Screening and assessment of type 2 diabetes risk factors among Pacific youth attending community health events in Auckland

Type 2 diabetes (T2D) is a major global health issue with a steadily rising number of cases, particularly early onset in young people.¹ In Aotearoa New Zealand, over 250,000 individuals have been diagnosed with diabetes. The prevalence rates are highest among people of Māori, Pacific and South Asian descent, while the absolute numbers are highest among New Zealand Europeans.² T2D is the most common type recorded, with around 228,000 diagnosed New Zealanders.³ It is projected that by 2040 about 400,000 people in Aotearoa New Zealand, especially Māori and Pacific peoples, may be diagnosed with T2D due to the increasing rate of obesity. ³

Lack of knowledge about T2D prevention and limited advocacy for accessible care contribute to this trend.³ Approximately 50% of diagnosed individuals face serious complications within 10 to 15 years.⁴ Early diagnosis and effective management are crucial, particularly for those with early-onset T2D, to reduce the risk of chronic conditions like kidney and cardiovascular diseases.⁵ Young people with T2D often struggle to manage their blood sugar levels and are frequently undertreated for related conditions such as hypertension and dyslipidaemia.⁴ They also face increased diabetes distress and obesity stigma,⁶ and an aggravated cardiovascular disease profile,⁷ leading to poor quality of life. Research shows that those with early-onset T2D are more susceptible to microvascular complications that worsen by early adulthood.⁸ A study in Australia noted higher mortality among these individuals than those diagnosed later.⁸ The TODAY study highlighted increased T2D-related complications in minority racial and ethnic groups.⁹

There is an emerging trend of early-onset T2D among young people in Aotearoa New Zealand,¹⁰ necessitating evidence to address healthcare needs and inform health policy changes, particularly for Pacific and Māori youth. This research aimed to explore T2D awareness, knowledge, attitudes and risk factors among youth in Auckland. We also explored participants’ preferred care models for T2D.

Methods

Study design

The study employed a cross-sectional design and convenience sampling for participant assessment.

Data collection and analysis

Data collection was implemented across several community outreach events between 25 May and 31 July 2024, in collaboration with the Tongan Health Society (THS), a Pacific primary care provider. The target population consisted of all individuals aged 16–25 years old who attended the THS community outreach events. However, three participants above the upper band of the targeted age group were opportunistically assessed for the study.

We held 10 pop-up events during the THS community outreach campaigns in South, Central and East Auckland. Participants were engaged with information about the research, screening procedures, knowledge assessments, attitude, risk, and health education. All participants provided verbal and written consent before data collection, which lasted about 30 minutes and involved a self-administered, paper-based questionnaire.

HbA_1c testing

The A1cNow Plus analyser (professional only) by Point of Care Diagnostics NZ was used to measure HbA_1c from a capillary blood sample, which has shown 97.83% sensitivity and 77.42% specificity (95% confidence limit) compared with standard laboratory venous HbA_1c.^9,10,11 The results were categorised as normal (HbA_1c <41 mmol/mol), pre-diabetes (HbA_1c 41–49mmol/mol) and diabetes (HbA_1c 50mmol/mol or higher).¹² Each participant was informed of their results after 5 minutes with the corresponding interpretation. Participants recording results that indicated pre-diabetes or diabetes were referred to a primary care service provider for further clinical investigations and management.

Body composition measurements

We conducted a body composition assessment using the TANITA RD-545 InnerScan PRO scale, which measures weight, body fat, muscle mass, muscle quality, physique rating, bone mass, visceral fat, basal metabolic rate, metabolic age, total body water and body mass index (BMI).¹³ Each participant’s weight, BMI and body fat percentage were recorded. Height measurements were taken using the Road Rod Portable Stadiometer from Hopkins Medical.¹⁴

