Prediabetes and Associated Risk in Young Adults - Alopecia Areata and Erectile Dysfunction

The rising prevalence of prediabetes among young adults signals early metabolic dysfunction, significantly increasing the risk of type 2 diabetes mellitus (T2DM) and associated complications. Real-world pan-India data (2023) from 19,66,449 HbA1c samples showed nearly 1 in 2 had prediabetes, with regional variation at 22.25%. (1) A study at Vydehi Institute of Medical Science and Research Centre, India, found 14.3% prediabetes prevalence among 895 adults, highest in ages 36-40 years (18.8%), with 52.3% males. (2) About 8% may develop T2DM in three years, indicating the urgent need for prevention and early intervention.(3)

Lifestyle factors play a crucial role in prediabetes among Indian youth, with 83.6% following sedentary routines.2 Another Indian study identified male gender, age >40, alcohol consumption, high body mass index (BMI), and hypertension (>140 mmHg) as major risk factors. (4) Key determinants include HbA1c levels, physical inactivity, and family history, demonstrating the need for targeted preventive measures. (5)

Prediabetes Associated Health Risks: From Alopecia Areata to Erectile Dysfunction

Alopecia Areata & Prediabetes: A large population-based study published recently in 2025 analyzed 33,401 Alopecia Areata patients and 66,802 controls, revealing a higher prevalence of prediabetes in AA patients (26.3% vs. 18.1%, odds ratio 1.62). Furthermore, obesity was also more common among alopecia areata patients (17.2% vs. 13.3%, odds ratio 1.35). Prediabetes risk significantly increased in alopecia areata patients aged 40+ (OR 2.02), emphasizing the need for early screening and management. (6)

Erectile Dysfunction (ED) & Prediabetes: A recently published Indian study (139 men, 18–50 years) found 50.3% of prediabetic men had ED (mild: 32.4%, mild-to-moderate: 11.5%, moderate: 6.5%). Further, ED correlated with higher blood sugar levels [random blood sugar (RBS): 151 mg/dL, fasting blood sugar(FBS): 109 mg/dL, postprandial blood sugar(PPBS): 178 mg/dL, HbA1c: 5.94%]. Worse glycemic control increased ED severity (RBS: r=-0.294, p=0.001; HbA1c: r=-0.203, p=0.020), linking prediabetes to vascular dysfunction. The findings indicate the importance of early screening for ED in men with prediabetes. (7)

Inflammation and Endothelial Dysfunction: Common Link Between Insulin Resistance, Alopecia Areata, and Erectile Dysfunction

Insulin resistance (IR) plays a key role in both alopecia areata and ED due to its pro-inflammatory effects. In alopecia areata, immune dysregulation involving cytokines like IL-1, IL-6, and TNF-α disrupts hair follicle immune privilege, contributing to hair loss. (8) Similarly, IR leads to chronic inflammation, oxidative stress, and endothelial dysfunction, impairing nitric oxide availability and promoting vasoconstriction. These mechanisms link IR to ED by reducing penile blood flow and increasing sympathetic nervous system activity, exacerbating vascular dysfunction. (9)

Managing Prediabetes: Proactive Integrated Approach

Preventing diabetes and managing prediabetes complications necessitate lifestyle changes, including a balanced diet and regular exercise (≥30 min/day, 5 days/week). When lifestyle modifications alone are inadequate, metformin remains the primary pharmacological option. (5) A recent meta-analysis including 12 RCTs (n=2,720) found that adding metformin significantly reduced T2D incidence (P=0.01), lowered HbA1c (P=0.03), with greater reductions at 3 and 6 months (P=0.02; P=0.01), and improved FPG at 12 months (P=0.01), reinforcing the importance of an integrated approach. (10)

