Type II diabetes is traditionally a disease of old age, why are so many American adolescents racing towards a diabetes diagnosis? University of Pittsburgh paediatric endocrinology researchers dug into government data to find out which kids are most at risk and what is driving the rise of teen prediabetes.
Teens with PrediabetesÂ
The researchers discovered that food insecurity, poverty and lack of health insurance were major contributors to the chances a teen would develop prediabetes. What’s more, the influence of these factors were so strong that they transcended ethnic background and race. They were surprised to find that social determinants had a stronger effect on teens than racial heritage because type II diabetes has a powerful hereditary element.
In a press release announcing the results, Mary Ellen Vajravelu, M.D., M.S.H.P., assistant professor of paediatrics who led the study explained, ‘Current guidelines for identifying children at high risk for type 2 diabetes and prediabetes use characteristics such as body size, race, ethnicity and family history, but those risk factors still don’t fully explain who presents with type 2 diabetes in childhood.’ She went on, ‘Many medical guidelines are moving away from the use of race and ethnicity to determine care and screening practices because it can exacerbate disparities instead of reducing them.’
Which teens are most at risk?
The Pittsburgh academics used data collected by the US government’s National Health and Nutrition Examination Survey to find kids from a cross section of society to see how their rates of prediabetes compared. From a pool of 4522 teens aged between 12 and 18, they compiled profiles of 1,563 adolescents who had an obese BMI and no diabetes diagnosis2. Â
This set of youngsters represented a cross section of society, with children from different household income levels, different family situations and different racial and ethnic backgrounds.Â
The epidemiologists calculated that the number of children in their sample (4522 teens) corresponded to around 10,178,400 Americans. This means that conclusions they drew from the 1500 kids in the survey give an idea of what’s going on for roughly 10,000,000 youths in real life.Â
Demographic Deep Dive
Because they chose kids in the 85% percentile of BMI, the children included in the study were more likely to come from backgrounds with higher rates of risk factors for obesity. Boys and girls were equally likely to be chosen, but the ethnic/racial mix did not correspond to overall US demographics. While 75% of Americans identify as White, only 49% of the identified kids were. Kids identifying as Asian American made up 3% (as opposed to 6.4% of population); Black, 14.9% (13.7% population); Mexican American, 18.8%, other Hispanic 8% (19.5% population self describe as Hispanic); other races 6%.Â
So how did the rates of high BMI compare to signs that diabetes was a threat? Not as expected. British researchers had previously found that Asian (South Asian, 23.9 Kg/m2, Chinese, 26.6 Kg/m2) and Black (28.1 Kg/m2) populations develop prediabetes at a lower BMI than White populations (30 Kg/m2). This means we would expect to see the highest rates of prediabetes in Asian American identifying peoples.bInteens, however,it seems economics trumped genetics.
Race to the Top
High HbA1c levels (a measure of the glucose bound to haemoglobin, or the average blood sugar levels over the lifespan of red blood cells, approximately 120 days) are a sign that a person is on the path to developing type II diabetes. A HbA1c level of 6.5 or more is the cut-off for a diabetes diagnosis while a level above 5.7 indicates prediabetes.
 Overall, 8.5% of the kids had prediabetic HbA1c levels, that was 14.3% of Asian children, 24.5% of Black children, 9.7% of Mexican ethnic background kids and 7.9% other Hispanic and just 3% of White teens.Â
Diabetes screening programs designed with body weight, ethnicity and family history in mind might miss cases. Teens from Black and Hispanic backgrounds had much higher rates of prediabetes than a race based strategy would expect.
