Trends in Prediabetes Among Youths in the US From 1999 Through 2018

Addressing Diabetes Distress in Primary Care: Where Are We Now, and Where Do We Need to Go?

PURPOSE OF REVIEW

Addressing diabetes distress (DD), the emotional demands of living with diabetes, is a crucial component of diabetes care. Most individuals with type 2 diabetes and approximately half of adults with type 1 diabetes receive their care in the primary care setting. This review will provide guidance on addressing DD and implementing targeted techniques that can be tailored to primary care patients.

RECENT FINDINGS

Structured educational, behavioral, and emotion-focused techniques have promise for treating DD. These interventions are unlikely to require advanced training and can be feasibly integrated into primary care settings without creating additional burdens on time or resources. Interventional studies examining treatment for DD are limited, leaving a gap for clear direction and consensus on how to target and treat DD in primary care patients. This review consolidates recommendations and approaches from recent findings on how to treat DD within the context of primary care.

The predictive value of combined insulin resistance and β-cell secretion in Yemeni school-aged children for type 2 diabetes mellitus

The present study aimed to determine the predictive power of the diabetic markers and metabolic syndrome factors in School-aged children for developing Type 2 DM. In this cross-sectional study, 1288 students aged 12-13 were recruited from public schools in the capital city of Sana'a. Anthropometric measurements and blood pressure were recorded and body mass index (BMI) was calculated. Fasting venous blood (5 ml) was collected for biochemical analysis including FBG, HbA1c, insulin, and lipid profile. Insulin resistance (HOMA-IR) and β-cell function (HOMA-β) were calculated. Our results showed that neither insulin, HOMA-IR nor HOMA-β individually were good predictors for Type 2 DM as assessed by the ROC curve with AUC < 0.75. However, the ROC curve of combined HOMA-IR and HOMA-β (Model 1) gave a superior AUC of 0.998 (p = 2.7 × 10-9) and predicted 140 (10.9%) children to develop Type 2 DM. This model picked up all impaired fasting glucose (IFG), 74% of metabolic glucose, and 71% of metabolic syndrome (MetS) groups. On the other hand, the ROC curve for metabolic syndrome (Model 2) gave an AUC of 0.751 (p = 0.003) and predicted a higher number of 416 (32.3%) children to develop prediabetes and Type 2 DM. This model picked up 75% of IFG, 71% of MetS, 82% of those having two factors of MetS, and 72% of obesity groups. Moreover, the 53 children common between the two models include 75% of IFG and 43% of MetS groups. Therefore, the combined HOMA-IR and HOMA-β model in children proved to be a good predictor for Type 2 DM development, whereas the MetS model predicts the development of prediabetes and Type 2 DM.

Prevalence, Trends, and Subsequent Outcomes of Prediabetes in the United States, 1999-2018

OBJECTIVE

To determine prevalence, trends, and subsequent outcomes of prediabetes defined by American Diabetes Association (ADA), World Health Organization (WHO), and International Expert Committee (IEC) criteria in the United States between 1999 and 2018.

METHODS

Ten cycles of cross-sectional National Health and Nutrition Examination Survey data were included. Prediabetes was defined by ADA, WHO, and IEC criteria. Unadjusted or covariate adjusted prevalence and trends of prediabetes were estimated. Cox proportional regression model was performed to evaluate the association between prediabetes and all-cause, cardiovascular, or diabetes-related mortality.

RESULTS

Among the 59 369 participants included (weighted mean age, 41.1 years; 48.7% male), the prevalence of prediabetes was 29.4% in ADA criteria, 16.3% in WHO criteria, and 5.0% in IEC criteria. The covariate adjusted prevalence of prediabetes defined by ADA criteria increased significantly in at least twofolds from 15.6% in 1999-2002 to 37.3% in 2015-2018 (P < .001). Similar significant increased trends were observed in WHO and IEC criteria (P < .001). Compared with normal glycemia, prediabetes participants had higher adjusted risk of diabetes-related mortality irrespective of the criteria used (ADA: hazard ratio [HR] 9.11 [95% CI, 5.83-14.22]; WHO: HR 5.35 [95% CI, 3.01-9.51]; IEC: HR 9.64 [95% CI, 5.92-15.71]). No significant associations between prediabetes and all-cause or cardiovascular mortality were observed in the adjusted models.

CONCLUSION

In the United States, approximately 1 in 3 individuals have prediabetes according to ADA criteria. The prevalence of prediabetes has shown a significant and more than twofold increase over the past 2 decades, posing an elevated risk of diabetes-related mortality, regardless of the criteria applied.

Obesity, Metabolic Syndrome, and Sugar-Sweetened Beverages (SSBs) in America: A Novel Bioethical Argument for a Radical Public Health Proposal

The prevalence of obesity, metabolic syndrome, and the associated long-term chronic diseases (cardiovascular disease, type II diabetes, cancer, Alzheimer's disease, depression) have reached epidemic levels in the United States and Western nations. In response to this public health calamity, the author of this paper presents and defends a novel bioethical argument: the consistency argument for outlawing SSBs (sugar-sweetened beverages) for child consumption (the "consistency argument"). This argument's radical conclusion states that the government is justified in outlawing SSBs consumption for child consumption. The reasoning is as follows: if one accepts that the physical harm caused by chronic alcohol consumption justifies the government outlawing alcoholic beverages for child consumption, and there is strong evidence that comparable physical harms result from chronic SSBs consumption, then, mutatis mutandis, the government is also justified in outlawing child consumption of SSBs. To support this argument, the author provides extensive evidence based on epidemiological observational studies, interventional studies, controlled trials, large meta-analyses, and the pathophysiology and biological mechanisms of action behind SSBs and chronic disease. Chronic consumption of large doses of SSBs and alcoholic beverages both drive the same diseases: obesity and insulin resistance, cardiovascular disease, hypertension, and cancer. Chronic SSB consumption carries the additional risk of Alzheimer's disease, dementia, and depression. The author concludes this paper by considering prominent objections to the consistency argument, and then demonstrating that each objection is unsound.

