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Risk of developing diabetes in children with overweight or obesity differs from that of adults

Kaiser Permanente study identifies overweight and obese adolescents at greatest risk of developing type 2 diabetes

When it comes to identifying the children at greatest risk of developing type 2 diabetes, new Kaiser Permanente research shows that kids aren’t just little adults — a finding that can help pediatricians better help adolescents with prediabetes.

The study, published January 17 in JAMA Network Open, is one of the largest to date to explore the incidence of diabetes in adolescents with overweight or obesity.

Francis Hoe, MD

As pediatricians like myself have begun caring for more of these adolescents, we recognized the need to study this population and identify those at greatest risk of developing diabetes,” said first author Francis M. Hoe, MD, a pediatric endocrinologist with The Permanente Medical Group. “The biggest thing we learned is that the risk for type 2 diabetes is still low in these adolescents, especially those with a hemoglobin A1C less than 5.9%.”

The study included a racially and ethnically diverse group of 74,552 boys and girls ages 10 to 17 who were members of Kaiser Permanente Northern California (KPNC). All the adolescents had a body mass index (BMI) classified as overweight or obese and had a hemoglobin A1C blood test recorded between 2010 and 2018.

The hemoglobin A1C blood test (also called an A1c test) measures average blood sugar levels over the past 3 months. An A1C level of 4% to 5.6% is considered normal; a result between 5.7% and 6.4% is an indicator of prediabetes; and a result of 6.5% or higher is a marker of diabetes. To be included in the study, the adolescents had to have an A1C under 6.5% — meaning none had diabetes.

The biggest thing we learned is that the risk for type 2 diabetes is still low in these adolescents, especially those with a hemoglobin A1C less than 5.9%.

— Francis Hoe, MD

The researchers found that at the start of the study 1 in 4 (17,036) of the adolescents had an A1C level between 5.7% and 6.5%, a marker of prediabetes. By 2019, there were 626 adolescents in the study who were diagnosed with type 2 diabetes.

The 5-year risk of type 2 diabetes ranged from 0.5% for the adolescents with an A1C below 5.7%, to 1% for those with with an A1c of 5.7-5.8%, to 28.5% for those with an A1C of 6.3% to 6.4%.

Screening and monitoring for diabetes

The American Diabetes Association developed diabetes screening guidelines specifically for adolescents. These guidelines recommend screening for youth with overweight or obesity who have at least one other risk factor, such as a family history of type 2 diabetes; Black, Hispanic, Asian American, Pacific Islander, or Native American race or ethnicity; or a health condition associated with insulin resistance.

Currently the guidelines developed for monitoring people with prediabetes — an A1C of 5.7% to 6.4% — are the same for children and adults. The findings from the new study suggest specific guidelines may need to be developed for adolescents.

“Our nearly 1 million pediatric members in Kaiser Permanente Northern California, made it possible to do this large study that focused specifically on incidence of type 2 diabetes at incremental increases in hemoglobin A1C levels,” said Hoe. “Our findings support our observation and suggest that it is primarily the youth with overweight and obesity who have an A1C between 6.1% and 6.4% who would most benefit from close monitoring for diabetes.

Joan Lo, MD

The study found that that absolute risk for developing type 2 diabetes is quite low, especially among children with an A1C in the lower end of the prediabetes range. Compared to the adolescents with an A1C under 5.5%, those with an A1C in the higher end of the prediabetes range of 6.1% to 6.2% had a 23-fold greater risk for developing type 2 diabetes while those with an A1C of 6.3% to 6.4% had a 72-fold greater risk for developing type 2 diabetes.

“Our study tells us that most overweight and obese adolescents who have a A1C of less than 5.9% can focus on developing a healthy lifestyle and healthy eating habits rather than close monitoring for diabetes,” said senior author Joan C. Lo, MD, a research scientist at the Kaiser Permanente Division of Research.  “This is important information for many pediatricians, parents, and families.”

Added Hoe, “Our findings will also help pediatricians identify the children at the greatest risk of developing type 2 diabetes who will benefit most from more intensive interventions and closer monitoring.”

The study was supported by a grant from Kaiser Permanente Northern California Community Health.

Co-authors include Jeanne A. Darbinian, MS, MPH, of the Division of Research, and Louise Greenspan, MD, of The Permanente Medical Group.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.


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