Global and Indian Guidelines Supporting Metformin Use in Prediabetes

In India, the Drug Controller General India (DCGI) has approved the use of metformin for the prevention and delaying of T2D. (5) The Indian Council of Medical Research (ICMR) Guidelines recommend metformin with lifestyle changes for individuals with combined impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) at high risk of T2D. (11) The Research Society for the Study of Diabetes in India (RSSDI) Guidelines advise metformin after six months if lifestyle changes fail, especially for IFG + IGT or HbA1c >5.7%. (12) The American Diabetes Association (ADA) 2025 Standards of Care suggest metformin for prediabetes with body mass index (BMI) ≥35 kg/m², age 25-59 years, or prior gestational diabetes. (13)

Key Take-Aways

• Prediabetes is rising in young adults, with nearly 1 in 2 affected and an 8% risk of developing T2DM within three years.
• Alopecia areata and erectile dysfunction (ED) seem to be linked with prediabetes. In recent observational studies, alopecia areata patients showed a 26.3% incidence of prediabetes, while 50.3% of prediabetic men reportedly experienced ED.
• Insulin resistance drives inflammation and endothelial dysfunction, contributing to both alopecia areata and ED.
• Lifestyle modifications remain essential, but metformin is recommended when lifestyle changes alone are insufficient.
• DCGI and guidelines from ICMR, RSSDI, and ADA support metformin use, especially in high-risk prediabetes individuals, when indicated

References:

1. Vora, Hardeep, and Preet Kaur. “Prediabetes and diabetes in India: An HbA1c based epidemiology study.” Diabetes research and clinical practice vol. 217 (2024): 111889. doi:10.1016/j.diabres.2024.111889

2. Achuth KS, SubramanianM, Pradeep C.Prevalence of pre-diabetes and its associated risk factors among people in rural field practice area of Vydehi institute of medical sciences and research centre Bangalore. Int J Community Med Public Health2024;11:1675-80.

3. Esquivel Zuniga, Rebeca, and Mark D DeBoer. “Prediabetes in Adolescents: Prevalence, Management and Diabetes Prevention Strategies.” Diabetes, metabolic syndrome and obesity : targets and therapy vol. 14 4609-4619. 25 Nov. 2021, doi:10.2147/DMSO.S284401

4. Muthunarayanan L, Ramraj B, Russel JK. Prevalence of prediabetes and its associated risk factors among rural adults in Tamil Nadu. Arch Med Health Sci. 2015;3(2):178-84.

5. Das AK, Mohan V, Ramachandran A, et al. An Expert Group Consensus Statement on “Approach and Management of Prediabetes in India”. J Assoc Physicians India 2022;70(12):69–78.

6. Wohl, Yonit et al. “Alopecia Areata Is Associated with an Increased Risk for Prediabetes and Obesity: A Nationwide Case-Control Study.” Journal of personalized medicine vol. 15,1 16. 3 Jan. 2025, doi:10.3390/jpm15010016

7. Vishwakarma RK et al. ED in Prediabetic Males in Central India. J Assoc Physicians India.2024;72(9):e10-e13.

8. Shahidi-Dadras, Mohammad et al. “Patients with alopecia areata show signs of insulin resistance.” Archives of dermatological research vol. 311,7 (2019): 529-533. doi:10.1007/s00403-019-01929-6

9. Patel, Jay Pravin et al. “Effects of metformin on endothelial health and erectile dysfunction.” Translational andrology and urology vol. 6,3 (2017): 556-565. doi:10.21037/tau.2017.03.52

10. Amer BE et al. Metformin plus lifestyle interventions for diabetes prevention: a meta-analysis. Diabetol Metab Syndr. 2024;16:273. doi:10.1186/s13098-024-01504-8.

11. ICMR Guidelines for Management of T2D 2018. Retrieved on 20th Feb 2025 from https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/ICMR_GuidelinesType2diabetes2018_0.pdf

12. RSSDI Clinical Practice Recommendations 2022. Retrieved on 20th Feb 2025 from https://www.rssdi.in/newwebsite/RSSDI-Clinical-Practice-Recommendations-2022%20(1).pdf

13. American Diabetes Association Professional Practice Committee; Summary of Revisions: Standards of Care in Diabetes—2025. Diabetes Care 1 January 2025; 48 (Supplement_1): S6–S13. https://doi.org/10.2337/dc25-SRE