People with prediabetes are encouraged to lose 5%-7% of their body weight to prevent progression to type 2 diabetes. However, your patients might become discouraged if they don’t see the number on the scale drop.

New findings published in Nature Medicine showed that people can enter prediabetes remission — and lower type 2 diabetes risk — even without weight loss. These findings could help motivate patients with prediabetes to stick with a healthy diet and exercise routine, even if they don’t meet weight-loss targets.

According to the research:

• About 22% of participants who did not lose weight normalized their blood sugar
• These participants were 71% less likely to develop type 2 diabetes

This was a post hoc analysis of the randomized, controlled Prediabetes Lifestyle Intervention Study, which included 1105 people with prediabetes in Germany. The intervention lasted 12 months, with a 9-year follow-up.

The findings suggest that achieving metabolic health through fat redistribution, not just weight loss, is crucial for prediabetes remission.

Physicians should “prioritize remission to normal glucose regulation (NGR) as a treatment goal in prediabetes together with weight loss because NGR confers a substantial and durable reduction in incident type 2 diabetes — even when achieved without weight loss,” Andreas Birkenfeld, MD, study leader, chairman of the department of internal medicine at University Hospital Tübingen, and director of the Institute for Diabetes Research and Metabolic Diseases (IDM) of Helmholtz Munich at the University of Tübingen, Tübingen, Germany, said in an email.

Shift to Subcutaneous Fat

Study participants who increased subcutaneous adipose tissue stores, rather than visceral adipose tissue, were more likely to enter prediabetes remission.

Subcutaneous fat is a “neutral fat storage area” just below the skin. Visceral fat, which is located deeper, surrounds internal organs. This type of fat releases pro-inflammatory proteins and has been associated with insulin resistance.

“Shifts from the visceral fat depot to subcutaneous depots have great benefits for glucose metabolism that can prevent future diabetes similarly as remission with weight loss,” Reiner Jumpertz-von Schwartzenberg, MD , study leader and head of the Clinical Study Center of the IDM of Helmholtz Munich at the University of Tübingen, said in an email.

This shift to subcutaneous fat is similar to the effect of thiazolidinediones (TZDs). These type 2 diabetes medications help reduce visceral adipose and increase subcutaneous adipose stores, which decreases insulin resistance. However, TZDs are not often used because they cause fluid retention and weight gain.

“They’ve fallen out of favor as first-line medicines because of the weight gain effect. Here we have this real-world experiment where we’re achieving the same outcome. I think that’s just really fascinating, from a physiology standpoint, that they were able to demonstrate something that we’ve seen with a drug,” Nestoras Mathioudakis, MD, MHS, an endocrinologist and co-medical director of Johns Hopkins Medicine Diabetes Prevention & Education Program, Baltimore, said.

Promote Sustainable Dietary Habits, Not Just Weight Loss

When helping patients work toward prediabetes remission, focus on developing a healthy dietary pattern they can maintain long-term.

“Encourage incremental, sustainable changes, like adding one ‘healthy swap’ per week, rather than a drastic overhaul, to promote adherence,” Grace Derocha, RDN, CDCES, a registered dietitian, certified diabetes care and education specialist, and a national media spokesperson for the Academy of Nutrition and Dietetics, said in an email.

The study does not outline a specific diet to recommend to your patients, but the authors suggest that diets high in polyunsaturated fats, compared with saturated fats, may lower the risk for visceral fat gain. Foods rich in polyunsaturated fats include walnuts, salmon, and sunflower seeds, while whole milk, bacon, and donuts contain high amounts of saturated fats.

In addition to replacing saturated fats with polyunsaturated fats, other small changes can include eating more minimally processed or unprocessed whole foods, vegetables, whole grains, legumes, lean proteins, and fiber-rich foods. Remind patients to “emphasize quality over quantity,” Derocha added.

Encourage Aerobic and Resistance Exercises

Along with dietary changes, help your patients create a manageable exercise routine to support optimal fat distribution and lower the risk for type 2 diabetes.

The American Diabetes Association recommends people with prediabetes get 150 minutes of physical activity per week and increase their daily incidental physical activities, such as taking the stairs over an elevator, walking their dogs, or standing.

When talking to patients about exercise, encourage them to adopt aerobic activities, like walking, swimming, or jogging, and resistance, or strength, training. Both can increase insulin sensitivity, and the combination is “more effective than either alone” for reducing visceral fat, even without weight loss, said Mathioudakis.

“I definitely encourage my patients to do both weightlifting and moderate-to-vigorous intensity aerobic exercise,” he added.

Monitor Waist Circumference and Utilize Glucose Meters

Many patients with prediabetes have overweight or obesity, defined as a BMI ≥ 30. However, BMI does not offer a clear picture of “adipose tissue distribution,” according to the American Diabetes Association.

“More and more, we are finding that our reliance on BMI as the sole measure of obesity and its related conditions leads to missed opportunities in helping our patients have healthier lives and better quality of life,” Shiara Ortiz-Pujols, MD , director of obesity medicine at Northwell Staten Island University Hospital, Staten Island, New York, said in an email.

Measuring waist circumference can give you a better idea of a patient’s visceral fat levels. Your patients can use a tape measure to track their weight circumference at home. Show patients how to take this measurement: Place the tape measure around their waist, right above the hip bones. Tell them to breathe in and then note the measurement right after breathing out.

Elevated diabetes risk:

• 35 in or higher in women
• 40 in or higher in men

Waist circumference is not always accurate for people who are pregnant, have distension of the abdomen due to a medical condition, or some people of Asian descent.

In addition to tracking waist circumference, clinicians can talk to patients about using glucose meters to track their blood sugar levels.

If you decide to use this method with a patient, remind them they can “spot check” rather than sticking their finger “seven times every day,” said David A. Rometo, MD, a board-certified endocrinologist and obesity medicine physician at the UPMC Center for Diabetes and Endocrinology.

Using the glucose meter can help patients see the direct impact of their lifestyle changes on insulin resistance and beta cell function, he added.

How Can You Motivate Patients Beyond the Scale

Because our society strongly associates weight with health status, your patients may find it difficult to let go of this metric.

Instead, encourage patients to celebrate “nonscale victories” like lower waist circumference, better fitness, or improved labs, said registered dietitian Derocha.

Clinicians can remind patients: “Your body is more than the scale. Meaningful metabolic improvements — including lowering blood sugar, improving insulin sensitivity, and reducing your risk of progressing to diabetes — can and do happen even if the number on the scale doesn’t budge,” said Derocha.

Mathioudakis reported receiving NIH funding for research in prediabetes; Rometo reported serving on advisory boards for Novo Nordisk for drugs that have not yet been approved; Derocha works as a Certified Pump Trainer for Omnipod — Insulet, Health Coach and Registered Dietitian for Marquee Health. Ortiz-Pujols, Birkenfeld, and Jumpertz-von Schwartzenberg reported no disclosures.