Acupuncture and Moxibustion for Prediabetes: Pathophysiological Rationale, Clinical Evidence, and Research Gaps

Prediabetes, an intermediate metabolic state between normoglycemia and type 2 diabetes mellitus, has emerged as a silent global epidemic with a rising prevalence and substantial cardiometabolic risks. Despite the established diagnostic criteria from major health organizations, significant controversies persist regarding optimal screening definitions, inter-ethnic variability, and low concordance among fasting glucose, HbA1c, and postprandial glucose assessments. Pathophysiologically, prediabetes involves a dynamic interplay between tissue-specific insulin resistance (hepatic in impaired fasting glucose and skeletal muscle in impaired glucose tolerance), β-cell dysfunction, and multi-organ crosstalk, underpinned by chronic low-grade inflammation, mitochondrial dysregulation, and lipotoxicity. Within this complex landscape, acupuncture and moxibustion, rooted in traditional Chinese medicine yet increasingly validated by modern mechanistic studies, offer a multimodal therapeutic strategy. Emerging evidence from randomized controlled trials and meta-analyses has demonstrated that acupuncture-related therapies significantly reduce fasting blood glucose, postprandial glucose, and HbA1c levels, while improving insulin resistance, modulating the leptin signaling pathway, and restoring β-cell homeostasis via neuroendocrine regulation (eg, vago-islet axis, hypothalamic-pituitary-adrenal axis). Innovative protocols, including electroacupuncture, Zhuang medicine scraping combined with blood-letting, and auricular acupoint embedding have shown promising clinical efficacy and favorable safety profiles. Nevertheless, methodological heterogeneity, small sample sizes, and limited long-term follow-up remain challenges. This manuscript critically synthesizes the contemporary understanding of prediabetes, from diagnostic controversies and global epidemiology to integrated pathophysiology, and positions acupuncture and moxibustion as a scientifically grounded, low-risk, and scalable intervention. Future studies should prioritize large-scale multicenter trials, multi-omics mechanistic dissection, and standardized clinical protocols to fully harness the therapeutic potential of acupuncture in curbing the diabetes pandemic.