Treatment of Patients with Prediabetes in a Primary Care Setting 2011–2018: an Observational Study



Over one third of American adults are at high risk for developing diabetes, which can be delayed or prevented using interventions such as medical nutrition therapy (MNT) or metformin. Physicians’ self-reported rates of prediabetes treatment are improving, but patterns of actual referral, prescription, and MNT visits are unknown.


To characterize treatment of prediabetes in primary care.


We conducted a retrospective cohort study using electronic health record data. We described patterns of treatment and used multivariable logistic regression to evaluate the association of patient factors and PCP-specific treatment rate with patient treatment.


We included overweight or obese outpatients who had a first prediabetes-range hemoglobin A1c (HbA1c) during 2011–2018 and had primary care provider (PCP) follow-up within a year.

Main Measures

We collected patient characteristics and the following treatments: metformin prescription; referral to MNT, diabetes education, endocrinology, or bariatric medicine; and MNT visit. We did not capture within-visit physician counseling.

Key Results

Of 16,713 outpatients with prediabetes, 20.4% received treatment, including metformin prescriptions (7.8%) and MNT referrals (11.3%), but only 7.4% of referred patients completed a MNT visit. The strongest predictor of treatment was the patient’s PCP’s treatment rate. Some PCPs never treated prediabetes, but two treated more than half of their patients; 62% had no patients complete a MNT visit. Being younger or female and having higher body mass index or HbA1c were also positively associated with treatment. Compared to white patients, black patients were more likely to receive MNT referral and less likely to receive metformin.


Almost 80% of patients with new prediabetes never received treatment, and those who did receive referrals had very poor visit completion. Treatment rates appear to reflect provider rather than patient preferences.

This is a preview of subscription content, access via your institution.

Figure 1
Figure 2
Figure 3


  1. 1.

    Prevention C for DC and National diabetes statistics report, 2017. Atlanta, GA Centers Dis Control Prev US Dep Heal Hum Serv. 2017.

  2. 2.

    Association AD. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2020. Diabetes Care. 2020;43(Supplement 1):S14-S31.

    Article  Google Scholar 

  3. 3.

    Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: a high-risk state for diabetes development. Lancet. 2012;379(9833):2279-2290.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Cai X, Zhang Y, Li M, et al. Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis. BMJ. 2020;370:m2297.

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346(6):393-403.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Li G, Zhang P, Wang J, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet. 2008;371(9626):1783-1789.

    Article  PubMed  Google Scholar 

  7. 7.

    Association AD. 3. Prevention or delay of type 2 diabetes: standards of medical care in diabetes-2020. Diabetes Care. 2020;43(Supplement 1):S32-S36.

    Article  Google Scholar 

  8. 8.

    LeFevre ML. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2014;161(8):587.

    Article  PubMed  Google Scholar 

  9. 9.

    Siu AL. Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2015;163(11):861-868.

    Article  PubMed  Google Scholar 

  10. 10.

    Keck JW, Thomas AR, Hieronymus L, Roper KL. Prediabetes knowledge, attitudes, and practices at an academic family medicine practice. J Am Board Fam Med 2019;32(4):505-512.

    Article  PubMed  Google Scholar 

  11. 11.

    Wu J, Ward E, Lu ZK. Addressing lifestyle management during visits involving patients with prediabetes: NAMCS 2013–2015. J Gen Intern Med 2018:1412-1418.

    Article  Google Scholar 

  12. 12.

    Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care 2019;42(5):731-754.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Team RC. R: a language and environment for statistical computing. 2019.

  14. 14.

    Wickham H. Tidyverse. 2017.

  15. 15.

    2. Classification and diagnosis of diabetes: standards of medical care in diabetesd2019. Diabetes Care. 2019;42:S13-S28.

  16. 16.