Preconception HbA1c Levels in Adolescents and Young Adults and Adverse Birth Outcomes

Importance

Subclinical hyperglycemia before pregnancy may be associated with the likelihood of maternal morbidity but is understudied among young people.

Objective

To explore the association of preconception hemoglobin A1c (HbA1c) levels among adolescents and young adults with risk of gestational diabetes at first live birth.

Design, Setting, and Participants

This retrospective cohort study used linked 2009 to 2017 birth registry, hospital discharge, and New York City Department of Health A1C Registry data for birthing individuals aged 10 to 24 years with no history of diabetes and at least 1 preconception HbA1c test in New York, New York. Statistical analysis was performed from August to November 2022.

Exposure

Preconception HbA1c values categorized as no diabetes (HbA1c <5.7%) or prediabetes (HbA1c ≥5.7% to <6.5%).

Main Outcomes and Measures

The primary outcome was gestational diabetes at first birth. Secondary outcomes included hypertensive disorders of pregnancy, preterm birth, cesarean delivery, and macrosomia. Log binomial regression was used to estimate the relative risk (RR) of gestational diabetes at first birth by preconception HbA1c level, adjusting for prepregnancy characteristics. The optimal HbA1c threshold for gestational diabetes was examined using receiver operating curve regression.

Results

A total of 14 302 individuals (mean [SD] age, 22.10 [1.55] years) met study eligibility criteria. Of these, 5896 (41.0%) were Hispanic, 4149 (29.0%) were Black, 2583 (18.1%) were White, 1516 (10.6%) were Asian, and 185 (1.3%) had other or unknown race and ethnicity. Most (11 407 individuals [79.7%]) had normoglycemia before pregnancy, and 2895 individuals (20.2%) had prediabetes. Adjusting for prepregnancy characteristics, those with preconception prediabetes had more than twice the risk of gestational diabetes vs those with normoglycemia (adjusted RR [aRR], 2.21; 95% CI, 1.91-2.56). Preconception prediabetes was associated with small increases in the likelihood of a hypertensive disorder of pregnancy (aRR, 1.18; 95% CI, 1.03-1.35) and preterm delivery (aRR, 1.18; 95% CI, 1.02-1.37). The aRRs for cesarean delivery (aRR, 1.09; 95% CI, 0.99-1.20) and macrosomia (aRR, 1.13; 95% CI, 0.93-1.37) were increased but not statistically significant. The optimal HbA1c threshold to identify gestational diabetes among adolescents and young adults was 5.6%. The threshold did not vary by obesity status but was slightly lower among Hispanic individuals (HbA1c of 5.5%).

Conclusions and Relevance

In this study of adolescents and young adults with at least 1 preconception HbA1c test, prediabetes was associated with increased likelihood of maternal cardiometabolic morbidity at first birth. Efforts to optimize cardiometabolic health before pregnancy may avert excess maternal risk.

Cardiovascular disease risk factors and their associations with inflammation among US adolescents: NHANES, 2015 to March 2020

INTRODUCTION

The prevalence of obesity and glycemic dysfunction in adolescents has increased over the past several decades but less is known on how these conditions are associated with systemic inflammation in this population. This study determined the associations between cardiovascular disease (CVD) risk factors and inflammation among a nationally representative sample of US. adolescents.

RESEARCH DESIGN AND METHODS

Cross-sectional analyses were conducted among 2693 adolescents aged 12-19 years who participated in the 2015 to March 2020 National Health and Nutrition Examination Surveys. Chronic inflammation was determined using laboratory measures for high-sensitivity C reactive protein (hs-CRP). Adjusted ORs (aOR, 95% CI) were calculated from logistic regression models to determine the association between CVD risk factors (obesity, overweight, dysglycemia, hypertension, hyperlipidemia) and elevated hs-CRP (>3.0 mg/L) while controlling for sociodemographic characteristics and other CVD risk factors.

RESULTS

Overall, 15.3% of adolescents had elevated hs-CRP. Adolescents who were older (16-19 years vs 12-15 years), obese, had A1c ≥5.7% (≥39 mmol/mol), high total cholesterol, or low high-density lipoprotein had hs-CRP distributions that were more high risk (χ2 p value <0.001). Adolescents with obesity or A1c ≥5.7% had a sixfold and a nearly twofold higher odds of elevated hs-CRP compared those without obesity and A1c <5.7% after full adjustment (aOR=6.39, 4.64 to 8.79 and aOR=1.70, 1.05 to 3.06, respectively). Adolescents with hypertension or hyperlipidemia were significantly more likely to have elevated hs-CRP compared with those without these conditions after adjustment for sociodemographic characteristics (aOR=2.46, 1.08 to 5.60 and aOR=2.19, 1.36 to 3.54, respectively), but the association was not significant after further adjustment for obesity.

CONCLUSIONS

Among US adolescents, obesity was strongly associated with elevated hs-CRP, a marker for future CVD risk. Given the obesity epidemic and the marked proportion with elevated CRP, concern should be given to future CVD risk in younger adults.