Body composition indicators, such as body fat percentage and BMI, were classified according to established standards to assess the risk of developing T2D.^15,16 BMI classifications followed ethnic-specific cutoffs: for overweight—Pacific/Māori ≥26.0kg/m² to <32.0kg/m² and European ≥25.0kg/m² to <30.0kg/m²; for obesity—Pacific/Māori ≥32.0kg/m² and European ≥30.0kg/m², as recommended by a prior study.¹⁷ We compared the standard BMI thresholds¹⁸ with these ethnic-specific cutoffs and estimated their concordance with corresponding body fat percentage categories from Macek et al.¹⁹ We reclassified participants based on BMI and excess adiposity thresholds identified by Macek et al. (defined as ≥25% for males and ≥35% for females). A participant was considered obese if their BMI indicated obesity and their body fat percentage confirmed excess adiposity. Conversely, if the BMI indicated obesity without excess adiposity, the participant was reclassified as overweight. Participants with a BMI of 40 or above were automatically categorised as obese.²⁰

Knowledge, attitude, risk assessment and preferred care models for T2D

We administered a structured questionnaire to assess participants’ knowledge of and attitude and risk for T2D. The questionnaire was adapted from prior validated tools^21,22 and pilot-tested with 10 youth from the targeted demographic. The questionnaire aimed to gather demographic and risk information, including dietary habits (e.g., sugary drink consumption), physical activity (e.g., exercise frequency), alcohol use (e.g., current alcohol consumption), knowledge of T2D, awareness of T2D, access to care (e.g., testing history for T2D) and preferences for care models (e.g., desirable care types for T2D in Pacific and Māori communities). Knowledge of T2D was categorised as “good”, “fair”, or “poor”: “good” if participants answered “yes” to both having heard of T2D and knowing it can cause other health complications; “fair” if they had heard of T2D but did not know about its complications; and “poor” if they had never heard of T2D. Attitudes were assessed through four questions: 1) Can anyone get T2D? 2) Am I at risk of developing T2D? 3) Should everyone be tested for T2D (HbA_1c)? 4) Is it essential to prevent T2D complications? Each question scored 1 point if the response was “yes”, while “no” and “don’t know” responses were scored 0. Four points indicated a “good” attitude (answering “yes” to all), 2–3 points was “fair” and 0–1 point was “poor”. Furthermore, preference for care model was assessed through predetermined options (e.g., lifestyle management programmes) and an open-ended field (other, specify) to capture information not anticipated in the predefined options.

Data entry and analysis

The completed paper-based questionnaires were entered into IBM SPSS Statistics Software (version 29.0; Chicago, Illinois, United States). The data from SPSS were imported, cleaned and stored in Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States). We conducted descriptive analyses and summarised the data into frequencies and proportions using the total number of valid responses for each variable as the denominator, respectively. For example, the question about ethnicity required multiple responses, where applicable; hence the denominator was more than the total sample assessed (n=138). All statistical analyses were performed using Stata (version 16.1; Stata Corp LLC, Texas, United States).

Health education for T2D prevention

A nurse provided one-on-one in-person targeted health education for T2D prevention and management for all participants post-assessment. HbA_1c and body composition results were discussed with the participants, highlighting risk factors associated with developing cardiometabolic conditions. Further education was provided regarding managing these risk factors, ensuring participants were actively involved in their health journey. The health education was targeted at improving awareness of T2D, increasing understanding of the benefits of early diagnosis and treatment for T2D, enhancing knowledge of the risks of T2D and lifestyle adjustments to prevent the disease and diabetes-related health complications, and increasing advocacy for access to diabetes care services, especially weight management programmes for people classified as obese or with pre-diabetes.

Ethical considerations

The Southern Health and Disability Ethics Committee granted ethical approval (ethics reference: 2024 EXP 20214). We obtained verbal and written informed consent from all participants before the screening and interviews. Acknowledging the significance of tikanga, we upheld Māori values, beliefs and worldviews. Our research team focussed on fostering relationships with participants while preserving mana throughout the study. We recognised the sacredness of the body (tapu) and ensured that blood samples were collected, tested and discarded with respect. Participants could request a lotu or karakia before sample disposal. Additionally, they were informed of their right to access their records to review and verify only the information they provided during the assessment.

Results

Demographics

We assessed 135 young people aged 16–25 years, and an additional three young people aged 26–31 years from several suburbs in the south, central and east of Auckland. Table 1 shows the demographic distribution of the study participants. Females represented 58% (n=80) of the study participants. The median age was 20 (16–31) years. There was an almost equal proportion of youth aged 16–19 (46.4%, n=64) and 20–24 (45.7%, n=63). Most participants identified as Tongan (62%, n=110), followed by Samoan (18%, n=31).

