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 A(1c) [HbA(1c)]). 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 HbA(1c) was present in 8.6% (HbA(1c) 5.7%-6.4%: 8.3% [95% CI, 6.5%-10.5%]; HbA(1c) ≥6.5%: 0.3% [95% CI, 0.1%-0.7%]). Nearly one-third of youth with elevated HbA(1c) 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.