AIMS: In a population at risk for type 2 diabetes (T2DM), we assessed early physical and metabolic markers that predict progression from normal to impaired glucose tolerance (IGT) and T2DM. METHODS: A total of 388 individuals (22% male, age 46 + 11 years) at risk for T2DM were randomized to Standard (n = 182) or Intervention (n = 206) care and evaluated at baseline and 5 annual follow-up visits, including blood pressure, BMI, A1C, lipids, urine albumin/creatinine ratio, VO2max, fasting glucose, insulin and C-peptide. The Standard group received results of annual lab tests and quarterly newsletters, while the Intervention group received quarterly newsletters and detailed discussions of lab results, routine self-directed activities, semi-annual group meetings and monthly telephone calls for ongoing support. RESULTS: Overall, 359 (93%) returned for at least one follow-up visit and 272 (70%) completed the final 5-year assessment. Return rates, changes in measures and incidence of IGT/T2DM were similar between groups. Low cardiorespiratory fitness (VO2max) was the most prevalent baseline abnormality. A1C and BMI were significant predictors of IGT/T2DM after controlling for other factors. The risk of IGT/T2DM within 5 years was 17.16 (95% CL: 6.169, 47.736) times greater for those with baseline A1C>=5.8% as compared to those <5.8% (p < 0.0001). CONCLUSION: Baseline A1C>=5.8% was a significant predictor of IGT/T2DM within 5 years in a population at high risk for T2DM. A1C is routinely performed among patients with diabetes, however these data and other evidence suggest that it may also be a useful tool for risk assessment and screening.