Non-Pharmacological Treatment for Cardiovascular Risk Prevention in Children and Adolescents with Obesity

In younger generations, excess weight has reached very alarming levels. Excess weight in adults is associated with increased mortality and morbidity from cardiovascular disease. However, it is not easy to distinguish to what extent these effects are the result of obesity itself or how much is due to the various cardiovascular risk factors that often accompany excess weight. Several risk factors, such as hypertension, dyslipidemia, hyperuricemia, glucose intolerance, and type 2 diabetes mellitus, are already present in pediatric age. Therefore, early intervention with the goal of correcting and/or eliminating them is particularly important. In the child and adolescent with obesity, the first approach to achieve weight reduction and correct the risk factors associated with severe excess weight should always be non-pharmacologic and based on changing poor eating habits and unhealthy lifestyles. The purpose of this review is to give an update on non-pharmacological interventions to be implemented for cardiovascular prevention in children and adolescents with obesity, and their effectiveness. In particular, interventions targeting each individual cardiovascular risk factor will be discussed.

A Comprehensive Youth Diabetes Epidemiological Data Set and Web Portal: Resource Development and Case Studies

BACKGROUND

The prevalence of type 2 diabetes mellitus (DM) and pre-diabetes mellitus (pre-DM) has been increasing among youth in recent decades in the United States, prompting an urgent need for understanding and identifying their associated risk factors. Such efforts, however, have been hindered by the lack of easily accessible youth pre-DM/DM data.

OBJECTIVE

We aimed to first build a high-quality, comprehensive epidemiological data set focused on youth pre-DM/DM. Subsequently, we aimed to make these data accessible by creating a user-friendly web portal to share them and the corresponding codes. Through this, we hope to address this significant gap and facilitate youth pre-DM/DM research.

METHODS

Building on data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018, we cleaned and harmonized hundreds of variables relevant to pre-DM/DM (fasting plasma glucose level ≥100 mg/dL or glycated hemoglobin  ≥5.7%) for youth aged 12-19 years (N=15,149). We identified individual factors associated with pre-DM/DM risk using bivariate statistical analyses and predicted pre-DM/DM status using our Ensemble Integration (EI) framework for multidomain machine learning. We then developed a user-friendly web portal named Prediabetes/diabetes in youth Online Dashboard (POND) to share the data and codes.

RESULTS

We extracted 95 variables potentially relevant to pre-DM/DM risk organized into 4 domains (sociodemographic, health status, diet, and other lifestyle behaviors). The bivariate analyses identified 27 significant correlates of pre-DM/DM (P<.001, Bonferroni adjusted), including race or ethnicity, health insurance, BMI, added sugar intake, and screen time. Among these factors, 16 factors were also identified based on the EI methodology (Fisher P of overlap=7.06×10-6). In addition to those, the EI approach identified 11 additional predictive variables, including some known (eg, meat and fruit intake and family income) and less recognized factors (eg, number of rooms in homes). The factors identified in both analyses spanned across all 4 of the domains mentioned. These data and results, as well as other exploratory tools, can be accessed on POND.

CONCLUSIONS

Using NHANES data, we built one of the largest public epidemiological data sets for studying youth pre-DM/DM and identified potential risk factors using complementary analytical approaches. Our results align with the multifactorial nature of pre-DM/DM with correlates across several domains. Also, our data-sharing platform, POND, facilitates a wide range of applications to inform future youth pre-DM/DM studies.

Prediabetes Prevalence by Adverse Social Determinants of Health in Adolescents

Importance

Several clinical practice guidelines advise race- and ethnicity-based screening for youth-onset type 2 diabetes (T2D) due to a higher prevalence among American Indian and Alaska Native, Asian, Black, and Hispanic youths compared with White youths. However, rather than a biological risk, this disparity likely reflects the inequitable distribution of adverse social determinants of health (SDOH), a product of interpersonal and structural racism.

Objective

To evaluate prediabetes prevalence by presence or absence of adverse SDOH in adolescents eligible for T2D screening based on weight status.

Design, Setting, and Participants

This cross-sectional study and analysis used data from the 2011 to 2018 cycles of the National Health and Nutrition Examination Survey. Data were analyzed from June 1, 2023, to April 5, 2024. Participants included youths aged 12 to 18 years with body mass index (BMI) at or above the 85th percentile without known diabetes.

Main Outcomes and Measures

The main outcome consisted of an elevated hemoglobin A1c (HbA1c) level greater than or equal to 5.7% (prediabetes or undiagnosed presumed T2D). Independent variables included race, ethnicity, and adverse SDOH (food insecurity, nonprivate health insurance, and household income <130% of federal poverty level). Survey-weighted logistic regression was used to adjust for confounders of age, sex, and BMI z score and to determine adjusted marginal prediabetes prevalence by race, ethnicity, and adverse SDOH.

Results

The sample included 1563 individuals representing 10 178 400 US youths aged 12 to 18 years (mean age, 15.5 [95% CI, 15.3-15.6] years; 50.5% [95% CI, 47.1%-53.9%] female; Asian, 3.0% [95% CI, 2.2%-3.9%]; Black, 14.9% [95% CI, 11.6%-19.1%]; Mexican American, 18.8% [95% CI, 15.4%-22.9%]; Other Hispanic, 8.1% [95% CI, 6.5%-10.1%]; White, 49.1% [95% CI, 43.2%-55.0%]; and >1 or other race, 6.1% [95% CI, 4.6%-8.0%]). Food insecurity (4.1% [95% CI, 0.7%-7.5%]), public insurance (5.3% [95% CI, 1.6%-9.1%]), and low income (5.7% [95% CI, 3.0%-8.3%]) were each independently associated with higher prediabetes prevalence after adjustment for race, ethnicity, and BMI z score. While Asian, Black, and Hispanic youths had higher prediabetes prevalence overall, increasing number of adverse SDOH was associated with higher prevalence among White youths (8.3% [95% CI, 4.9%-11.8%] for 3 vs 0.6% [95% CI, -0.7% to 2.0%] for 0 adverse SDOH).

