Not all prediabetes is equal: young adults with high fasting glucose face a 25% diabetes risk in five years

The 7.5% five-year risk of progressing from prediabetes to Type 2 diabetes sounds manageable. But buried in that average is a group with a risk more than three times higher - and current clinical guidelines treat them all the same way.

Preliminary research presented March 17 at the American Heart Association's EPI|Lifestyle Scientific Sessions 2026 in Boston breaks down that average into starkly different risk profiles among young adults ages 18 to 40. The findings suggest that a one-size-fits-all approach to prediabetes may be leaving the highest-risk patients underserved.

A four-fold spread in risk

The study, led by Mary Rooney at the Johns Hopkins Bloomberg School of Public Health, followed 662 young adults with prediabetes drawn from three U.S.-based longitudinal studies. The participants had an average age of 32 and were followed for a median of about seven years.

The overall five-year progression rate was 7.5%. But when the researchers stratified by fasting glucose levels and eligibility criteria for GLP-1 receptor agonist (GLP-1 RA) medications - the weight-loss drugs that have recently transformed obesity treatment - the numbers diverged dramatically:

• Overall prediabetes group: 7.5% five-year risk
• Those meeting GLP-1 RA criteria (BMI 30+ or BMI 27+ with high blood pressure or cholesterol): 10.9%
• Those with higher fasting glucose (110-125 mg/dL): 15.1%
• Those with both higher fasting glucose and GLP-1 RA criteria: 24.8%

One in four young adults in that highest-risk group developed Type 2 diabetes within five years. That is a fundamentally different clinical situation from the one-in-thirteen overall rate.

GLP-1 drugs as a diabetes prevention tool?

GLP-1 RA medications are currently FDA-approved for Type 2 diabetes management and for weight loss in people meeting specific BMI thresholds. They are not approved for diabetes prevention in people with prediabetes. But the study's findings raise an obvious question: should they be?

The researchers used existing GLP-1 RA eligibility criteria as a way to stratify risk, not as a treatment recommendation. But the correlation between meeting those criteria and having elevated diabetes risk suggests that the same patients who qualify for weight-loss medication may be the ones who would benefit most from early, intensive intervention to prevent diabetes altogether.

"Current approaches to Type 2 diabetes prevention are 'one-size-fits-all,'" Rooney said. "Our results signal that some people with prediabetes have a higher risk of progressing to Type 2 diabetes. These are the patients who may benefit from more targeted, intensive treatment than others."

The cost-effectiveness of using GLP-1 RA drugs for diabetes prevention, however, remains unknown - a significant gap given the medications' current price tags.

The rising tide in young adults

The study matters partly because of who it focuses on. Diagnoses of Type 2 diabetes and prediabetes are increasing in adults under 40 - a demographic that historically was not considered high-risk. The complications of Type 2 diabetes - heart disease, kidney disease, stroke, nerve damage - accumulate over time, so earlier onset means a longer window for damage.

Lifestyle interventions such as weight loss, dietary changes, and regular physical activity remain the frontline approach for prediabetes, and they work. But they require sustained behavior change, and adherence rates in real-world settings are often lower than in clinical trials. For the quarter of young adults in the highest-risk group who will develop diabetes within five years, time is not on the side of gradual lifestyle modification.

Preliminary data, important caveats

This is a conference abstract, not a peer-reviewed publication, and the findings should be treated as preliminary. The study has several specific limitations: hemoglobin A1c measurements, which provide a two-to-three-month average of blood sugar and are commonly used to define prediabetes, were not available. Only fasting glucose was used. The sample of 662 participants, while drawn from three established cohorts, is modest. And the health data was collected between 1985 and 2011, before GLP-1 RA medications were available for weight loss, so the study cannot directly test whether those drugs would prevent progression.

The participant demographics also warrant attention: 47% self-identified as Hispanic/Latino, 45% as non-Hispanic White, and only 7% as non-Hispanic Black. Whether the risk stratification works similarly across a more diverse population remains to be established.

But the core finding - that prediabetes risk in young adults spans a four-fold range depending on glucose levels and metabolic risk factors - challenges the practice of treating all prediabetes as a single condition requiring a uniform response.