Obesity affects more than 14.7 million US children and adolescents (19.7%),¹ making it one of the most common pediatric chronic conditions. Children with obesity have high amounts of adipose cells that secrete inflammatory cytokines in the body; this chronic inflammation can lead to cardiometabolic health risks, such as impaired glucose tolerance, abnormal cholesterol and other lipid levels, and high blood pressure.² Obesity also increases risk for other serious chronic diseases, including type 2 diabetes, dyslipidemia, and nonalcoholic fatty liver disease (NAFLD, now commonly called metabolic dysfunction-associated steatotic liver disease or MASLD).³

Due to the high burden of obesity and its well-established association with chronic diseases, screening youth with obesity for co-occurring chronic diseases has been recommended for more than a decade.⁴ Most recently, in 2023, the American Academy of Pediatrics (AAP) released a clinical practice guideline (CPG) to further support evidence-based evaluation and treatment of childhood obesity.⁵ Though it was not the first to recommend screening, it did consolidate a wealth of existing evidence and recommendations for pediatric healthcare providers. According to the CPG, clinicians should evaluate all children with obesity aged 10 years and older for abnormal lipids, glucose metabolism, and liver function (Key Action Statement #3). Screening can provide early detection, diagnosis, and intervention. Interventions are based on patient and family readiness as well as severity of obesity and comorbidities, and can include: motivational interviewing to encourage behavior change; family-centered intensive health behavior and lifestyle treatment (IHBLT) programs; or pharmacotherapy. These interventions can prevent or delay serious complications and improve health outcomes.

Despite benefits of screening and early intervention, prior studies using electronic health record (EHR) data generally found very low rates of laboratory screening for obesity-related conditions. For example, studies reported a dyslipidemia screening rate of 9–11% among 9–16-year-olds with obesity,⁶ a diabetes screening rate of 13% among 10–19-year-olds with obesity,⁷ and a NAFLD screening rate of 14% among 9–19-year-olds with obesity⁸ during 2019–2021. Screening rates were higher in children with higher body mass index (BMI),^6–10 older children,^6,9–10 and females.^7–10 Another study of commercial claims data found that approximately 27% of children with diagnosed obesity received laboratory screening for diabetes, dyslipidemia, and NAFLD.¹¹ Although screening prevalence was generally low, the prevalence of elevated lab results was high.^6–9 For example, among children and adolescents with obesity in 2019–2021, 22% of those screened for diabetes, 44% of those screened for NAFLD, and more than 50% of those screened for dyslipidemia had elevated lab results.^6–8 Abnormal results were even more common in those with severe obesity.

Prior studies have assessed screening for these conditions individually^6–10 or in combination but without demographics or measured BMI data.¹¹ However, we are not aware of any that have assessed screening for all three conditions, calculated prevalence of abnormal laboratory results, and used measured BMI to examine differences by obesity severity. Baseline estimates prior to the release of the CPG can help track changes in uptake of CPG recommendations over time. The present study used a large cross-sectional cohort of US children and adolescents with obesity to estimate (1) the prevalence of screening for NAFLD, dyslipidemia, and diabetes, individually and in combination, and (2) the prevalence of abnormal test results for NAFLD, dyslipidemia, and diabetes, overall and by obesity severity and patient demographics.

Among 1.5 million patients aged 10–18 years during 2020–2022, approximately 3% had a BMI classified as underweight, 56% healthy weight, 17% overweight, and 23% obesity (14% class 1, 6% class 2, and 3% class 3) (Table 2). Among 333,110 patients with obesity in the final study sample, 54% were male, 59% had class 1 obesity, and 57% were White (Table 3). Approximately one-quarter (27%) had evidence of a well-child visit during 2020–2022.