Conclusions and Relevance

Adverse SDOH were associated with higher prediabetes prevalence, across and within racial and ethnic categories. Consideration of adverse SDOH may offer a more actionable alternative to race- and ethnicity-based screening to evaluate T2D risk in youth.

Greater Improvement in Obesity Among Children With Prediabetes in a Clinical Weight Management Program

Background: There is a range of responses among individuals seen for medical management of their obesity. This retrospective analysis of longitudinal data considers the relationship between identified prediabetes and subsequent weight change among children (8-17 years) in a weight management clinic. Methods: Analysis included 733 patients (2687 visits in 2008-2016) with overweight and obesity (but not diabetes) whose referral laboratories included a hemoglobin A1c (HbA1c) within 90 days. Mixed-effects modeling examined the association between baseline prediabetes (serum HbA1c 5.7%-6.4%) and growth curve of percentage of the 95th percentile for BMI (%BMIp95). Random effects (individual growth curves) and fixed effects (prediabetes status, starting age and %BMIp95, sex, race/ethnicity, and linear slope and quadratic term of months since the initial visit) were modeled. Interactions between prediabetes and elapsed time estimated the influence of a recent prediabetic-range HbA1c on weight during the subsequent 12 months. Results: Mean %BMIp95 was 125.5% (SD 22.5), corresponding to severe obesity, and 35% had prediabetes. Adjusted monthly decrease in %BMIp95 was stronger for children with prediabetes compared with the peers in this clinic (slope: -0.62, standard error 0.10, p < 0.001). Conclusion: There was greater weight improvement among children with prediabetes compared with their peers with normal HbA1c.

The Reproducibility and Reliability of Insulin Sensitivity and Secretion Indices in Children and Adolescents

Context

Insulin sensitivity and secretion indices can be useful tools in understanding insulin homeostasis in children at risk for diabetes. There have been few studies examining the reproducibility of these measures in pediatrics.

Objective

To determine whether fasting or oral glucose tolerance test (OGTT)-derived insulin measures would be more reproducible and whether there would be differences based on weight, sex, race, and pubertal status.

Design

Observational study.

Setting

Clinical research unit.

Patients or Other Participants

Two hundred fifty-seven overweight/obese (BMI ≥ 85th%, n = 186) and normal weight (BMI < 85th%, n = 71) children without diabetes between ages of 8 and 17 were included in the study.

Methods

OGTT tests performed in study participants at two separate visits within a 3-week period. We performed two formal oral glucose tolerance tests within a 3-week period. The reproducibility of fasting measures was compared with OGTT-derived measures by weight categories and compared by weight, sex, race, and pubertal status. Comparisons were made between the correlation coefficients of fasting vs. OGTT-derived measures and between normal weight vs. obese/overweight participants, male vs. female, White vs. Black, and pre- vs. post-midpubertal. Intraclass correlation coefficients were calculated for each comparison as well.

Results

For insulin sensitivity, the OGTT-derived measure was more reproducible than the fasting measures. There were no significant differences in reproducibility in the overweight/obese population compared to the normal weight population nor by sex, race, or pubertal status.

Conclusions

Nonfasting insulin sensitivity measures are more reproducible than fasting insulin sensitivity measures, regardless of weight category. Insulin secretion measures have poor reproducibility overall. Weight status, sex, race, and midpubertal stage do not impact the reproducibility of insulin sensitivity and secretion measures.

Special considerations for the adolescent with obesity: An obesity medicine association (OMA) clinical practice statement (CPS) 2024

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details special considerations for the management of the adolescent with obesity. The information in this CPS is based on scientific evidence, supported by medical literature, and derived from the clinical experiences of members of the OMA.

Methods

The scientific information and clinical guidance in this CPS are based on scientific evidence, supported by the medical literature, and derived from the clinical perspectives of the authors.

Results

This OMA Clinical Practice Statement addresses special considerations in the management and treatment of adolescents with overweight and obesity.

Conclusions

This OMA Clinical Practice Statement on the adolescent with obesity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of adolescents with obesity, especially those with metabolic, physiological, and psychological complications. This CPS also addresses treatment recommendations and is designed to help the provider with clinical decision making.

Associations Between Risk Factors of Cardiovascular Disease in Young Adults

Introduction

Cardiovascular disease (CVD) impacts 50% of U.S. adults although few studies evaluate young adults' cardiovascular disease risk. Early identification of cardiovascular disease risk may mitigate increased adulthood incidence. We analyzed (CVD) risk factors and their association with cardiovascular fitness (V ˙ o2max) to devise effective strategies to improve cardiovascular health across the lifespan.

Methods

A cross-sectional study evaluated the effect of a single bout of aerobic exercise on cardiovascular disease risk factors in adults aged 18 to 36 years. Glycemic control (HbA1C), cardiovascular fitness (V ˙ o2max), percent body fat, lean body mass, waist circumference, and body mass index (BMI) were analyzed using correlation analysis and multiple linear regression.

Results

Statistically significant relationships were observed between percent body fat (r = .83, P < .001) and BMI, and waist circumference (r = .83, P < .001) and BMI. Percent body fat (P < .001) and race (P = .018) predicted exercise time, with Asians exercising the longest. Percent fat (P < .001) and HbA1C (P = .039) were identified as predictors of cardiovascular fitness which was low in spite of primarily normal average HbA1C levels.

