 The staggering number of Americans with prediabetes, now 1 in 3 adults,1, 2 reinforces the urgency of implementing effective action to prevent incident diabetes. Several randomized controlled trials RCTs including the Diabetes Prevention Program DPP have demonstrated that both intensive lifestyle change and metformin significantly reduce the risk of progression to diabetes compared to placebo.3-5 Prior efforts to disseminate treatment with lifestyle into practice have resulted in variable uptake and very limited population reach,6 and their has been minimal to virtually no uptake of metformin for the treatment of prediabetes. 