Food for thought
Over the past twenty years, the number of teenagers in the United States with prediabetes has nearly doubled. Today, it affects about 28% of all teens in the U.S. and an alarming 40% of those with a BMI over 30 Kg/m2 1. So what did the study reveal about the causes of prediabetes? According to Vajravelu and her colleagues, it’s all about access to food and healthcare. After adjusting for race and BMI, food insecurity (4.1%), public insurance (5.3%), and low income (5.7%) each independently contributed to a child’s chance of developing prediabetes.Â
Food insecurity, inadequate access to nutritious and sufficient food, stood out as a critical factor contributing to prediabetes in adolescents 6. The scarcity of affordable, healthy food options often forces families to rely on cheaper, calorie-dense alternatives. This diet, high in processed sugars and fats, not only promotes obesity but also disrupts metabolic health.Â
Teen prediabetes can be reversed with diet
Studies show that teens who don’t have enough food often have higher HbA1C levels, which is a key indicator of prediabetes 7. Evidence also seems to suggest that adults experiencing food insecurity are two to three times more likely to develop diabetes compared to those who have reliable access to food. This is even after considering key risk factors such as income, job status, physical health measures, and lifestyle choices 8. Likewise, the stress associated with food insecurity can lead to hormonal imbalances that exacerbate insulin resistance increasing the risk of developing diabetes 9.
Addressing food insecurity goes beyond ensuring access to food; it demands policies and interventions that improve the affordability and nutritional quality of available food options. Initiatives such as promoting community gardens, school meal programs, and nutritional education are pivotal in fostering healthier dietary habits among vulnerable populations.
Insuring Against Teen Prediabetes
Having health insurance made a big difference in how doctors help parents to manage prediabetes and its outcomes in adolescents. It plays a crucial role in determining whether individuals with diabetes can access screenings and care for their condition 10. Interventions that might involve regular appointments and access to nutritionists are expensive and difficult to access without top-of-the-line health insurance. The obstacles to getting necessary healthcare, preventive screenings, and diabetes treatment 11, make it difficult to detect and treat prediabetes early, before it turns into diabetes.
The highest prevalence of obesity is usually found in low- and middle-income countries 12. Having access to healthcare and health insurance coverage are essential to support lifestyle interventions and psychological support services. These are integral to managing stress and promoting healthy behaviors among adolescents at risk for prediabetes.
What’s next?
The study, published in JAMA Network Open, found that these social factors, dubbed adverse social determinants of health (ADOH), independently increase the risk of teen prediabetes regardless of different ethnic groups. This discovery highlights the urgent need for doctors to consider socioeconomic influence when diagnosing and treating prediabetes . What’s more, it nderscores the importance of embracing and recognizing differences among individuals as the first step in easing healthcare divides –. ay doing so, we can develop more accurate and personalized treatments to reduce the rising rates of type 2 diabetes and other related health complications in young individuals.
References:
- Liu J, Li Y, Zhang D, Yi SS, Liu J. Trends in Prediabetes Among Youths in the US From 1999 Through 2018. JAMA Pediatr. 2022;176 (6):608-611. doi:10.1001/jamapediatrics.2022.0077
- Harrison C, Peyyety V, Rodriguez Gonzalez A, et al. Prediabetes Prevalence by Adverse Social Determinants of Health in Adolescents. JAMA Netw Open. 2024;7(6): e2416088. Published 2024 Jun 3. doi:10.1001/jamanetworkopen.2024.16088
- American Diabetes Association Professional Practice Committee. 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47 (Suppl 1): S20-S42. doi:10.2337/dc24-S002
- Brannick B, Dagogo-Jack S. Prediabetes and Cardiovascular Disease: Pathophysiology and Interventions for Prevention and Risk Reduction. Endocrinol Metab Clin North Am. 2018;47(1):33-50. doi:10.1016/j.ecl.2017.10.001
- Echouffo-Tcheugui JB, Perreault L, Ji L, Dagogo-Jack S. Diagnosis and Management of Prediabetes: A Review. JAMA. 2023;329 (14):1206-1216. doi:10.1001/jama.2023.4063
- Lee AM, Scharf RJ, Filipp SL, Gurka MJ, DeBoer MD. Food Insecurity Is Associated with Prediabetes Risk Among U.S. Adolescents, NHANES 2003-2014. Metab Syndr Relat Disord. 2019;17(7):347-354. doi:10.1089/met.2019.0006