Conclusions

HbA1C and body fat negatively influence cardiovascular fitness (V ˙ o2max) in young adults increasing adulthood cardiovascular disease risk. Research investigating the effect of HbA1C on cardiovascular health especially in youth is warranted.

Reproductive risk factors across the female lifecourse and later metabolic health

Metabolic health is characterized by optimal blood glucose, lipids, cholesterol, blood pressure, and adiposity. Alterations in these characteristics may lead to the development of type 2 diabetes mellitus or dyslipidemia. Recent evidence suggests that female reproductive characteristics may be overlooked as risk factors that contribute to later metabolic dysfunction. These reproductive traits include the age at menarche, menstrual irregularity, the development of polycystic ovary syndrome, gestational weight change, gestational dysglycemia and dyslipidemia, and the severity and timing of menopausal symptoms. These risk factors may themselves be markers of future dysfunction or may be explained by shared underlying etiologies that promote long-term disease development. Disentangling underlying relationships and identifying potentially modifiable characteristics have an important bearing on therapeutic lifestyle modifications that could ease long-term metabolic burden. Further research that better characterizes associations between reproductive characteristics and metabolic health, clarifies underlying etiologies, and identifies indicators for clinical application is warranted in the prevention and management of metabolic dysfunction.

The Role of Glutathione and Its Precursors in Type 2 Diabetes

Type 2 diabetes (T2D) is a major worldwide health crisis affecting about 6.2% of the world's population. Alarmingly, about one in five children in the USA have prediabetes. Glutathione (GSH) and its precursors play a promising role in the prevention and management of type T2D. Oxidative stress (OxS) is a probable factor in both T2D initiation and progression. GSH is the major cytosolic water-soluble chemical antioxidant and emerging evidence supports its role in improving T2D outcomes. Dietary supplementation with N-acetyl-cysteine (NAC) and/or glycine (GLY), which are GSH precursors, has also been studied for possible beneficial effects on T2D. This review will focus on the underlying pathophysiological and molecular mechanisms linking GSH and its precursors with T2D and OxS. In addition to their traditional antioxidant roles, the in vivo effects of GSH/NAC/GLY supplements will be evaluated for their potential abilities to modulate the complex pro-oxidant pathophysiological factors (e.g., hyperglycemia) driving T2D progression. Positive feedback loops that amplify OxS over long time intervals are likely to result in irreversible T2D micro- and macro-vascular damage. Most clinical studies with GSH/NAC/GLY have focused on adults or the elderly. Future research with pediatric populations should be a high priority since early intervention is critical.

Hemoglobin A1c and Type 2 Diabetes Incidence Among Adolescents With Overweight and Obesity

Importance

With the increase in prediabetes among adolescents with overweight and obesity, identifying those at highest risk for type 2 diabetes (T2D) can support prevention strategies.

Objective

To assess T2D risk by hemoglobin A1c (HbA1c) levels among adolescents with overweight and obesity.

Design, Setting, and Participants

This retrospective cohort study was conducted using data for January 1, 2010, to December 31, 2019, from a large California health care system. The study population comprised adolescents aged 10 to 17 years who had a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) at or above the 85th percentile, had HbA1c measured during 2010 to 2018, and did not have preexisting diabetes. Data abstraction and analyses were conducted from January 1, 2020, to November 16, 2023.

Exposures

Baseline HbA1c, with covariates including BMI category (overweight: 85th to <95th percentile; moderate obesity: 100% to <120% of 95th percentile; or severe obesity: ≥120% of 95th percentile), age, sex, race and ethnicity, and Neighborhood Deprivation Index score.

Main Outcomes and Measures

The main outcome was incident T2D during follow-up through 2019, including cumulative incidence and multivariable hazard ratios (HRs) with 95% CIs using Cox proportional hazard regression analyses.

Results

This study included 74 552 adolescents with a mean (SD) age of 13.4 (2.3) years. More than half (50.6%) were female; 26.9% of individuals had overweight, 42.3% had moderate obesity, and 30.8% had severe obesity. Individuals identified as Asian or Pacific Islander (17.6%), Black (11.1%), Hispanic (43.6%), White (21.6%), and other or unknown race or ethnicity (6.1%). During follow-up, 698 adolescents (0.9%) developed diabetes, and 626 (89.7%) had T2D; 72 individuals (10.3%) who had type 1, secondary, or other diabetes were censored. The overall T2D incidence was 2.1 (95% CI, 1.9-2.3) per 1000 person-years, with a 5-year cumulative incidence of 1.0% (95% CI, 0.9%-1.1%). Higher baseline HbA1c (from <5.5% to 5.5%-5.6%, 5.7%-5.8%, 5.9%-6.0%, 6.1%-6.2%, and 6.3-6.4%) was associated with higher 5-year cumulative T2D incidence (from 0.3% [95% CI, 0.2%-0.4%] to 0.5% [0.4%-0.7%], 1.1% [0.8%-1.3%], 3.8% [3.2%-4.7%], 11.0% [8.9%-13.7%], and 28.5% [21.9%-36.5%], respectively). In addition, higher baseline HbA1c was associated with greater T2D risk (reference [HbA1c <5.5%]: HR, 1.7 [95% CI, 1.3-2.2], 2.8 [2.1-3.6], 9.3 [7.2-12.1], 23.3 [17.4-31.3], and 71.9 [51.1-101.1], respectively). Higher BMI category, older age, female sex, and Asian or Pacific Islander race (HR, 1.7 [95% CI, 1.3-2.2]), but not Black race or Hispanic ethnicity (compared with White race), were also independent indicators of T2D. In stratified analyses, incremental risk associated with higher HbA1c was greater for Asian or Pacific Islander and White adolescents than for Black and Hispanic adolescents.

