For over a decade, the term “pre-diabetes” has served as a clinical warning light—a signal that blood glucose levels are elevated but not yet high enough to warrant a formal diagnosis of type 2 diabetes. Although, a growing movement within the global medical community suggests that this terminology may actually be hindering patient care by framing the condition as a “waiting room” rather than the start of a disease process.
The Società Italiana di Diabetologia (SID) is currently monitoring an international scientific debate, recently highlighted in The Lancet Diabetes & Endocrinology, which proposes replacing the “pre-diabetes” label with a staged classification system for type 2 diabetes (T2D). The goal is to shift the medical perspective from treating a manifested disease to managing a continuous biological progression.
As a physician, I have seen how the word “pre” can inadvertently minimize the urgency of a diagnosis. When a patient is told they are “pre-diabetic,” there is often a psychological tendency to view the condition as optional or reversible through simple effort, potentially overlooking the fact that the underlying physiological damage—such as the decline of insulin-producing beta cells—is already underway.
This shift toward a staged model is not merely a semantic update; it is a strategic move to reduce “clinical inertia,” the delay in intensifying treatment despite a patient’s worsening condition. By recognizing early stages as part of the disease itself, clinicians can justify more aggressive and personalized interventions long before a patient reaches the traditional diagnostic threshold for diabetes.
The Danger of the ‘Pre’ Label
The term pre-diabetes was coined in 2011 by the American Diabetes Association (ADA) to identify an intermediate state and encourage lifestyle corrections. While the intent was preventative, subsequent evidence has revealed that this “limbo” is far from benign. Patients in this stage already face a significantly increased risk of chronic kidney disease, cardiovascular complications, early-onset dementia, and specific malignancies, including pancreatic, breast, and colorectal cancers.
The SID notes that this phenomenon has happened before in other fields of medicine. For instance, the abandonment of the term “pre-hypertension” in cardiovascular medicine led to a better perception of risk and more timely treatment. By categorizing the condition into stages, the medical community hopes to achieve the same result for metabolic health.
Defining the Three New Stages of Type 2 Diabetes
The proposed framework describes type 2 diabetes as a continuous process characterized by increasing insulin resistance and a progressive decline in the function of pancreatic beta cells. Rather than a binary “on-off” switch, the disease is divided into three distinct stages based on glycemic markers and risk scores.
| Stage | Clinical Status | Key Glycemic Markers |
|---|---|---|
| Stage 1 | Increased Risk | Fasting glucose < 101 mg/dl; HbA1c < 5.7%; Titr > 90-95% |
| Stage 2 | Dysglycemia | Fasting glucose 101-124 mg/dl; HbA1c 5.7-6.4%; Titr 80-90% |
| Stage 3 | Manifest Diabetes | Fasting glucose ≥ 126 mg/dl; HbA1c ≥ 6.5%; Titr < 80% |
Stage 1 identifies individuals who, despite having glucose levels within the normal range, show a slight decline in beta-cell function and possess risk scores that suggest a high probability of progression. Stage 2 encompasses what is currently called pre-diabetes or dysglycemia. Crucially, Stage 2 would be further subdivided into Stage 2a (unhurried progression) and Stage 2b (rapid progression).
Stage 3 represents the traditional diagnosis of diabetes, where glycemic levels have crossed the threshold into a state of manifest disease requiring comprehensive management.
Personalizing Care: Rapid vs. Slow Progressors
One of the most significant clinical advantages of this new model is the ability to distinguish between different speeds of disease progression. According to Raffaella Buzzetti, president of the SID, “Un elemento innovativo fondamentale è la distinzione tra soggetti a progressione rapida… E soggetti a progressione lenta.”
Rapid progressors are typically younger individuals with obesity and high insulin resistance. For this group, the “wait and see” approach of the pre-diabetes era can be dangerous. Early, intensive intervention is critical to minimize long-term complications. Conversely, slow progressors—often older adults—may require a more tempered approach to avoid over-treatment and the associated risks of hypoglycemia.
While lifestyle modifications—such as increased physical activity and dietary adjustments—remain the first line of defense, the staged approach opens the door for earlier pharmacological support. Although current regulatory guidelines may not explicitly mandate medication for “pre-diabetics,” drugs such as metformin, pioglitazone, and GLP-1 receptor agonists have demonstrated efficacy in slowing the progression to Stage 3 and reducing cardiovascular risk.
A Cultural Shift in Preventative Medicine
The transition to a staged model represents a cultural shift in how we perceive metabolic health. By acknowledging that type 2 diabetes begins long before the traditional diagnostic point, the medical community can move toward a “preventative” rather than “reactive” model of care. Here’s expected to improve the sustainability of healthcare systems by reducing the incidence of expensive, late-stage complications like stroke, myocardial infarction, and renal failure.
However, this transition requires a sophisticated communication strategy. The SID emphasizes that moving away from “pre-diabetes” must be accompanied by clear education for both patients and healthcare providers to avoid confusion and ensure that the increased urgency is understood without causing unnecessary alarm.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
The global medical community is now awaiting an international consensus document regarding this new classification, expected in the coming months. The SID will continue to analyze how this model can be applied within the Italian healthcare context to maximize the impact on public health. We invite you to share your thoughts on this shift in diagnosis in the comments below.