    Kattan MW. Judging new markers by their ability to improve predictive accuracy. JNCI J Natl Cancer Inst 2003;95(9):634-635.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Kattan MW. Evaluating a new marker’s predictive contribution. Clin Cancer Res 2004;10(3):822-824.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Wu J, Ward E, Threatt T, Lu ZK. Metformin prescribing in low-income and insured patients with prediabetes. J Am Pharm Assoc (2003). 2017;57(4):483-487.

    Article  Google Scholar 

  19. 19.

    Moin T, Li J, Duru OK, et al. Metformin prescription for insured adults with prediabetes from 2010 to 2012: a retrospective cohort study. Ann Intern Med 2015;162(8):542-548.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Shiyanbola OO, Brown CM, Ward EC. “I did not want to take that medicine”: African-Americans’ reasons for diabetes medication nonadherence and perceived solutions for enhancing adherence. Patient Prefer Adherence 2018;12:409-421.

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Shenolikar RA, Balkrishnan R, Camacho FT, Whitmire JT, Anderson RT. Race and medication adherence in medicaid enrollees with type-2 diabetes. J Natl Med Assoc 2006;98(7):1071-1077.

    PubMed  PubMed Central  Google Scholar 

  22. 22.

    Medical nutrition therapy insurance coverage. Accessed April 6, 2020.

  23. 23.

    Tseng E, Greer RC, O’Rourke P, et al. National survey of primary care physicians’ knowledge, practices, and perceptions of prediabetes. J Gen Intern Med 2019.

  24. 24.

    Schmittdiel JA, Adams AS, Dlott R. Preventing diabetes in high-risk patients: time for a system-level approach to disease prevention. J Gen Intern Med 2019;34(8):1367-1368.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Bowen ME, Schmittdiel JA, Kullgren JT, Ackermann RT, O’Brien MJ. Building toward a population-based approach to diabetes screening and prevention for us adults. Curr Diab Rep. 2018;18(11).

  26. 26.

    Schmittdiel JA, Adams SR, Goler N, et al. The impact of telephonic wellness coaching on weight loss: a “Natural Experiments for Translation in Diabetes (NEXT-D)” study. Obesity (Silver Spring) 2017;25(2):352-356.

    Article  Google Scholar 

  27. 27.

    Sun Y, You W, Almeida F, Estabrooks P, Davy B. The effectiveness and cost of lifestyle interventions including nutrition education for diabetes prevention: a systematic review and meta-analysis. J Acad Nutr Diet. 2017;117(3):404-421.e36.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Jayapaul-Philip B, Dai S, Kirtland K, Haslam A, Nhim K. Availability of the National Diabetes Prevention Program in United States counties, March 2017. Prev Chronic Dis. 2018;15(9).

  29. 29.

    Briggs Early K, Stanley K. Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes. J Acad Nutr Diet 2018;118(2):343-353.

    Article  PubMed  Google Scholar 

  30. 30.

    Raynor HA, Davidson PG, Burns H, et al. Medical nutrition therapy and weight loss questions for the evidence analysis library prevention of type 2 diabetes project: systematic reviews. J Acad Nutr Diet 2017;117(10):1578-1611.

    Article  PubMed  Google Scholar 

  31. 31.

    Tseng E, Yeh HC, Maruthur NM. Metformin use in prediabetes among U.S. adults, 2005-2012. In: Diabetes Care. Vol 40. American Diabetes Association Inc.; 2017:887-893.

Download references

Author information



Corresponding author

Correspondence to Michael B. Rothberg MD, MPH.

Ethics declarations

Conflict of Interest

Dr. Misra-Hebert has received grant research support from the Agency for Healthcare Research and Quality K08 HS024128, grants from NHLBI, grants from Novo Nordisk, Inc, grants from Merck Inc, grants from Boehringer Ingelheim Pharmaceuticals, Inc, outside the submitted work. The other authors have no conflicts of interest to disclose.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information


(CSV 5 kb)


(DOCX 507 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Speaker, S.L., Rastogi, R., Sussman, T.A. et al. Treatment of Patients with Prediabetes in a Primary Care Setting 2011–2018: an Observational Study. J GEN INTERN MED (2021).

Download citation