BY DR. RACHNA RELWANI*
For many people, the word prediabetes sounds reassuring. It’s not full-blown diabetes. It’s not serious. We can just “watch it.” Especially in our community, where diabetes is so common, it is often treated as a warning that can be ignored for a while.
But the heart does not see it that way. Prediabetes rarely travels alone. Elevated blood sugar often coexists with hidden cardiovascular risk long before symptoms appear and long before standard labs are flagged as abnormal.
As a physician, I routinely meet South Asian patients who are shocked to learn they had silent heart disease brewing for years with no risk factors except insulin resistance. Many had been labeled “borderline,” reassured, and advised to just “be careful.” By the time symptoms appeared, the damage was already done. South Asians can have acceptable LDL cholesterol and only borderline blood sugar – yet advanced testing shows a very different cardiovascular risk profile.
Recent long-term data now make it clear: prediabetes itself is a cardiovascular risk factor, not a benign phase on the way to something worse. A major study published in The Lancet Diabetes & Endocrinology followed people with prediabetes for 20–30 years, tracking what happened to their hearts over time. This wasn’t a short snapshot. It was a lifetime view of cardiovascular risk.
The results were striking: People whose prediabetes remitted back to normal blood sugar had a cardiovascular disease rate of 1.74 events per 1,000 person-years but those whose prediabetes persisted had a rate of 4.17 events per 1,000 person-years. That is more than double the risk when prediabetes was allowed to persist.
Importantly, this wasn’t just about heart attacks from blocked arteries. The increased risk included death or hospitalization from heart failure. Prediabetes is known to increase the risk of stroke and heart failure in addition to classic atherosclerotic disease.
In other words, prediabetes affects the heart and blood vessels in multiple ways, quietly and over decades. Even when blood sugar is just slightly high, it drives:
- Chronic inflammation
- Endothelial dysfunction (damage to blood vessel lining)
- Abnormal lipid particles
- Insulin resistance that stresses the heart muscle itself
Prediabetes increases cardiovascular risk through pathways that are not fully captured by standard cholesterol panels. These include inflammation, insulin resistance, small dense LDL particles, and myocardial damage. Large population studies consistently show that prediabetes increases cardiovascular risk by roughly 20–30%, independent of whether someone ever develops full diabetes.
This matters deeply for South Asians, who already have:
- Higher visceral fat at lower BMI
- Earlier insulin resistance
- Smaller blood vessels
- Greater risk of heart disease at younger ages
Waiting until blood sugar crosses an arbitrary diabetes threshold is a missed opportunity. Many people are told, “Your numbers are fine,” only to experience a heart attack or stroke years later. When we look back, the clues were there, but they weren’t measured together.
For years, the message around prediabetes has been “prevent diabetes.”
That framing is incomplete. The real goal should be normalizing blood sugar, not merely slowing progression. The Lancet study shows that returning glucose levels to normal meaningfully lowers long-term heart risk.
Lifestyle changes remain foundational:
- Nutrition to reduce glucose spikes
- Muscle-building activity
- Regular movement, not just exercise sessions
- Adequate sleep and stress regulation
For those with prediabetes – especially South Asians – a comprehensive cardiovascular risk assessment is essential. It includes integrating blood sugar trends, lipid particle burden, inflammation, family history, and imaging – not viewing each result in isolation.
And for many people, especially those with genetic risk, lifestyle alone may not be enough. There is still stigma in our community around taking medication for blood sugar unless diabetes is “severe.” That thinking is outdated and harmful. Modern glucose-lowering medications don’t just affect sugar numbers. They protect the heart, reduce stroke risk and slow kidney disease. Some reduce heart failure risk dramatically. In fact, many of the same medications used for blood sugar control are now prescribed because of their cardiovascular and renal benefits, even in patients without advanced diabetes. Using medication early, when appropriate, is not giving up; it is organ protection.
February is American Heart Month, and we talk a lot about cholesterol, blood pressure, and smoking. Blood sugar often gets less attention, especially when it is “not that bad.”
The good news is that early action works. Normalizing blood sugar through thoughtful lifestyle changes, targeted therapy, or both can cut cardiovascular risk in half over the long term.
For South Asians, whose heart disease often strikes earlier and more aggressively, this window matters even more. Prediabetes is not a pause button; It is a fork in the road. And choosing the path back to normal blood sugar may be one of the most powerful heart-protective decisions you make.
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Dr.Rachna Relwani is an Ivy League-trained clinical endocrinologist in practice for over 17 years in Atlanta, GA. She is active in the Ga Society of Endocrinology, the American Association of Clinical Endocrinologists, and the American Society of Preventive Cardiology. She has won numerous awards, and has written for NRI Pulse and Khabar magazine. She speaks nationally about South Asians and Cardiometabolic Disease. She recently founded Desidil, the country’s first clinic focused on precision cardiometabolic prevention in South Asians, www.desidil.org.
