Youth Diabetes Risk Perception Not Associated With Engagement in Risk-Reducing Behaviors

Diabetes risk perception was linked to increased TV watching and 1 less day per week of at least 60 minutes of exercise, and was not associated with nutrition or weight loss attempts among adolescents.

In a representative sample of adolescents with overweight or obesity in the United States, researchers found that diabetes risk perception and awareness was not associated with greater engagement in risk-reducing behaviors in this age group.

“These findings suggest the need to address barriers to engagement in lifestyle change, including economic disadvantage,” the researchers said.

The study was published in JAMA Network Open and included 1341 adolescents aged 12 to 17 years with a body mass index (BMI) in the 85th percentile or higher and without known diabetes. This sample is representative of more than 8.7 million Americans in this age group. The mean age in the sample was 15 years and mean BMI z score was 1.76 (95% CI, 1.73-1.79).

The researchers analyzed data from the 2011 to 2018 US National Health and Nutrition Examination Survey (NHANES) waves, and analyses were conducted between February 2022 and February 2023. Main outcomes were physical activity, screen time, and attempted weight loss, while potential confounders included age, sex, race, ethnicity, and objective diabetes risk measured by BMI and hemoglobin A1c (HbA1c).

The study also examined the relationship between diabetes risk perception—how much participants felt at risk—and awareness—whether participants were told by clinicians. Potential barriers such as food insecurity, household size, and insurance were also examined.

Of the 1341 adolescents in the study, 8.6% had elevated HbA1c, with 8.3% having an HbA1c level in the prediabetes range of 5.7% to 6.4% (95% CI, 6.5%-10.5%), and 0.3% having a level in the diabetes range of 6.5% or higher (95% CI, 0.1%-0.7%).

Nearly a third (30.1%) of youth with elevated HbA1c reported risk perception (95% CI, 23.1%-38.1%), which was significantly more than youths with normal HbA1c. Risk perception was also significantly higher among participants aged 16 to 17 years compared with those aged 12 to 15 years.

Additionally, a quarter of youths (26.5%) had risk awareness (95% CI, 20.0%-34.2%), and risk awareness did not differ between age groups.

“However, due to potential unreliability of the point estimate of prediabetes awareness (relative standard error >30%), we used a combined measure of awareness of either ‘prediabetes’ or ‘diabetes risk,’” the authors noted. “This combined awareness was significantly higher among youth with elevated HbA1c than among those with normal HbA1c.”

Overall, while awareness of prediabetes increased with more recent survey waves (odds ratio [OR], 1.50; 95% CI, 1.05-2.15), perception of diabetes risk decreased (OR, 0.78; 95% CI, 0.64-0.95).

Diabetes 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 of at least 60 minutes of physical activity (β = −1.2; 95% CI, −2.0 to −0.4). Risk perception was not associated with nutrition or weight loss attempts.

Diabetes awareness was also not associated with health behaviors, though it’s important to note that potential barriers led to mixed associations.

For instance, compared with smaller 1-2 person households, larger households of 5 or more members reported less consumption of non–home-prepared meals (OR 0.4; 95% CI, 0.2-0.7) and less screen time (β = −1.1 hours per day; 95% CI, −2.0 to −0.3 hours per day).

Additionally, public insurance was associated with approximately 20 fewer minutes per day of physical activity compared with private insurance (β = −20.7 minutes per day; 95% CI, 35.5 to −5.8 minutes per day).

In multivariable linear regression analyses unadjusted for potential confounders, risk perception and awareness were not linked to frequency of attempted weight loss, and there were no potential barriers associated with weight loss attempts. However, significant potential confounders included higher BMI z score, female sex, and Mexican American and non-Hispanic Asian youth.

"Our finding that youth with lower rates of physical activity perceive themselves to be at higher risk of diabetes suggests that the failure to engage in healthy lifestyle behaviors is not a knowledge gap, but perhaps the result of limited self-efficacy or other barriers to health behavior change that were not measurable via NHANES,” the authors concluded. “Further exploration of how risk perception emerges and its causal role in health behaviors may also inform future intervention design, as traditional motivational interviewing alone has not been demonstrated to be effective for treating adolescents with overweight and obesity.”


Chu P, Patel A, Helgeson V, Goldschmidt AB, Ray MK, Vajravelu ME. Perception and awareness of diabetes risk and reported risk-reducing behaviors in adolescents. JAMA Netw Open. Published online May 3, 2023. doi:10.1001/jamanetworkopen.2023.11466

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