Conclusions and Relevance

In this cohort study of adolescents with overweight and obesity, T2D risk increased substantially with baseline HbA1c above 6.0%. Risk varied by BMI, age, sex, and race and ethnicity. These findings suggest that diabetes surveillance in adolescents should be tailored to optimize identification among high-risk subgroups.

Trends and risk factors of diabetes and prediabetes in US adolescents, 1999-2020

AIMS

To assess the national trends in prevalence of diabetes and prediabetes and their major risk factors among adolescents in the US.

METHODS

We analyzed data on 6,936 adolescents aged 12 to 19 years from the National Health and Nutrition Examination Surveys (NHANES) between 1999 and 2020. Diabetes was defined by self-reported physician-diagnosis (diagnosed) and by fasting plasma glucose and HbA1c levels (undiagnosed). Prediabetes was identified by fasting plasma glucose and HbA1c levels. Logistic regression was performed to estimate the associations of major risk factors with diabetes and prediabetes.

RESULTS

The prevalence of prediabetes in adolescents increased from 11.5% in 1999-2002 to 36.3% in 2015-2020. The prevalence of diabetes increased from 0.82% (0.62% of diagnosed and 0.20% of undiagnosed) in 1999-2002 to 1.14% (0.76% of diagnosed and 0.38% of undiagnosed) in 2015-2020, but the increase was not statistically significant (P value = 0.69). Obesity was significantly associated with higher odds of diabetes and prediabetes while boys and Mexican Americans had a significantly higher risk of prediabetes than their counterparts.

CONCLUSIONS

The prevalence of prediabetes among adolescents in the US has more than tripled from 1999 to 2020. Obese adolescents are at the greatest risk for diabetes and prediabetes.

Risk Factors for Progression to Type 2 Diabetes in a Pediatric Prediabetes Clinic Population

Background

Pediatric type 2 diabetes (T2D) is increasing in prevalence, yet it is unclear what definition of pediatric prediabetes predicts progression to T2D. Strategies are needed to better identify at risk individuals who could benefit from early intervention.

Methods

Retrospective chart review of a pediatric prediabetes clinic over 7 years. Inclusion criteria include hemoglobin A1c (HbA1C) and ≥1 glucose from oral glucose tolerance test. Exclusion criteria include type 1 diabetes, maturity onset diabetes of the young, or T2D on initial visit.

Results

A total of 552 patients were included, 6.5% (n = 36) progressed to T2D over 2.4 ± 1.5 years. At initial visit, T2D progressors had a higher body mass index (38.6 ± 6.5 vs 34.2 ± 8.4 kg/m2, P = .002), HbA1C (6.0 ± 0.3%, vs 5.7± 0.3, P < .001), 2-hour glucose (141 ± 28 vs 114 ± 29 mg/dL, P < .001), and C-peptide (4.8 vs 3.6 ng/mL, P = .001). Fasting glucose was not significantly different. In a multivariable model, male sex (hazard ratio [HR], 2.4; P = .012), initial visit HbA1C (HR, 1.3 per 0.1% increase; P < .001), and 2-hour glucose level (HR, 1.2 per 10 mg/dL increase; P = .014) were all predictive of T2D progression. Patients who progressed to T2D had an increase in body mass index of 4.2 kg/m2 and children consistently taking metformin took longer to progress (43 ± 21 vs 26 ± 16 months; P = .016).

Discussion

A total of 6.5% of patients with prediabetes developed T2D over a 7-year period. Initial visit laboratory values and weight trajectory may allow for risk stratification, whereas fasting plasma glucose is less helpful. Weight stabilization and metformin therapy could be important interventions for diabetes prevention in children.

Facilitating youth diabetes studies with the most comprehensive epidemiological dataset available through a public web portal

The prevalence of type 2 diabetes mellitus (DM) and prediabetes (preDM) is rapidly increasing among youth, posing significant health and economic consequences. To address this growing concern, we created the most comprehensive youth-focused diabetes dataset to date derived from National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2018. The dataset, consisting of 15,149 youth aged 12 to 19 years, encompasses preDM/DM relevant variables from sociodemographic, health status, diet, and other lifestyle behavior domains. An interactive web portal, POND (Prediabetes/diabetes in youth ONline Dashboard), was developed to provide public access to the dataset, allowing users to explore variables potentially associated with youth preDM/DM. Leveraging statistical and machine learning methods, we conducted two case studies, revealing established and lesser-known variables linked to youth preDM/DM. This dataset and portal can facilitate future studies to inform prevention and management strategies for youth prediabetes and diabetes.

Pediatric Obesity: Complications and Current Day Management

Obesity affects approximately 1 in 5 youth globally and increases the risk of complications during adolescence and young adulthood, including type 2 diabetes, dyslipidemia, hypertension, non-alcoholic fatty liver disease, obstructive sleep apnea, and polycystic ovary syndrome. Children and adolescents with obesity frequently experience weight stigma and have an impaired quality of life, which may exacerbate weight gain. Pediatric obesity is typically defined using sex-, age-, and population-specific body mass index percentiles. Once identified, pediatric obesity should always be managed with lifestyle modification. However, adolescents with obesity may also benefit from anti-obesity medications (AOM), several of which have been approved for use in adolescents by the US Food and Drug Administration, including liraglutide, phentermine/topiramate, and semaglutide. For children with specific, rare monogenic obesity disorders, setmelanotide is available and may lead to significant weight loss. Metabolic and bariatric surgery may be used for the management of severe obesity in youth; though highly effective, it is limited to specialized centers and has had relatively low pediatric uptake. In this narrative review using pediatric-focused data from original research, reviews, clinical practice guidelines, governmental agencies, and pharmaceutical companies, we review obesity-related metabolic complications in youth and management strategies, including AOM and bariatric surgery.

