Millions of people in Germany live with elevated blood glucose levels without knowing it. They are considered to have “prediabetes” – an early stage that until now has lacked clearly defined treatment targets. People with prediabetes are usually advised to lose weight, be more physically active, and eat a healthier diet. These lifestyle changes make sense, as they improve fitness, well-being, and several risk factors. However, one crucial question has remained unanswered: Do they also protect the heart in the long term? So far, no lifestyle program for people with prediabetes has been able to clearly demonstrate a sustained reduction in heart attacks, heart failure, or cardiovascular deaths over decades.
Breakthrough in prevention research
A joint analysis of two of the world’s largest diabetes prevention studies, from the United States and China, now provides clarity. Together with colleagues in the U.S. and China, researchers from the DZD, University Hospital Tübingen, and Helmholtz Munich were able to show that the decisive factor is apparently not the lifestyle change itself, but whether people with prediabetes manage to bring their blood glucose back into the normal range – in other words, whether they achieve remission of prediabetes.
Risk to heart and vessels cut in half
Long-term data from more than 2,400 people with prediabetes show that those who succeed in normalizing their blood glucose have a significantly lower risk of dying from cardiovascular disease or being hospitalized for heart failure than those whose glucose levels remain elevated, even when both groups lose a similar amount of weight. In both studies, participants’ risk of cardiovascular death was reduced by roughly 50%, and overall mortality also fell significantly. The U.S. study followed its participants for 20 years, while its Chinese counterpart tracked participants for 30 years.
Under the leadership of the Tübingen team, these datasets were harmonized and reanalyzed to compare rates of cardiovascular death and hospitalization for heart failure in people with and without prediabetes remission.
A new, measurable target for medicine
Cardiovascular prevention has so far rested on three pillars: blood pressure control, lowering LDL cholesterol, and smoking cessation.
With these new findings, a fourth pillar could be added: sustained normalization of blood glucose in prediabetes. “Our results suggest that remission of prediabetes not only delays or prevents the onset of type 2 diabetes, as already known, but also protects people from serious cardiovascular diseases in the long term, over the span of decades,” says Professor Dr. Andreas Birkenfeld, a board member of the DZD and Medical Director of Department of Medicine IV at University Hospital Tübingen. A fasting blood glucose value of ≤ 97 mg/dL proved to be a simple marker for a persistently lower risk of heart disease, regardless of age, weight, or ethnic background. This threshold could be applied in primary care practices worldwide, making prevention more tangible.
Germany lagging in international comparison
Germany is lagging behind when it comes to preventive health care. According to the current Public Health Index, the country ranks second to last among 18 European nations in implementing evidence-based prevention measures. As a result, the risk of dying from cardiovascular disease is significantly higher in Germany than in many neighboring European countries.
The new study highlights the untapped potential and shows how concrete target values can improve public health. “We see a clear therapeutic window: If glucose levels are normalized already at the prediabetes stage, the long-term risk of heart attack, heart failure, and premature death can be markedly reduced. Our data support explicitly anchoring remission as a primary treatment goal in guidelines for the prevention of diabetes and cardiovascular disease,” urges Professor Birkenfeld.
Original publication:
Elsa Vazquez Arreola et al.: Prediabetes Remission and Cardiovascular Morbidity and Mortality: A post-hoc analysis from DPPOS and DaQingDPOS. The Lancet Diabetes & Endocrinology. DOI: https://doi.org/10.1016/S2213-8587(25)00295-5
Scientific contact:
Prof. Dr. Andreas Birkenfeld
DZD Board Member
Medical Director
Department of Diabetology, Endocrinology, and Nephrology
University Hospital Tübingen
Institute for Diabetes Research and Metabolic Diseases (IDM) of Helmholtz Munich at the University of Tübingen
Founded in 1805, Tübingen University Hospital is one of the leading centers of university medicine in Germany. Being one of the 33 university hospitals in Germany, it contributes to the successful combination of high-performance medicine, research and teaching. More than 400,000 inpatients and outpatients from all over the world benefit from this combination of science and practice every year. The clinics, institutes and centers bring together specialists from a wide range of disciplines under one roof.
The experts work together on an interdisciplinary basis and offer each patient the best possible treatment based on the latest research findings. The University Hospital of Tübingen is researching for better diagnoses, therapies and chances of recovery. Many new treatment methods are being clinically tested and applied here. In addition to diabetology, research in Tübingen focuses on neurosciences, oncology, immunology, infection research and vascular medicine. Over the past 25 years, the Chair of Diabetology / Endocrinology has been a center of interdisciplinary research, particularly involving surgery, radiology and laboratory medicine.
The discovery of prediabetes subtypes was only possible thanks to interdisciplinary collaboration. The University Hospital is a reliable partner of four of the six German Centers for Health Research initiated by the federal government. www.medizin.uni-tuebingen.de/en-de
Helmholtz Munich is a top biomedical research center. Its mission is to develop solutions for a healthier society in a rapidly changing world. Interdisciplinary research teams focus on various diseases, in particular the treatment and prevention of diabetes, obesity, allergies and chronic lung diseases. www.helmholtz-munich.de/en
The German Center for Diabetes Research (DZD) is a national association that brings together experts in the field of diabetes research and combines basic research, translational research, epidemiology and clinical applications. The aim is to develop novel strategies for personalized prevention and treatment of diabetes. Members are Helmholtz Munich – German Research Center for Environmental Health, the German Diabetes Center in Düsseldorf, the German Institute of Human Nutrition in Potsdam-Rehbrücke, the Paul Langerhans Institute Dresden of Helmholtz Munich at the University Medical Center Carl Gustav Carus of the TU Dresden and the Institute for Diabetes Research and Metabolic Diseases of Helmholtz Munich at the Eberhard-Karls-University of Tuebingen together with associated partners at the Universities in Heidelberg, Cologne, Leipzig, Lübeck and Munich. www.dzd-ev.de/en
