In Favor of a Prediabetes Indication for GLP-1s

In the International Journal of Obesity, obesity medicine physician and researcher Caroline Apovian offers a compelling case to favor a prediabetes indication for GLP-1s. She writes:

“The approval of a GLP-1 for prediabetes will change the landscape for prevention of T2DM and its complications due to early detection. Currently, most individuals at risk of T2DM are not identified promptly and therefore do not receive adequate referrals for lifestyle interventions based on ADA guidance. The approval of a new drug for prediabetes would prompt providers not just to test HbA1c but to then act more promptly with lifestyle in addition to treatment with a GLP-1. Timely intervention is necessary to reverse the T2DM epidemic in the US and worldwide.”

Why Bother?

This question is perhaps the most frustrating question we encounter. FDA suggests in draft guidance that they would have to see evidence of a benefit for preventing prediabetes. This is odd. We might even say it’s nuts.

We say this because the benefits of preventing diabetes are clear. Preventing diabetes is important for basic reasons. It prevents really bad outcomes from cardiovascular disease like heart attacks and strokes. It also prevents damage to blood vessels that can lead to loss of vision and kidney function.

In fact, as Apovian points out, researchers have known this for some time. The Diabetes Prevention Program showed it. When people do not progress from prediabetes to diabetes, their risk of microvascular damage to blood vessels goes down significantly. In the Swedish Obese Subjects trial, persons with prediabetes who had metabolic and bariatric surgery enjoyed a reduction in microvascular complications – by almost half. The authors explained in 2017:

“Bariatric surgery was associated with reduced risk of microvascular complications in all subgroups, but the greatest relative risk reduction was observed in patients with prediabetes at baseline. Our results suggest that prediabetes should be treated aggressively to prevent future microvascular events, and effective non-surgical treatments need to be developed for this purpose.”

Foot Dragging

Everywhere we turn, we find reluctance to embrace actually treating obesity as the complex chronic disease that it is. Caution is good. Stubborn resistance to providing care is not. When we have drugs like GLP-1s that can prevent prediabetes from progressing to diabetes with dramatic effectiveness, the reluctance to acknowledge this indication is tough to defend.

Click here for Apovian’s perspective in IJO.

Blood Sugar, illustration by Ted Kyle / ConscienHealth

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October 11, 2025