The Role of Natural Antioxidant Products That Optimize Redox Status in the Prevention and Management of Type 2 Diabetes

The worldwide prevalence of type 2 diabetes (T2D) and prediabetes is rapidly increasing, particularly in children, adolescents, and young adults. Oxidative stress (OxS) has emerged as a likely initiating factor in T2D. Natural antioxidant products may act to slow or prevent T2D by multiple mechanisms, i.e., (1) reducing mitochondrial oxidative stress, (2) preventing the damaging effects of lipid peroxidation, and (3) acting as essential cofactors for antioxidant enzymes. Natural antioxidant products should also be evaluated in the context of the complex physiological processes that modulate T2D-OxS such as glycemic control, postprandial OxS, the polyol pathway, high-calorie, high-fat diets, exercise, and sleep. Minimizing processes that induce chronic damaging OxS and maximizing the intake of natural antioxidant products may provide a means of preventing or slowing T2D progression. This "optimal redox" (OptRedox) approach also provides a framework in which to discuss the potential benefits of natural antioxidant products such as vitamin E, vitamin C, beta-carotene, selenium, and manganese. Although there is a consensus that early effective intervention is critical for preventing or reversing T2D progression, most research has focused on adults. It is critical, therefore, that future research include pediatric populations.

Perception and Awareness of Diabetes Risk and Reported Risk-Reducing Behaviors in Adolescents

Importance

Lifestyle change is central to diabetes risk reduction in youth with overweight or obesity. Feeling susceptible to a health threat can be motivational in adults.

Objective

To evaluate associations between diabetes risk perception and/or awareness and health behaviors in youth.

Design, Setting, and Participants

This cross-sectional study analyzed data from the US National Health and Nutrition Examination Survey 2011 to 2018. Participants included youths aged 12 to 17 years with body mass index (BMI) in the 85th percentile or higher without known diabetes. Analyses were conducted from February 2022 to February 2023.

Main Outcomes and Measures

Outcomes included physical activity, screen time, and attempted weight loss. Confounders included age, sex, race and ethnicity, and objective diabetes risk (BMI, hemoglobin A1c [HbA1c]).

Exposures

Independent variables included diabetes risk perception (feeling at risk) and awareness (told by clinician), as well as potential barriers (eg, food insecurity, household size, insurance).

Results

The sample included 1341 individuals representing 8 716 794 US youths aged 12 to 17 years with BMI in the 85th percentile or higher for age and sex. The mean age was 15.0 years (95% CI, 14.9-15.2 years) and mean BMI z score was 1.76 (95% CI 1.73-1.79). Elevated HbA1c was present in 8.6% (HbA1c 5.7%-6.4%: 8.3% [95% CI, 6.5%-10.5%]; HbA1c ≥6.5%: 0.3% [95% CI, 0.1%-0.7%]). Nearly one-third of youth with elevated HbA1c reported risk perception (30.1% [95% CI, 23.1%-38.1%), while one-quarter (26.5% [95% CI, 20.0%-34.2%]) had risk awareness. Risk perception was associated with increased TV watching (β = 0.3 hours per day [95% CI, 0.2-0.5 hours per day]) and approximately 1 less day per week with at least 60 minutes of physical activity (β = -1.2 [95% CI, -2.0 to -0.4) but not with nutrition or weight loss attempts. Awareness was not associated with health behaviors. Potential barriers had mixed associations: larger households (≥5 members vs 1-2) reported lower consumption of non-home-prepared meals (OR 0.4 [95% CI, 0.2-0.7]) and lower screen time (β = -1.1 hours per day [95% CI, -2.0 to -0.3 hours per day), while public insurance (vs private) was associated with approximately 20 fewer minutes per day of physical activity (β = -20.7 minutes per day [95% CI, 35.5 to -5.8 minutes per day]).

Conclusions and Relevance

In this cross-sectional study including a US-representative sample of adolescents with overweight or obesity, diabetes risk perception and awareness were not associated with greater engagement in risk-reducing behaviors in youth. These findings suggest the need to address barriers to engagement in lifestyle change, including economic disadvantage.

Youth-Onset Type 2 Diabetes: The Epidemiology of an Awakening Epidemic

In this narrative review, we describe the epidemiology (prevalence, incidence, temporal trends, and projections) of type 2 diabetes among children and adolescents (<20 years), focusing on data from the U.S. and reporting global estimates where available. Secondarily, we discuss the clinical course of youth-onset type 2 diabetes, from prediabetes to complications and comorbidities, drawing comparisons with youth type 1 diabetes to highlight the aggressive course of this condition, which, only recently, has become recognized as a pediatric disease by health care providers. Finally, we end with an overview of emerging topics in type 2 diabetes research that have potential to inform strategies for effective preventive action at the community and individual levels.

