Prediabetes and Insulin Resistance: The Warning Signs, What Your HbA1c Means, and How to Reverse It
An HbA1c of 6.0, a 'borderline sugar' result, or a dark velvety patch on the back of the neck: prediabetes is the warning before type 2 diabetes, and in Pakistan it is extremely common. Here is what the numbers mean, the signs of insulin resistance, what the big prevention trials achieved — including one in South Asians — and a desi plan to bring your sugar back to normal.
By Taha Raza
Published
Many Pakistanis hear 'your sugar is a bit high' and are told to stop eating sweets — then nothing else happens until a few years later, when the diagnosis becomes diabetes. That gap is the most valuable window there is. Prediabetes is not a disease to wait out; it is the stage when diabetes can still be prevented.
What do the prediabetes numbers mean?
| Test | Normal | Prediabetes | Diabetes |
|---|---|---|---|
| HbA1c (3-month average) | Below 5.7% | 5.7% to 6.4% | 6.5% or above |
| Fasting blood glucose | Below 100 mg/dL | 100 to 125 mg/dL | 126 mg/dL or above |
| 2 hours after a 75 g glucose drink (OGTT) | Below 140 mg/dL | 140 to 199 mg/dL | 200 mg/dL or above |
A diabetes diagnosis normally needs two abnormal results. Some labs and the WHO use 110–125 mg/dL as the fasting prediabetes range. HbA1c can be misleading if you are anaemic or have thalassaemia trait, both common in Pakistan — ask your doctor whether a fasting glucose or glucose tolerance test is better for you.
How common is prediabetes in Pakistan?
Very. The second National Diabetes Survey of Pakistan, published in BMJ Open in 2018, tested 10,834 adults with glucose tolerance tests and HbA1c. It found diabetes in 26.3 percent — about one in four adults, and more than a quarter of them did not know — and prediabetes in another 14.4 percent. South Asians develop diabetes at younger ages and lower body weights than Europeans, which is why the warning signs are worth acting on early.
What are the signs of insulin resistance?
- Often none — most people find out from a routine blood test.
- A large waist: the International Diabetes Federation's cut-off for South Asians is 90 cm for men and 80 cm for women.
- Dark, velvety skin on the back of the neck, armpits or groin (acanthosis nigricans), and skin tags.
- High triglycerides and low HDL cholesterol on a lipid profile; fatty liver on an ultrasound.
- PCOS in women.
- Feeling sleepy and hungry soon after high-carbohydrate meals.
- A parent or sibling with type 2 diabetes.
Can prediabetes be reversed?
| Trial | Who | What they did | Result |
|---|---|---|---|
| Diabetes Prevention Program (US, NEJM 2002) | 3,234 adults with prediabetes, average BMI 34 | Aim for 7% weight loss and 150 min/week of activity | 58% lower risk of diabetes; metformin 31% lower |
| Indian Diabetes Prevention Programme (2006) | 531 Asian Indians, average BMI 25.8 | Lifestyle advice on diet and walking | 28.5% lower risk; 55% of the control group developed diabetes in 3 years |
| Da Qing study, China (30-year follow-up, 2019) | 577 adults with prediabetes | 6 years of diet and exercise | Diabetes delayed by about 4 years; fewer heart attacks, strokes and heart deaths |
| DPP Outcomes Study (Lancet 2012) | DPP participants followed for years | Compared those whose sugar returned to normal | 56% lower risk of later diabetes |
The Indian trial is the most relevant for Pakistanis: its participants were younger and leaner than the Americans, yet more than half of the untreated group developed diabetes within three years. Being slim does not protect South Asians the way it does Europeans.
How much weight do you need to lose?
Less than most people think. In a 2006 analysis of the Diabetes Prevention Program lifestyle group, weight loss was the strongest predictor of who avoided diabetes: every kilogram lost lowered the risk by 16 percent. For an 85 kg person, the 7 percent target is about 6 kg. Activity helped independently too — among people who did not reach the weight goal, those who met the activity goal still had a 44 percent lower rate of diabetes.
