Factors Predicting Prediabetes Progression to Type 2 Diabetes

Dr Jedha, Host

Hello there, Dr. Jedha here and thanks for joining me for another episode dedicated to our listeners living with prediabetes.

If you’ve ever wondered whether there are specific factors that might predict if your prediabetes will progress to type 2 diabetes—and what those risk factors actually are—this episode is for you.

01:18

Having concerns about this when you have prediabetes is actually a good thing. Because if you can, you want to prevent your prediabetes from becoming type 2 diabetes. But here’s the thing—many people overlook the seriousness of prediabetes or stick their head in the sand and ignore it. And that’s demonstrated in research showing that up to 70% of people with prediabetes will eventually develop type 2 diabetes, if nothing changes. That’s a big statistic! However—and this is important—progression is not inevitable. Those high statistics only apply, IF you do nothing about it.

In previous episodes we’ve shared that prediabetes is reversible and we’ve had members share their stories of doing so, such as Lisa in episode 61 and Paul in episode 72. That’s why understanding factors that might predict if your prediabetes will progress to type 2 diabetes is so important. Then you can go get proactive to address those factors so you can avoid a T2 diagnosis. 

So, I’m always looking for new and interesting research. And a recent study caught my attention—a large systematic review and meta-analysis published in March 2025. It looked at 59 cohort studies across 19 countries, identifying the key factors that increase the risk of progressing from prediabetes to type 2 diabetes.

Now before we dive in, I want to pause for a moment and acknowledge something we’ve discussed in previous episodes. Cohort studies—especially those using population-level data—have limitations. They’re not suitable for making cause-and-effect claims, especially around things like food intake. For example, in episode 45 we talked about the sensational claims that red meat causes diabetes, a claim that simply can’t be made off the back of population studies. When it comes to dietary intake, these types of studies can be flawed in how data is collected, categorized, and interpreted. And the studies themselves can only ever show association, not causation, full stop.

But in this context—where we’re discussing risk factors rather than causes—a cohort study serves a different purpose and can be useful. It helps us observe patterns that consistently emerge across large populations over time. So while it won’t tell us why something happens, it can suggest what to watch out for. This helps us gain understanding about the factors that may predict who is most likely to move from prediabetes to type 2 diabetes—and that’s incredibly valuable knowledge for us all to have. 

And here’s a powerful incentive: even delaying the onset of diabetes by four years can lower your risk of heart disease and premature death. The sooner you start taking care of yourself, the more you gain in the long run. 

04:36

Let’s begin with what researchers call sociodemographic risk factors—these are characteristics like age, sex, body shape, and family history that influence your underlying risk of progressing from prediabetes to type 2 diabetes.

Firstly, this study suggested that age plays a major role in progression from prediabetes to type 2 diabetes. In this review, each additional year of age increased the likelihood of progressing to type 2 diabetes by about 3%. This is interesting because we actually have conflicting data here. For instance, other cohort studies have shown that people under 30 and those over 65 had a slower risk of progression from pre‐diabetes to type 2 diabetes, than those 40 to 65 years. I think we can safely say here that age may be a risk factor but not necessarily, and it’s less important than other factors as we can’t change our age and there are many other factors we can change. 

If you have a parent or sibling with type 2 diabetes, your risk goes up by about 48%, according to this review.  This reflects both genetic factors and lifestyle-related factors. Certainly we know that there are genetic risk factors when it comes to type 2 diabetes, and that’s always a powerful reminder to be proactive if diabetes runs in your family. Of course that doesn’t mean diabetes is inevitable, it just increases your risk.

Then there’s body shape and fat distribution and this one is a big one. Several body measurements were assessed in this study, and all showed increased risk. Those with prediabetes who also have higher Body Mass Index (BMI), high Waist Circumference and high Waist-to-Hip Ratio are more likely to progress to type 2 diabetes. Of these factors, the waist-to-hip ratio was the strongest predictor. Why? Because it reflects visceral fat—the deep belly fat around your organs that’s strongly linked to insulin resistance, an altered metabolism and metabolic disease. If your waist is larger than your hips, that’s a red flag. Even if your weight or BMI is ‘normal,’ carrying more fat around your middle—especially visceral fat—can significantly raise your risk. That’s because visceral fat isn’t just stored energy. It’s actually more metabolically active and inflammatory, meaning it can interfere with insulin signaling, increase insulin resistance, and drive up your blood sugar levels over time.