View Table 1–6, Figure 1.

Knowledge of diabetes

Most participants (60.1%, n=83), reported having heard about T2D. The most common sources of information about T2D were from a family member, (40%, n=58), health promotion materials, (16%, n=24) and social media (13%, n=19). Approximately 36% (n=50) of participants reported having a first-degree relative with T2D. More than half (56.8%, n=46) of the participants who had ever heard about T2D knew about other types of diabetes. In addition, 62.0% (n=49) of participants mentioned that T2D causes other health complications. Furthermore, over a third (36.6%, n=49) of participants displayed a “good” knowledge of T2D, and participants with a “poor” knowledge of T2D represented 41.0% (n=55) of the sample (Table 2).

Attitude towards T2D

Regarding participants’ attitudes towards T2D prevention and management, 56.2% (n=77) thought anyone could develop T2D, but 32.1% (n=44) thought they were at risk of developing the condition. In addition, 75.4% (n=104) of respondents indicated that testing for T2D should be universally accessible, whereas 76.1% (n=105) underscored the significance of preventing complications associated with T2D. Meanwhile, less than a quarter (24.6%, n=34) of participants believed a person with T2D could reverse their glucose level to normal. Regarding a scale of attitude, more than half (52.9%, n=73) of the participants recorded a “fair” attitude towards T2D, while an almost equal proportion of participants displayed “good” (23.2%, n=32) and “poor” attitude (23.9%, n=33) (Table 3).

Assessment of risk factors for T2D

Dietary factors

Most participants (91.3%, n=126) reported consuming sugary drinks like Coca-Cola, Fanta, processed fruit juices and energy drinks. Nearly equal proportions reported consuming either 1–1.5 litres (23.5%, n=24) or more than 1.5 litres (22.5%, n=23) daily, while 54.0% (n=55) consumed less than a litre. More than a third reported consuming sugary drinks several (3 or more) days a week, with 39.4% (n=49) drinking twice weekly and 31.5% (n=39) drinking once weekly before assessment (Table 4). Meanwhile, 93.4% (n=128) reported eating fruit. Among these, 22.7% (n=29) consumed two servings daily, and 17.9% (n=23) less than one serving. Most participants reported eating fruits several times a week before their assessment (Table 4). Furthermore, 89.7% (n=122) confirmed eating non-starchy vegetables. Among these, 23.8% (n=29) consumed two servings daily, while 14.8% (n=18) ate three servings. Meanwhile, 28.9% (n=35) of participants reported eating non-starchy vegetables several days a week before the assessment (Table 4).

Nondietary factors

Table 5 summarises the non-dietary risk factors evaluated. Over one-third of participants (36.2%, n=50) reported a blood relative (e.g., parent or sibling) have been diagnosed with T2D. Regarding physical activity, 70.8% (n=97) incorporated exercise into their daily routines. Among these, 39.5% (n=51) engaged in vigorous activities (e.g., heavy weightlifting, rugby). For the 88 participants who reported their exercise duration, the majority (31.8%, n=28) lasted between 90 and 120 minutes. Additionally, 34.4% (n=33) exercised several days a week but not daily and 20.8% (n=20) were active every day before the assessment (Table 5). Furthermore, 47.1% (n=65) of participants reported ever smoking tobacco (e.g., cigarettes, pipes, cigars and vapes), with 38.5% (n=25) being current smokers. Additionally, 47.5% (n=65) reported having a current smoker in their household. Regarding alcohol use, 58.8% (n=80) indicated they had consumed alcohol, with 45.0% (n=36) of this group currently drinking alcohol (Table 5).

Preferred care model for T2D

Participants (287 response) recommended a preferred care model for individuals with T2D of a similar age. Over half (25.1%, n=72) suggested lifestyle management programmes, including diet modification and physical activity. Other recommendations included self-monitoring of blood sugar levels (15.3%, n=44), supportive community health promotion programmes (13.2%, n=38) and psychosocial support, such as stress management and emotional wellbeing counselling (10.5%, n=30). Additionally, 15.3% (n=44) did not know any recommended care model for T2D (Figure 1).

Health screening results

HbA_1c test

Approximately 99.3% (n=137) of participants had a “normal” HbA_1c result (<41 mmol/mol). One female participant tested positive for T2D with a result of 57mmol/mol, representing 0.7% (n=1). She was referred to her general practitioner for further investigation and management.

