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.

Primary care perspectives on prescribing anti-obesity medication for adolescents.

BACKGROUND: Recent pediatric guidelines recommend clinicians offer anti-obesity medication (AOM) as an adjunct to intensive lifestyle intervention. OBJECTIVE: To investigate pediatricians' perspectives about prescribing AOM, including barriers and facilitators. METHODS: An investigator-developed survey was emailed to primary care pediatric physicians (n = 187) and advanced practice providers (n = 190) within an academic-affiliated network. The survey evaluated how willing clinicians were to prescribe AOM and their agreement with 25 statements about barriers and facilitators. Three vignettes explored AOM decision-making. Multinomial logistic regression was used to determine relative risk ratios for willingness to prescribe by agreement with each statement. RESULTS: Among 74 respondents (20% response rate), 24% were willing, 42% uncertain and 34% unwilling to prescribe. Most (64%) agreed that AOM should be managed only by specialists. Willingness to prescribe was associated with clinician motivation and belief in guideline practicality and applicability. Unwillingness was associated with beliefs that patients would not continue AOM long enough for benefit and that there was insufficient time or resources to implement. In vignettes, 52% were willing to prescribe AOM for a patient with severe obesity and metabolic complications, versus 11% for a patient with obesity and possible disordered eating. CONCLUSIONS: Willingness to prescribe AOM was low and was associated with perceived practicality and appropriateness for patients.