While we can’t change our age or genetics, BMI, waist circumference and waist-to-hip ratio are modifiable factors. Reducing body weight and belly fat through diet and movement is one of the most powerful ways to reduce your overall risk.

08:12

Which brings us to the lifestyle factors that increase risk of progression from prediabetes to type 2 diabetes. These are things you can change, which makes them some of the most important to know, and act on.

In the 2025 review, the factors that stood out were lack of physical activity, smoking and weight gain. 

Not getting enough movement was one of the most consistent risk factors. The review found that low physical activity levels increased diabetes risk by 86%. That’s significant. But here’s the encouraging part: even moderate physical activity—we’re not talking intense workouts—was shown to be protective. In fact, one study included in the review showed that moderate physical activity reduced the risk by 76%.

And this is backed by an abundance of other research that shows physical activity helps to improve glucose tolerance and lower fasting glucose in people with prediabetes, even without major weight loss.

The key takeaway here that you can act on right away is to get your body moving each day. Our body was made to move. And you don’t need to run marathons. Just walking regularly, gardening, stretching, or doing household chores can make a real difference—especially if you’re consistent. And doing strength training to build and maintain muscle can be very important to improving your blood glucose, insulin resistance and metabolism. 

It’s likely no surprise that smoking showed up as a risk factor, increasing the likelihood of developing type 2 diabetes by about 31%. Smoking promotes inflammation, insulin resistance, and worsens blood vessel function—all of which contribute to diabetes progression. If you’re currently a smoker, this is another reason to seek support in quitting. It’s never too late to benefit from stopping.

We touched on body shape earlier, but lifestyle-related weight gain—especially around the waist—is a key driver. Excess weight contributes directly to systemic inflammation in all the body’s cells, along with driving insulin resistance and poor glucose regulation. So if you are carrying excess weight, losing it will help prevent type 2 diabetes. 

Now, you might be wondering—what about diet? Isn’t what you eat one of the biggest factors in whether prediabetes turns into type 2 diabetes?

And the answer is—absolutely, yes. 

However, in this particular review, the researchers didn’t include dietary intake as one of the primary risk factors. And that’s not because diet isn’t important. It’s because in large population studies—like cohort studies—dietary data is notoriously unreliable, as we mentioned earlier in this episode. But rest assured—there’s a wealth of evidence showing that diet plays a central role in preventing and even reversing prediabetes, and preventing the progression of prediabetes to type 2 diabetes.  

Diet and nutrition absolutely should be a cornerstone of any diabetes prevention plan.

12:19

Now let’s look at a category that’s often overlooked but incredibly important, an area that researchers call psychosocial factors, which refers to emotional, psychological, and social circumstances that can influence health—and in this case, your risk of progression from prediabetes to type 2 diabetes.

Firstly, the review found that people with anxiety had more than double the risk of developing type 2 diabetes compared to those without it. In terms of psychosocial factors, anxiety presents the strongest risk.

Why would this happen? Chronic anxiety elevates stress hormones like cortisol, which can lead to insulin resistance, increased abdominal fat storage, and elevated blood sugar levels, all of which contribute to this elevated risk of progression.

Similarly, depression was associated with a significantly increased risk—about 88% higher than in people without depression.  

Depression can lead to poor sleep, low motivation to exercise, emotional eating, and less engagement in health-promoting behaviors—all of which can worsen metabolic health.

We also know that social circumstances such as finances, education and employment, and access to resources can influence the level of a person’s risk by about 15%. 

What’s interesting here is how much mental and emotional well-being directly affects physical health. If you’re feeling anxious, overwhelmed, or stuck in a cycle of stress, it’s not “just in your head”—it’s an important part of the diabetes picture. And getting support can help reduce your risk and improve your outcomes.

14:50

Now let’s talk about associated conditions—these are existing health issues or biological markers that can significantly increase the risk of progressing from prediabetes to type 2 diabetes.

