieved in the original trial enough to delay diabetes for many people, but often not enough to send them back to fully normal glucose handling.

So you can do "everything right" by the standard playbook and still be prediabetic five years later. That's not a personal failure, it's a function of what the goal was set to in the first place.

Symptom management vs. prediabetes remission

Symptom management keeps the numbers in an acceptable range. Lower the spike after a meal. Bring the morning fasting reading down a few points. Shave a tenth off your A1c. Real and worthwhile. These changes reduce real harm.

Prediabetes remission restores the underlying biology enough that your body handles glucose properly on its own. The driving conditions are well established: insulin resistance in muscle (the body's biggest site of glucose disposal), excess fat stored in the liver and pancreas where it shouldn't be (ectopic fat), and the gradual stress on beta cells that follows.

A recent analysis of DPP data found that participants who achieved prediabetes remission (not just preventing progression) had substantially greater long-term protection against diabetes than those who hit the weight-loss goal alone, with insulin sensitivity improvement as the critical mechanism. The biology can shift. The standard goal just rarely aims that high.

The OGTT is especially worth understanding here, because it's the clearest demonstration of what we mean by "your body's ability to process glucose." Drink the standardized 75g glucose drink, and:

• A person with normal glucose tolerance typically peaks around 60 minutes and is back under 140 mg/dL by 2 hours. Their insulin response is fast, their muscles pull glucose out of the blood efficiently, and the system resets quickly.

• A person with prediabetes often hits a similar peak (or higher), but their 2-hour reading is still 140–199 mg/dL. The glucose is still circulating because muscles aren't taking it up efficiently and the insulin response is sluggish.

Same glucose load. Very different ability to handle it.

This is why prediabetes remission isn't just about getting your A1c into the normal range through strict daily control (though there's nothing wrong with that if you can sustain it). It's about restoring your body's actual ability to process glucose — so that when a celebration, a stressful week, or a life event happens, your body absorbs the hit and resets.

So where are you on the spectrum?

If your numbers have been roughly stable in the prediabetic range for years, you most likely have a maintenance plan that's working — your habits are successfully holding your blood sugar steady, even though the underlying insulin resistance probably hasn't improved much. The lid is on, but the pressure underneath is still there.

If you keep cycling between prediabetic and diabetic ranges, your plan controls spikes and averages most of the time, but it isn't durable. Stress, sleep loss, a holiday, a busy season tips you over — which usually means root-cause drivers are still active underneath.

If your numbers are steadily climbing, your plan isn't yet robust enough for spikes or averages, or there's a second metabolic driver in the mix (PCOS, sleep apnea, significant ectopic fat, certain medications, perimenopause) that needs its own attention.

And the outcome we hear about least often, but which is real and well-documented: people who've reached normal numbers and are sustaining them. They almost always got there — knowingly or unknowingly — by addressing root causes, not just managing symptoms.

The point isn't more testing — it's clearer goals

None of this means you should be doing OGTTs every month or chasing new metrics. The point is much simpler:

Define what you actually want. Is your goal to keep your numbers stable so you don't progress? Or is it to restore your body's ability to handle glucose so life doesn't feel like a constant battle? Both are legitimate. They just require different plans.

Then check whether your plan fits your goal. A symptom-management plan that's keeping you stable is doing exactly its job — celebrate that. A symptom-management plan that you've been hoping would deliver remission is the mismatch that makes prediabetes feel like an impossible fight.

Don't worry about what anyone else is doing. The right plan is the one whose goal matches yours, that you can sustain, and that's actually moving the part of the problem you care about.

In Part 2, we'll walk through the most common prediabetes approaches and look at each through this lens — so you can see which tools fit which goal.

Have questions? We got answers. Email [email protected]