The Hidden Crossroad of Metabolic Health
Prediabetes is often described as a wake-up call. It is that precarious middle ground where blood glucose levels are higher than normal but not yet high enough to be classified as type 2 diabetes. For millions of people worldwide, this diagnosis represents a critical window of opportunity. The goal is no longer just to ‘manage’ the condition, but to achieve remission—returning blood sugar levels to a completely healthy range.
Historically, the medical community has focused heavily on weight loss as the primary lever for reversing prediabetes. While shedding pounds is undeniably beneficial, a groundbreaking secondary analysis of the PREVIEW trial (Prevention of Diabetes through Lifestyle Intervention and Population Studies in Europe and Around the World) suggests that the quality of what we eat might be even more important for long-term success than the scale suggests. Surprisingly, the study found that a standard ‘prudent’ diet outperformed the trendy high-protein, low-glycaemic index diets for long-term remission.
The PREVIEW Trial: A Rigorous Approach to Prevention
The PREVIEW study was a three-year, multicentre, parallel, randomised trial involving adults with overweight or obesity who were also diagnosed with prediabetes. The study began with an intensive eight-week rapid weight loss phase using a low-energy diet. Following this initial success, participants entered a three-year maintenance phase where they were assigned to one of two dietary patterns.
The first group followed a high-protein, low-glycaemic index (GI) diet, where protein accounted for 25% of their total energy intake and the GI was kept below 50. The second group followed what researchers called a ‘prudent diet’—a more moderate approach consistent with general dietary guidelines. This group consumed 15% of their energy from protein and had a moderate GI (above 56).
The Patient Journey: Meet Mark
To understand the practical implications of these findings, consider the story of Mark, a 52-year-old software engineer from Chicago. When Mark was told he had prediabetes, his first instinct was to cut all carbohydrates and triple his protein intake, believing that ‘more protein equals better health.’
Mark initially lost weight, but he found the high-protein lifestyle difficult to maintain socially and digestively over the long haul. His experience mirrors many participants in clinical trials: the initial enthusiasm for a restrictive diet often wanes. However, if Mark had been in the PREVIEW trial’s prudent diet group, he would have focused on moderate amounts of lean protein and balanced, whole-grain carbohydrates—a pattern that proved surprisingly more effective at keeping his blood sugar in the ‘normal’ zone three years down the line.
What the Data Tell Us: The Results
The primary outcome of the analysis was the number of participants who achieved prediabetes remission—defined as returning to normal fasting glucose and normal glucose tolerance. The results were striking and consistent across the timeline of the study.
At the one-year mark, the moderate-protein, moderate-GI group saw a 26.3% remission rate, compared to 20.7% in the high-protein, low-GI group. This trend continued into the third year, with 20.6% of the moderate group remaining in remission compared to 15.5% of the high-protein group.
Perhaps the most significant finding was that these differences in remission were independent of weight change. Both groups were equally successful at maintaining their weight loss (with roughly 30% of participants in both groups keeping off at least 8% of their initial body weight at three years), yet the moderate diet consistently led to better metabolic outcomes.
Long-Term Remission Rates Comparison
| Outcome Metric | Moderate-Protein / Moderate-GI Group | High-Protein / Low-GI Group |
|---|---|---|
| Remission Rate (1 Year) | 26.3% | 20.7% |
| Remission Rate (3 Years) | 20.6% | 15.5% |
| Weight Loss Target (≥8%) at 1 Year | 54.0% | 57.3% |
| Weight Loss Target (≥8%) at 3 Years | 31.4% | 30.4% |
Challenging the High-Protein Status Quo
For years, high-protein and low-GI diets have been the darlings of the weight-loss world. The logic was simple: protein increases satiety and has a low impact on blood sugar. However, the PREVIEW trial challenges this simplicity. Why did a moderate approach work better?
Researchers suggest several possibilities. First, the ‘prudent diet’ is often more sustainable. When a diet is easier to follow, participants are more likely to stick to the underlying healthy habits that support metabolic health. Second, very high protein intake may have subtle long-term effects on insulin sensitivity or kidney load that counteract the short-term benefits of glucose control. Furthermore, a moderate GI diet allows for a wider variety of fibre-rich whole grains and fruits, which support a healthy gut microbiome—a key player in glucose metabolism.
Practical Recommendations for Health and Wellness
Based on these findings, how should individuals with prediabetes approach their nutrition? The evidence points toward a ‘goldilocks’ approach—not too high, not too low, but just right.
Instead of obsessing over maximizing protein, focus on ‘Prudent’ eating habits:
1. Prioritize Quality Over Restriction: Rather than aiming for the lowest possible GI, choose ‘moderate’ GI foods like whole-wheat bread, brown rice, and oats. These provide sustained energy without the extreme restriction that leads to burnout.
2. Moderate Protein is Sufficient: Aim for about 15% to 20% of your daily calories from protein. This can be achieved through lean sources like poultry, fish, legumes, and low-fat dairy.
3. Focus on the Long Game: Remission is not a sprint. The fact that the moderate group performed better at three years suggests that this dietary pattern supports the body’s internal glucose-regulating mechanisms more effectively over time.
Expert Insights and Commentary
Dr. Sarah Thompson, a fictitious clinical nutritionist and metabolic researcher, notes that ‘The PREVIEW trial is a vital reminder that more is not always better. In our quest for optimal health, we often gravitate toward extreme dietary interventions. However, the metabolic system thrives on balance. This study provides clinical validation for the dietary guidelines that many have dismissed as too conservative.’
She adds, ‘What is particularly fascinating is that the benefits were independent of weight loss. This means that even if the scale isn’t moving as fast as you’d like, choosing a moderate-protein, prudent diet is doing invisible, positive work on your insulin sensitivity and glucose tolerance.’
Conclusion
The journey from prediabetes back to normal glucose health is a marathon, not a sprint. While rapid weight loss can jumpstart the process, the maintenance phase requires a sustainable, balanced approach. The PREVIEW trial provides a clear signal: a prudent diet with moderate protein and moderate glycaemic index carbohydrates is more effective for long-term remission than more aggressive, high-protein strategies.
For those currently navigating a prediabetes diagnosis, this news should be encouraging. It suggests that a balanced, varied, and non-restrictive diet is not just a compromise—it is actually the superior clinical choice for long-term health.
Funding and Trial Registration
The PREVIEW trial was supported by various international grants and funding bodies dedicated to diabetes prevention. ClinicalTrials.gov Identifier: NCT01777893.
References
Zhu R, Guo J, Huttunen-Lenz M, Silvestre M, Stratton G, Macdonald IA, Handjieva-Darlenska T, Handjiev S, Navas-Carretero S, Poppitt SD, Fogelholm M, Martinez-Urbistondo D, Martinez JA, Raben A, Brand-Miller J. Long-term effects of dietary protein and carbohydrate quality on prediabetes remission: results from the PREVIEW randomised multinational diabetes prevention trial. Diabetologia. 2026 Jan;69(1):81-92. doi: 10.1007/s00125-025-06560-x.