Overall, 74% of patients (n = 247,492) had no evidence of screening for NAFLD, dyslipidemia, or diabetes during 2020–2022 (Table 4). Thirteen percent were partially screened (1–2 conditions), and 13% had complete screening (all 3 conditions). Prevalence of complete screening was higher among those with more severe obesity (9% class 1, 15% class 2, and 22% class 3). Prevalence of complete screening was substantially higher in those with evidence of well-child visits than those without (21% vs 9%). Screening occurred more often in older patients aged 15–18 years than those aged 10–14 years (complete: 14% vs 11%) and females than males (partial: 15% vs 11%, complete: 14% vs 12%). All differences were statistically significant, p < .0001.

The prevalence of screening was 22% for diabetes, 19% for NAFLD, and 18% for dyslipidemia (Table 4). For each condition, screening occurred significantly more often for patients aged 15–18 years than 10–14 years (e.g., 22% vs. 16% for NAFLD) and for females than males (e.g., 26% vs. 19% for diabetes) (p < .0001). For each condition, the prevalence of screening was higher for those with more severe obesity; for example, dyslipidemia screening occurred in 15%, 21%, and 28% among those with class 1, 2, and 3 obesity, respectively (Table 4).

Figure 1 shows screening by combinations of conditions. Nearly 42,000 patients (13%) were screened for all 3 conditions. Among the 27,244 patients screened for 2 conditions (8%), the most common combination was diabetes and NAFLD (n = 19,218) followed by diabetes and dyslipidemia (n = 7,413). Among the 16,455 patients screened for only 1 condition (5%), screening for dyslipidemia was the most common (n = 10,417).

Figure 2 displays the prevalence of abnormal test results. Among those screened for dyslipidemia, 56% had at least 1 abnormal test result. The proportion of patients with abnormal results was higher in those with more severe obesity (50% vs 60% vs 64% for class 1, 2, and 3 obesity, respectively). Males had a higher proportion of abnormal results than females (61% vs 51%), and older adolescents had a higher proportion of abnormal results than younger (59% vs 54%) (p < .0001).

Among patients screened for NAFLD, 13% had at least 1 abnormal result, and another 31% had at least 1 borderline result. The proportion of patients with abnormal results was higher in those with more severe obesity (10% vs 15% vs 19% in those with class 1, 2, and 3 obesity, respectively) (p < .0001). The proportion of patients with abnormal results was much higher in males than females (19% vs 9%) and in those aged 15–18 years than 10–14 years (15% vs 11%) (p < .0001).

Among patients screened for diabetes, 3% had at least 1 result in the diabetes range (i.e., abnormal) and 11% had at least 1 result in the prediabetes range (i.e., borderline). The proportion of patients with results in the prediabetes or diabetes range was higher in those with more severe obesity (9% vs 15% vs 23% in those with class 1, 2, and 3 obesity, respectively). The proportion of patients with results in the prediabetes range was higher in patients 10–14 years than those 15–18 years (13% vs 9%, p < .0001).

Using EHR data for >330,000 patients, this study found no evidence of screening for diabetes, dyslipidemia, or NAFLD for nearly 75% of patients aged 10–18 years with obesity during 2020–2022. Even among patients with a documented well-child visit in this period, two thirds (64%) did not have documentation of screening. Laboratory screening for these conditions has been recommended since at least 2007,^4,19–21 and was most recently recommended by AAP’s 2023 CPG.⁵ The low prevalence of screening directly before the release of the CPG highlights an opportunity for substantial improvement in provider uptake of these recommendations. Improving provider self-efficacy²² and addressing key barriers, including inadequate and inconsistent coverage for obesity services,²³ may facilitate uptake of evidence-based obesity care.

Among the 26% of patients who received screening, approximately half had screening for all 3 conditions; thus, complete screening was more common than screening for any single condition or combination of conditions. This finding is promising as it aligns with comprehensive evaluation recommended for patients aged ≥10 years with obesity, outlined in AAP’s CPG algorithm.²⁴ This approach can help providers more completely understand the range of factors influencing patients’ health and inform decision-making for appropriate treatments.

