Prevalence of Prediabetes in India

Current Statistics

Prediabetes is increasingly prevalent, with the IDF 2025 Atlas estimating that nearly 90 million individuals in India are affected. Contributing factors such as rising obesity rates, urbanization, sedentary lifestyles, and high-calorie diets are exacerbating metabolic dysfunction.

Study Insights

Research from India indicates that approximately 80% of individuals with prediabetes are either overweight or obese. The recent ICMR study involving 113,043 participants highlights the growing metabolic burden in the country: 43.3% are metabolically obese non-obese (MONO), 28.3% are metabolically obese obese (MOO), 26.6% are metabolically healthy non-obese (MHNO), and only 1.8% are metabolically healthy obese (MHO). The correlation between obesity and increased cardiovascular (CV) risk, as well as a fourfold increase in diabetes risk, underscores the urgent need for focused prediabetes management in India’s increasingly overweight population.

Understanding Insulin Resistance

Connection to Obesity and Prediabetes

Obesity and prediabetes are linked through insulin resistance, yet they differ in phenotype. Normoglycemic obesity primarily involves adipose-driven insulin resistance, while obesity associated with prediabetes shows genetically determined muscular insulin resistance. This condition accelerates beta-cell stress, inflammation, and glucotoxicity. The rapid conversion from prediabetes to diabetes in South Asians can be attributed to their unique phenotype, characterized by abdominal obesity, low muscle mass, ectopic liver fat, elevated postprandial glucose levels, and early beta-cell failure, which further intensifies insulin resistance and hastens beta-cell exhaustion.

Risk Factors for Obesity and Insulin Resistance

Key Risk Factors and Clinical Implications

  • Family History: A family history of obesity increases the risk of developing related conditions by twofold, highlighting the genetic predisposition to obesity-related insulin resistance.
  • NAFLD/NASH: Individuals with obesity face a 2-3 fold higher risk of developing Non-Alcoholic Steatohepatitis (NASH), with 30% affected. This condition reflects the strong connection between adipose tissue and liver health, where dysfunctional adipose tissue drives NAFLD, contributing to insulin resistance.
  • PCOS: In cases of Polycystic Ovary Syndrome (PCOS), 38-88% of women are overweight or obese, and 50-90% exhibit insulin resistance, primarily due to defects in the PI3-kinase pathway. This dysfunction promotes hyperandrogenemia and reproductive issues through compensatory hyperinsulinaemia.
  • Obstructive Sleep Apnoea (OSA): Each 10% weight gain increases the risk of OSA sixfold. OSA independently contributes to insulin resistance and abnormal glucose metabolism, serving as a significant prediabetes risk factor.

Role of Metformin in Managing Obesity-Linked Prediabetes

Pharmacotherapy Benefits

Pharmacotherapy is crucial in delaying diabetes progression among high-risk obese prediabetic individuals. Metformin plays a significant role by reducing hepatic gluconeogenesis, decreasing intestinal glucose absorption, and enhancing glucose uptake in the liver and skeletal muscle through AMPK activation, which regulates energy homeostasis. Additionally, it modulates obesity-induced meta-inflammation by impacting immune cells in adipose tissue and the liver.

Clinical Evidence

An observational study involving 304 obese prediabetic patients demonstrated that metformin reduced HbA1c levels by 0.22% and BMI by 1.46 kg/m², indicating positive outcomes. Furthermore, in overweight or obese adults with symptomatic knee osteoarthritis, RCT data showed that metformin led to a greater reduction in pain compared to placebo.

Metformin as Maintenance Therapy Post GLP-1 RA

A recent study presented at the 61st EASD 2025 Annual Meeting indicated that patients who lost weight using GLP-1 receptor agonists (GLP-1 RAs) were able to maintain their results after switching to generic anti-obesity medications, with metformin being used in 80% of cases. This suggests the potential of metformin in sustaining weight loss achieved through GLP-1 RA therapy, although further large-scale randomized controlled studies are necessary.

Global and Indian Recommendations

Approval and Guidelines

Globally, metformin has received approval for prediabetes management in at least 66 countries, reinforcing its established role in diabetes prevention. The Indian Expert Group Consensus Statement also supports metformin’s use in individuals with prediabetes, particularly in those with a BMI exceeding 35 kg/m².

Key Messages

– Both prediabetes and obesity share a pathway of insulin resistance, with South Asians experiencing a rapid progression to diabetes due to factors such as abdominal obesity and low muscle mass.
– Identified obesity-linked risks, including family history, NAFLD/NASH, PCOS, and OSA, heighten insulin resistance and metabolic deterioration, increasing the likelihood of progression to Type 2 Diabetes (T2D).
– Metformin offers significant benefits in managing obesity-linked prediabetes, improving glycemic control and reducing BMI, as endorsed by Indian guidelines for high-risk patients. The prospect of metformin in maintaining weight loss after GLP-1 RA therapy is also encouraging.

Abbreviations

IDF = International Diabetes Federation; ICMR = Indian Council of Medical Research; MONO = Metabolically Obese Normal Weight; MOO = Metabolically Obese Overweight; MHNO = Metabolically Healthy Normal Weight; CV = Cardiovascular; FPG = Fasting Plasma Glucose; IFG = Impaired Fasting Glucose; IGT = Impaired Glucose Tolerance; HbA1c = Glycated Hemoglobin A1c; NAFLD = Non-Alcoholic Fatty Liver Disease; NASH = Non-Alcoholic Steatohepatitis; PCOS = Polycystic Ovary Syndrome; OSA = Obstructive Sleep Apnoea; AHI = Apnea–Hypopnea Index; FHS = Family History Score; PRS = Polygenic Risk Score; AMPK = AMP-Activated Protein Kinase; ATP = Adenosine Triphosphate; RCT = Randomized Controlled Trial; VAS = Visual Analog Scale; SD = Standard Deviation; GLP-1 RA = Glucagon-Like Peptide-1 Receptor Agonist; AOM = Anti-Obesity Medication; RSSDI–ESI = Research Society for the Study of Diabetes in India–Endocrine Society of India; ADA = American Diabetes Association; EASD = European Association for the Study of Diabetes; T2D = Type 2 Diabetes.