- Fulay AP, Lee JM, Baylin A, Wolfson JA, Leung CW. Associations between food insecurity and diabetes risk factors in US adolescents in the National Health and Nutrition Examination Survey (NHANES) 2007-2016. Public Health Nutr. 2024;27(1): e68. Published 2024 Feb 12. doi:10.1017/S1368980024000284
- Seligman HK, Bindman AB, Vittinghoff E, Kanaya AM, Kushel MB. Food insecurity is associated with diabetes mellitus: results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999-2002. J Gen Intern Med. 2007;22(7):1018-1023. doi:10.1007/s11606-007-0192-6
- Sharma K, Akre S, Chakole S, Wanjari MB. Stress-Induced Diabetes: A Review. Cureus. 2022;14(9): e29142. Published 2022 Sep 13. doi:10.7759/cureus.29142
- Kazemian P, Shebl FM, McCann N, Walensky RP, Wexler DJ. Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016. JAMA Intern Med. 2019;179 (10):1376-1385. doi:10.1001/jamainternmed.2019.2396
- Stark Casagrande S, Cowie CC. Health insurance coverage among people with and without diabetes in the U.S. adult population. Diabetes Care. 2012;35(11):2243-2249. doi:10.2337/dc12-0257
- Templin T, Cravo Oliveira Hashiguchi T, Thomson B, Dieleman J, Bendavid E. The overweight and obesity transition from the wealthy to the poor in low- and middle-income countries: A survey of household data from 103 countries. PLoS Med. 2019;16(11): e1002968. Published 2019Â Nov 27. doi:10.1371/journal.pmed.1002968
- U.S. Census Bureau QuickFacts: United States. Accessed December 17, 2024. https://www.census.gov/quickfacts/fact/table/US/PST045223
- Caleyachetty R, Barber TM, Mohammed NI, et al. Ethnicity-specific BMI cut-offs for obesity based on type 2 diabetes risk in England: a population-based cohort study. Lancet Diabetes Endocrinol. 2021;9(7):419-426. doi:10.1016/S2213-8587 (21) 00088-7
Type II diabetes is traditionally a disease of old age, why are so many American adolescents racing towards a diabetes diagnosis? University of Pittsburgh paediatric endocrinology researchers dug into government data to find out which kids are most at risk and what is driving the rise of teen prediabetes. The researchers discovered that food insecurity, poverty and lack of health insurance were major contributors to the chances a teen would develop prediabetes. What’s more, the influence of these factors were so strong that they transcended ethnic background and race. They were surprised to find that social determinants had a stronger effect on teens than racial heritage because type II diabetes has a powerful hereditary element. In a press release announcing the results, Mary Ellen Vajravelu, M.D., M.S.H.P., assistant professor of paediatrics who led the study explained, ‘Current guidelines for identifying children at high risk for type 2 diabetes and prediabetes use characteristics such as body size, race, ethnicity and family history, but those risk factors still don’t fully explain who presents with type 2 diabetes in childhood.’ She went on, ‘Many medical guidelines are moving away from the use of race and ethnicity to determine care and screening practices because it can exacerbate disparities instead of reducing them.’ The Pittsburgh academics used data collected by the US government’s National Health and Nutrition Examination Survey to find kids from a cross section of society to see how their rates of prediabetes compared. From a pool of 4522 teens aged between 12 and 18, they compiled profiles of 1,563 adolescents who had an obese BMI and no diabetes diagnosis2.  This set of youngsters represented a cross section of society, with children from different household income levels, different family situations and different racial and ethnic backgrounds. The epidemiologists calculated that the number of children in their sample (4522 teens) corresponded to around 10,178,400 Americans. This means that conclusions they drew from the 1500 kids in the survey give an idea of what’s going on for roughly 10,000,000 youths in real life. Because they chose kids in the 85% percentile of BMI, the children included in the study were more likely to come from backgrounds with higher rates of risk factors for obesity. Boys and girls were equally likely to be chosen, but the ethnic/racial mix did not correspond to overall US demographics. While 75% of Americans identify as White, only 49% of the identified kids were. Kids identifying as Asian American made up 3% (as opposed to 6.4% of population); Black, 14.9% (13.7% population); Mexican American, 18.8%, other Hispanic 8% (19.5% population self describe as Hispanic); other races 6%. So how did the rates of high BMI compare to signs that diabetes was a threat? Not as expected. British researchers had previously found that Asian (South Asian, 23.9 Kg/m2, Chinese, 26.6 Kg/m2) and Black (28.1 Kg/m2) populations develop prediabetes at a lower BMI than White populations (30 Kg/m2). This means we would expect to see the highest rates of prediabetes in Asian American identifying peoples.bInteens, however,it seems economics trumped genetics. High HbA1c levels (a measure of the glucose bound to haemoglobin, or the average blood sugar levels over the lifespan of red blood cells, approximately 120 days) are a sign that a person is on the path to developing type II diabetes. A HbA1c level of 6.5 or more is the cut-off for a diabetes diagnosis while a level above 5.7 indicates prediabetes.  