Among those screened, a high proportion had abnormal test results. For example, more than half of patients screened for dyslipidemia had ≥1 abnormal lipid biomarker. Further, 13% of patients screened for NAFLD had high ALT, and an additional 31% had borderline high values. Consistent with previous studies,^6–8 these findings show how common metabolic abnormalities are among youth with high BMIs, and underscore the importance of screening for early detection. Early detection coupled with providing or referring to evidence-based interventions, such as IHBLT, can help improve health outcomes and reduce risk for future disease.⁵

Both the prevalence of screening and the prevalence of abnormal results were higher among those with more severe obesity. Complete screening occurred in 22% of patients with class 3 obesity, up from 9% and 15% in those with class 1 and 2 obesity, respectively, which aligns with previous studies showing that children with higher BMIs have higher rates of screening.^6–9 Higher screening rates of these children could be due to a variety of factors, such as patient and family concern, higher provider self-efficacy in obesity-related care for those with very high BMI, or provider awareness of increased health risks associated with higher levels of excess adiposity. In addition, children with more severe obesity may have had obesity-related signs and symptoms (e.g., acanthosis nigricans or elevated blood pressure) that prompted clinicians to conduct lab screening. These diagnoses may help substantiate payer reimbursement for laboratory screening, which is not universally covered with only an obesity diagnosis. Insufficient reimbursement for obesity services has been long identified as a major barrier to evidence-based obesity care.^23,25

Importantly, among patients with class 3 obesity who had laboratory testing, nearly two-thirds had abnormal lipids and nearly one-quarter had abnormal ALT or elevated diabetes markers (borderline or abnormal), which is markedly higher than patients with less severe obesity. This dose response effect mirrors an analysis of nationally representative data from 8,500 US youth with overweight or obesity; Skinner et al. found that the more severe the obesity, the higher the risk for abnormal cardiometabolic markers, including high triglycerides and A1c.²⁶ Given that more than 4.5 million US children are affected by severe obesity, screening for this high-risk group is a critical step to early identification of obesity-related complications and evidence-based intervention to prevent long-term consequences.

The prevalence of abnormal labs is impacted by the thresholds used to define them. We used well-established cutpoints for abnormal lipid levels¹⁹ and diabetes markers.²⁰ However, thresholds for ALT elevation and how to interpret them are less clear. Pediatric studies have used a variety of thresholds.^9,27–29 We aligned with biology-based cutpoints identified by Schwimmer et al. using NHANES data. In our study, most abnormal ALT results were above Schwimmer’s threshold for twice the upper limit of normal (≥50 U/L for males, ≥44 U/L for females) but <80 U/L (both sexes). Nonalcoholic steatohepatitis (NASH), the most severe form of NAFLD, is more common in children with ALT values ≥80 U/L.²⁹ Although not many youth in our study had ALT values this high, NASH is the most rapidly increasing indicator for liver transplantation in the US,³⁰ thus important for screening and awareness. Similarly, for diabetes and dyslipidemia, many of the non-healthy lab values were in the borderline or prediabetes range, highlighting an opportunity for lower-cost treatment such as lifestyle interventions to help patients improve health behaviors, lose excess weight, and prevent disease progression. In our study, the overall proportion of patients aged 10–18 years who had evidence of well-child visits was low (27%). This may be due in part to specialists representing 60% of providers contributing data to IQVIA overall. As expected, the proportion of patients with well-child visits in our study decreased with age (e.g., 33% in 10-year-olds, 27% in 14-year-olds, and 21% in 18-year-olds). Despite recommendations for annual visits,³¹ older children and adolescents are less likely to receive routine preventive care than younger children;^32–33 further, there was a large decline in preventive care during the COVID-19 pandemic.³² Children and adolescents who receive well-child care may have more opportunities to get recommended screenings for chronic conditions as well as other components of comprehensive care, including mental and behavioral health assessment and physical examination. During our 3-year study, patients with evidence of well-child visits were much more likely to receive complete screening than those without (21% vs. 9%).