You can prevent type 2 diabetes without losing weight, study finds

For years, the classic prescription for those at risk of diabetes has been simple: lose weight. But new research contradicts that old cliche, suggesting that weight reduction is not the only way to reduce blood sugar levels to normal. Instead, some with prediabetes can reverse themselves to normal blood sugar without losing even one pound.

The findings were the result of a close re-examination of the German Prediabetes Lifestyle Intervention Study (PLIS) and were backed by researchers from the University Hospital of Tübingen, Helmholtz Munich, and the German Center for Diabetes Research.

Taken together, the research presents a more subtle truth, one in which fat distribution and insulin function are the pièce de résistance of the equation, not the number on the scale.

Prediabetes is found in about one in ten adults worldwide, typically asymptomatic. It is defined as blood glucose values that are higher but not high enough to be diagnosed as diabetes. Left undetected and untreated, it increases the risk of developing type 2 diabetes, a condition that already occurs more than 460 million times around the world and can lead to nerve damage, kidney disease, and heart disease.

Usually, the chance of getting diabetes from prediabetes is 5–10% per year, and three-quarters of individuals will go on to develop type 2 diabetes. Health guidelines have traditionally suggested losing 5–10% of body weight by diet and exercise as the best means to reduce that risk. But as anyone who's attempted it knows, durable weight reduction is difficult to sustain, and most individuals ultimately regain it.

The German study followed more than 1,100 people, but the researchers focused on 234 participants who did not lose weight on a 12-month lifestyle intervention. Miraculously, 51 of them — about 22% — went into remission. Their blood sugars returned to normal, protecting them from diabetes even though their weight didn't change or even increased a bit.

The deciding factor wasn't the amount of fat they possessed, but where it was. Using MRI scans, the researchers compared two major types of body fat:

In remitters, visceral fat was unchanged but increased subcutaneous fat. In nonresponders, visceral fat was elevated. The shift resulted in responders having a more advantageous fat profile, with a greater proportion of subcutaneous than visceral fat. The variation appears to be protective against diabetic progression even in the absence of weight change.

The study also investigated insulin — the hormone that helps the body move sugar from blood into cells. Researchers checked insulin sensitivity and how efficiently the beta cells of the pancreas secreted insulin in glucose tolerance tests.

Responders did both better too. Their bodies handled insulin more efficiently, and their beta cells were more sensitive when glucose was added to the bloodstream. This powerful combination helped them better control blood sugar, much in the same way that some diabetes drugs work by changing fat storage patterns.

In contrast, nonresponders showed relatively little or no improvement in sensitivity or secretion. This contrast can explain why some patients attained remission without weight loss and others did not.

Maybe the most hopeful discovery is that remission without weight loss still provided long-term protection. During almost a decade of follow-up, responders were 71% less likely to get type 2 diabetes compared with their peers. That's virtually indistinguishable from protection in previous studies in which remission occurred after weight loss, averaging 73%.

To confirm their results, the researchers also examined data from the U.S. Diabetes Prevention Program. There too, those who normalized their blood sugar without weight loss had an equally about 73% reduction in diabetes risk, with analogous trends in fat storage and insulin improvement.

The study authors point out that weight loss remains beneficial but no longer must be regarded as the only priority. "Normalizing a fasting blood glucose is the most important goal in type 2 diabetes prevention and not as such the number on the scale," said Prof. Dr. Andreas Birkenfeld of Helmholtz Munich.

He and co-author Prof. Dr. Reiner Jumpertz-von Schwartzenberg argue that clinical practice guidelines need to go beyond including weight loss to include blood sugar normalization and fat distribution.

This development could make prevention available to millions who struggle with dieting. It reframes the conversation from simply "lose weight" to "work toward healthy blood sugar," a goal set by exercise, food quality, and the body's fat storage.

The discovery that remission can be achieved independent of weight loss offers a new model of diabetes prevention. It suggests that medical treatment can aim for blood sugar levels, fat distribution, and increasing the effect of insulin so prevention is more possible and less difficult.

More research may offer treatments or regimens that redirect fat storage away from the belly and to more safe reservoirs in the skin. For the patient, it holds hope: you can lower your risk of diabetes when the scale refuses to budge.

For doctors, it is a chance to reimagine care in a way that is less discouraging and more feasible.

Research findings are available online in the journal Nature Medicine.

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