Overall, 8.5% of the kids had prediabetic HbA1c levels, that was 14.3% of Asian children, 24.5% of Black children, 9.7% of Mexican ethnic background kids and 7.9% other Hispanic and just 3% of White teens. Diabetes screening programs designed with body weight, ethnicity and family history in mind might miss cases. Teens from Black and Hispanic backgrounds had much higher rates of prediabetes than a race based strategy would expect. Over the past twenty years, the number of teenagers in the United States with prediabetes has nearly doubled. Today, it affects about 28% of all teens in the U.S. and an alarming 40% of those with a BMI over 30 Kg/m2 1. So what did the study reveal about the causes of prediabetes? According to Vajravelu and her colleagues, it’s all about access to food and healthcare. After adjusting for race and BMI, food insecurity (4.1%), public insurance (5.3%), and low income (5.7%) each independently contributed to a child’s chance of developing prediabetes. Food insecurity, inadequate access to nutritious and sufficient food, stood out as a critical factor contributing to prediabetes in adolescents 6. The scarcity of affordable, healthy food options often forces families to rely on cheaper, calorie-dense alternatives. This diet, high in processed sugars and fats, not only promotes obesity but also disrupts metabolic health. Studies show that teens who don’t have enough food often have higher HbA1C levels, which is a key indicator of prediabetes 7. Evidence also seems to suggest that adults experiencing food insecurity are two to three times more likely to develop diabetes compared to those who have reliable access to food. This is even after considering key risk factors such as income, job status, physical health measures, and lifestyle choices 8. Likewise, the stress associated with food insecurity can lead to hormonal imbalances that exacerbate insulin resistance increasing the risk of developing diabetes 9. Addressing food insecurity goes beyond ensuring access to food; it demands policies and interventions that improve the affordability and nutritional quality of available food options. Initiatives such as promoting community gardens, school meal programs, and nutritional education are pivotal in fostering healthier dietary habits among vulnerable populations. Having health insurance made a big difference in how doctors help parents to manage prediabetes and its outcomes in adolescents. It plays a crucial role in determining whether individuals with diabetes can access screenings and care for their condition 10. Interventions that might involve regular appointments and access to nutritionists are expensive and difficult to access without top-of-the-line health insurance. The obstacles to getting necessary healthcare, preventive screenings, and diabetes treatment 11, make it difficult to detect and treat prediabetes early, before it turns into diabetes. The highest prevalence of obesity is usually found in low- and middle-income countries 12. Having access to healthcare and health insurance coverage are essential to support lifestyle interventions and psychological support services. These are integral to managing stress and promoting healthy behaviors among adolescents at risk for prediabetes. The study, published in JAMA Network Open, found that these social factors, dubbed adverse social determinants of health (ADOH), independently increase the risk of teen prediabetes regardless of different ethnic groups. This discovery highlights the urgent need for doctors to consider socioeconomic influence when diagnosing and treating prediabetes . What’s more, it nderscores the importance of embracing and recognizing differences among individuals as the first step in easing healthcare divides –. ay doing so, we can develop more accurate and personalized treatments to reduce the rising rates of type 2 diabetes and other related health complications in young individuals. References:
Teens with PrediabetesÂ
Which teens are most at risk?
Demographic Deep Dive
Race to the Top
Food for thought
Teen prediabetes can be reversed with diet
Insuring Against Teen Prediabetes
What’s next?