This is where the numbers get really compelling, because several of these risk factors stood out as strong and consistent predictors, not only in this recent review, but we also know these are strong risk factors from other research as well. Plus, these are modifiable risk factors that you can proactively change. 

Let’s start with the big one. Out of all the risk factors identified, a high fatty liver index had the strongest association with diabetes progression.  

Fatty liver—more formally known as non-alcoholic fatty liver disease, or NAFLD—means there’s too much fat stored in your liver. Now, your liver naturally contains a small amount of fat, but when it starts building up excessively, that’s when it becomes a problem.

The liver is an incredibly important organ for us all and especially in prediabetes and type 2 diabetes. The liver plays a central role in managing blood sugar and fat metabolism. When it becomes overloaded with fat, it doesn’t work properly. This contributes to insulin resistance—which is when your body stops responding effectively to insulin, stops utilizing insulin efficiently—and that’s the key driving force behind prediabetes and type 2 diabetes. 

According to this review, people with a high fatty liver index were over six times more likely to develop type 2 diabetes compared to those without fatty liver. That makes it the strongest single risk factor across all 59 studies in the review. 

Studies have indicated that 55-78% of people with prediabetes have fatty liver. That’s a high statistic. You can’t feel fatty liver, as in most cases it has no symptoms. Most people don’t even know they have a fatty liver until it’s picked up on a blood test or scan for something else. That’s why it’s sometimes called a silent disease. But of course you can have this tested by your doctor, so make sure your doctor runs those labs when they do a fasting glucose or A1c test, they often do, but you can request it and it’s well-worth having it checked. 

The great news here is that fatty liver is very responsive to nutritional changes—especially when you reduce processed carbs and added sugars, so that’s a great place to start. Being the liver is able to regenerate, in many cases, fatty liver can be fully reversed, and doing so can dramatically improve insulin sensitivity and lower your diabetes risk.

The next factor to be aware of is hypertension. If you have high blood pressure, this significantly increases your risk of progressing to type 2 diabetes. 

This aligns with what we know about metabolic syndrome—a cluster of conditions, including high blood sugar, high blood pressure, and high triglycerides, that tend to occur together and increase the risk for both diabetes and heart disease.

Which brings us to the next significant risk factor and that is cholesterol or blood lipids. 

If you have high triglycerides, high total cholesterol and low HDL cholesterol, your risk of progressing to type 2 diabetes is higher. But, having high triglycerides, that’s the most obvious risk factor that increases your risk of progressing from prediabetes to type 2 diabetes.

These findings reinforce what we often see in practice: blood sugar, cholesterol, and blood pressure don’t exist in isolation—they’re metabolically intertwined. When one is off, others often follow, which we’ve talked about in many previous episodes. Prediabetes and type 2 diabetes are conditions of altered metabolism, so often blood pressure and cholesterol and/or weight are affected. But with the right treatment, primarily focusing on your nutrition, you can re-alter metabolism back to normal. 

19:31

To bring all this together, the three strongest risk factors according to this review, were having a fatty liver, followed by anxiety and a high Waist-to-Hip Ratio. 

Some risk factors, like age or family history, you can’t change, but what you do can have influence over your risk. Other risk factors – such as fatty liver, body weight, high blood pressure, or high triglycerides – you can influence through diet and nutrition and lifestyle, dramatically reducing your risk of progressing to type 2 diabetes or even reversing prediabetes all together. 

And what this research really tells us is that you don’t need to wait for a diagnosis to take action. Even if you don’t have these risk factors, you can prevent them. Every small step you take toward better health—whether it’s changing how you eat, moving more, managing stress or taking care of your mental health—can shift your risk in the right direction. 

As we’ve discussed in previous episodes, prediabetes is an opportunity for you to completely reverse the state of your health. Use your diagnosis as an invitation to explore the ways in which you can improve your health. For inspiration, go back and hear from Lisa in episode 61 or Paul in episode 72. They’re real-life examples of people just like you who took control and reversed their prediabetes.

Until next time—keep moving forward with small proactive steps each day. 

Dr Jedha, over and out.