Diet Quality Is Associated with Glucose Regulation in a Cohort of Young Adults

Young-onset type 2 diabetes and prediabetes is a growing epidemic. Poor diet is a known risk factor for T2D in older adults, but the contribution of diet to risk factors for T2D is not well-described in youth. Our objective was to examine the relationship of diet quality with prediabetes, glucose regulation, and adiposity in young adults. A cohort of young adults (n = 155, age 17-22) was examined between 2014-2018, and 89 underwent a follow-up visit from 2020-2022. At each visit, participants completed diet and body composition assessments and an oral glucose tolerance test. Adherence to four dietary patterns was assessed: Dietary Approaches to Stop Hypertension (DASH), Healthy Eating Index (HEI), Mediterranean diet, and Diet Inflammatory Index (DII). Regression analyses were used to determine adjusted associations of diet with risk for prediabetes and adiposity. Each one-point increase in DASH or HEI scores between visits reduced the risk for prediabetes at follow-up by 64% (OR, 95% CI: 0.36, 0.17-0.68) and 9% (OR, 95% CI: 0.91, 0.85-0.96), respectively. The DASH diet was inversely associated with adiposity, while DII was positively associated with adiposity. In summary, positive changes in HEI and DASH scores were associated with reduced risk for prediabetes in young adults.

The Progression of Prediabetes to Type 2 Diabetes in Children and Adolescents in the United States: Current Challenges and Solutions

Prediabetes, the precursor of type 2 diabetes (T2D), is on the rise among children and adolescents in the United States. The natural history of prediabetes is poorly characterized in children compared to adults. The available data indicate a phenotype of an accelerated β-cell failure in youth with prediabetes. Data from randomized controlled trials showed no benefit on β-cell preservation or A1c in youth with prediabetes from therapeutic agents such as metformin and insulin. As a result, the American Diabetes Association recommends only lifestyle intervention, but not therapeutic agents, for the management of prediabetes in children and adolescents. These recommendations for lifestyle modification in youth, largely derived from data in adults, lack the precision necessary for efficacy in youth. However, a recent 4-year real-world study on youth reported that adherence to nutrition visits was associated with a 4-fold reduction in the likelihood of progressing from prediabetes to T2D. The finding that this reversal is associated with reduced insulin resistance (IR) and not with decreased body weight is novel and provides the foundation for trialing investigational products that may protect β-cells and reduce IR and/or body weight. This study provides the much-needed foundation for further exploration of the impact of lifestyle modification in conjunction with other approaches for the reversal of prediabetes in youth. The systematization of the protocol for medical nutrition therapy for the reversal of prediabetes in youth will ensure optimal and consistent results from adherent patients. This communication provides updates on the pathobiology of prediabetes in youth and a clear direction for efficacious studies in the field.

Emergence of the adolescent obesity epidemic in the United States: five-decade visualization with humanoid avatars

BACKGROUND/OBJECTIVES

Body size and shape have increased over the past several decades with one in five adolescents now having obesity according to objective anthropometric measures such as weight, height, and body mass index (BMI). The gradual physical changes and their consequences may not be fully appreciated upon visual inspection by those managing the long-term health of adolescents. This study aimed to develop humanoid avatars representing the gradual changes in adolescent body size and shape over the past five decades and to align avatars with key BMI percentile cut points for underweight, normal weight, overweight, and obesity.

PARTICIPANTS/METHODS

Participants included 223 children and adolescents between the ages of 5 and 18 years approximately representative of the race/ethnicity and BMI of the noninstitutionalized US population. Each participant completed a three-dimensional whole-body scan, and the collected data was used to develop manifold regression models for generating humanoid male and female avatars from specified ages, weights, and heights. Secular changes in the mean weights and heights of adolescents were acquired from six U.S. National Health and Nutrition Surveys beginning in 1971-1974 and ending in 2015-2018. Male and female avatars at two representative ages, 10 and 15 years, were developed for each survey and at the key BMI percentile cut points based on data from the 2015-2018 survey.

RESULTS

The subtle changes in adolescent Americans' body size and shape over the past five decades are represented by 24 male and female 10- and 15-year-old avatars and 8 corresponding BMI percentile cut points.

CONCLUSIONS

The current study, the first of its kind, aligns objective physical examination weights and heights with the visual appearance of adolescents. Aligning the biometric and visual information may help improve awareness and appropriate clinical management of adolescents with excess adiposity passing through health care systems.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT03706612.

Prediabetes: Adherence to Nutrition Visits Decreases HbA1c in Children and Adolescents

BACKGROUND

Prediabetes, the precursor of type 2 diabetes (T2D), is on the rise in the US, but the determinants of its progression are poorly characterized in youth.

OBJECTIVE

To determine the impact of nutrition visits, as a surrogate marker of lifestyle modification, on the trajectory of prediabetes over a 4-year period.

HYPOTHESIS

Adherence to nutrition visits could reduce BMI and lower HbA1c.

METHODS

A 4-year retrospective study of 108 youth with prediabetes who were recommended to receive medical nutrition therapy every 3 months following their diagnosis. Subjects were divided into 2 groups: the non-adherent group who had ≤1 nutrition visit/year, and the adherent group with ≥2 nutrition visits/year.

RESULTS

There were 46 male subjects, mean age 12.4 ± 3.6y; and 62 female subjects, mean age, 13.3 ± 3.0y, p=0.2. The adherent group (n=44, 41.5%) had higher BMI z-scores, but similar values for HbA1c, metformin use, and racial/ethnic composition compared to the non-adherent group. Overall, 18(17.0%) subjects progressed to T2D in 4y and consisted of 14(22.6%) of the 62 non-adherent subjects and 4(9.1%) of the 44 adherent subjects. The non-adherent subjects progressed to T2D at a mean duration of 25.8 ± 12.6 months while the adherent subjects progressed at a mean duration of 34.9 ± 11.8 months. The hazard ratio of progression from prediabetes to T2D for the non-adherent versus adherent group was 3.88 (95%CI 1.26-11.98, p=0.02). The results remained significant after adjusting for age, sex, race/ethnicity, BMI, and metformin use.

CONCLUSION

Adherence to nutrition visits was associated with a 4-fold reduction in the likelihood to progress from prediabetes to T2D in US youth.