A desi plan to bring your sugar down
| Change | How |
|---|---|
| Cut sugary drinks and sweet tea | Soft drinks, packaged juice and Rooh Afza go first; reduce sugar in tea gradually to one spoon or none |
| Rebuild the plate | Half sabzi or salad, a quarter protein (daal, chicken, fish, eggs, dahi), a quarter roti or rice — one roti, or a cupped handful of rice |
| Walk after meals | 10–15 minutes after lunch and dinner; walking breaks during long sitting lower blood sugar after meals (Buffey 2022) |
| Strength train twice a week | Muscle is where most glucose from a meal is stored; more muscle means more storage |
| Lose 5–7% of your weight | A modest deficit of about 500 kcal a day, steady over months |
| Swap refined carbs | Whole-wheat roti over naan and paratha, basmati or sela over sticky white rice, fruit over mithai |
| Sleep 7–9 hours | Short sleep worsens insulin resistance and hunger |
Our guides to the glycemic index, rice versus roti, how much sugar per day and desk-job fat loss go deeper into each of these. Recheck your HbA1c after three months — the length of time it reflects.
When is medication needed?
Metformin lowered diabetes risk by 31 percent in the Diabetes Prevention Program, and some doctors prescribe it for people with prediabetes who are younger, heavier, or whose sugar keeps rising despite lifestyle changes. It works alongside diet and exercise, not instead of them. Have your HbA1c or fasting glucose checked at least once a year if you have prediabetes, along with blood pressure, cholesterol and kidney function.
This article is general information, not medical advice. Prediabetes and diabetes need diagnosis and monitoring by a doctor. See a doctor promptly for excessive thirst, frequent urination, unexplained weight loss or blurred vision, and do not change diabetes medication without medical advice.
Frequently Asked Questions
What HbA1c level is prediabetes?
An HbA1c of 5.7 to 6.4 percent is prediabetes by American Diabetes Association criteria; 6.5 percent or above is diabetes. Fasting glucose of 100–125 mg/dL, or 140–199 mg/dL two hours after a glucose drink, also counts as prediabetes.
Can prediabetes be reversed?
Usually, yes. In the Diabetes Prevention Program, aiming for 7 percent weight loss and 150 minutes of activity a week cut the risk of diabetes by 58 percent, and people whose sugar returned to normal had a 56 percent lower risk of diabetes later on.
How long does it take to reverse prediabetes?
HbA1c reflects about three months of blood sugar, so recheck after three months of consistent changes. Many people see improvement in that time; the prevention trials ran for around three years, so keep the habits going rather than stopping once numbers improve.
What are the signs of insulin resistance?
Often there are none. Common clues are a waist over 90 cm in South Asian men or 80 cm in women, dark velvety skin on the neck or armpits, skin tags, high triglycerides, fatty liver, PCOS, and a family history of type 2 diabetes.
Can I eat rice and roti with prediabetes?
Yes, in smaller portions. Fill half the plate with sabzi or salad and a quarter with protein, and keep rice or roti to about a quarter — one roti or a cupped handful of rice. Basmati or sela rice and whole-wheat roti are better choices than sticky white rice, naan or paratha.
Does walking after meals lower blood sugar?
Yes. Short walks after meals and breaks from long periods of sitting lower the rise in blood sugar after eating. Ten to fifteen minutes after lunch and dinner is an easy habit to start with.
Sources
- American Diabetes Association Professional Practice Committee. 2. Diagnosis and classification of diabetes: Standards of Care in Diabetes—2025. Diabetes Care, 2025
- Basit A et al. Prevalence of diabetes, pre-diabetes and associated risk factors: second National Diabetes Survey of Pakistan (NDSP), 2016–2017. BMJ Open, 2018
- Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 2002
- Hamman RF et al. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care, 2006
- Ramachandran A et al. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia, 2006
- Gong Q et al. Morbidity and mortality after lifestyle intervention for people with impaired glucose tolerance: 30-year results of the Da Qing Diabetes Prevention Outcome Study. Lancet Diabetes & Endocrinology, 2019
- Perreault L et al. Effect of regression from prediabetes to normal glucose regulation on long-term reduction in diabetes risk: results from the Diabetes Prevention Program Outcomes Study. The Lancet, 2012
- Alberti KGMM, Zimmet P, Shaw J. Metabolic syndrome — a new world-wide definition. A consensus statement from the International Diabetes Federation. Diabetic Medicine, 2006
- Buffey AJ et al. The acute effects of interrupting prolonged sitting time in adults with standing and light-intensity walking on biomarkers of cardiometabolic health: a systematic review and meta-analysis. Sports Medicine, 2022
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