Body composition measurements

Table 6 presents the classification of body composition measurements for 120 participants of Pacific and Māori descent. Full body composition data were unavailable for 18 out of 138 participants due to physical limitations: inability to stand on the bioimpedance scale or presence of a limb cast that interfered with scanning. Approximately 71.7% (n=86) of participants had a very high body fat percentage, followed by 16.7% (n=20) with a high body fat percentage. Utilising standard BMI thresholds, about two-thirds of participants (60.8%, n=73) were classified as obese, while 28.3% (n=34) were categorised as overweight. In contrast, the ethnicity-adjusted thresholds indicated that 53.3% (n=64) were obese and 31.7% (n=38) were overweight. Using the ethnic-specific adjusted cutoffs, 69.4% (n=59) of participants categorised as obese and 15.3% (n=13) as overweight were consistent with their body fat percentage categories. Additionally, 14.1% (n=12) of those with a BMI indicating a healthy weight were similarly aligned with normal body fat percentage.

Discussion

This study assessed 138 youth aged 16–31 years, primarily of Tongan ethnicity, across several Auckland suburbs, and it identified one previously undiagnosed diabetes case. About two-thirds of participants reported awareness of T2D, mainly from family members. Generally, knowledge of T2D was good, with females demonstrating better understanding than males. Participants’ attitudes towards T2D were predominantly positive.

Dietary risk factors revealed that many participants frequently consumed high amounts of sugary drinks. Non-dietary risk factors included about a third confirming a family history of T2D, and nearly half reported ever smoking, with a third as current smokers. Approximately two-thirds reported alcohol consumption, with most being current drinkers.

Despite regular participation in moderate and vigorous physical activities, most showed a high or very high body fat percentage, aligning with overweight and obese BMI categories. Higher BMI and body fat may increase the likelihood of developing T2D and other chronic conditions.²³ Perng et al. identified obesity as a significant factor for early-onset T2D in young people, noting that most classified as “obese” may develop T2D within 10 years.²⁴ This trend disproportionately affects First Nations and minority populations.²⁵

The number of young people categorised as overweight and obese was underestimated using ethnicity-adjusted BMI and better approximated by the standard BMI. Even though the body fat percentage threshold for obesity presented by Macek et al.¹⁹ aligns with that of Rush et al.,²⁶ generally non-ethnic-specific body fat percentage thresholds may explain the significant discordance. Our findings reveal the discrepancies between the two approaches and highlight the importance of ethnicity-adjusted thresholds for BMI and body fat percentage concordance, particularly for Pacific and Māori participants to accurately estimate obesity.

Participants favoured lifestyle management, blood sugar self-monitoring, community health promotion and psychosocial support for T2D care. These suggested interventions align with a randomised controlled trial by Peña et al., which demonstrated that lifestyle interventions, including nutrition and health education, can improve outcomes among young participants with T2D and prediabetes.²⁷ Furthermore, Eva et al. documented the positive impact of self-care activities and supportive networks in improving health outcomes for young people with T2D.²⁸

Though our findings indicated low T2D prevalence, various risk factors—including family history, alcohol consumption, dietary habits and high body fat—pose substantial risks for developing T2D. Individuals with high body fat and BMI are at greater risk for chronic health issues, including T2D and its complications.²³ Furthermore, increased intake of sugary beverages has also been correlated to T2D risk.^29,30

Our study’s limitations include its cross-sectional design, which provides only a “snapshot” of the situation. Meanwhile, our sampling technique limits our ability to estimate T2D prevalence among the study population. However, these findings accurately reflect real-world T2D conditions in the population and can guide policy for T2D prevention and management. Additionally, physical issues limited full-body measurements for all participants, though complete data were collected for HbA_1c and surveys.

This research demonstrates several strengths. Firstly, this research contributes to the growing scientific evidence documenting the knowledge, attitude, practice and risk for T2D among young people of Pacific and Māori descent in Auckland, Aotearoa New Zealand. Secondly, it identifies and builds an understanding of the knowledge and attitude toward T2D and its risks among the study participants by measuring their HbA_1c levels, BMI, body fat percentages, survey responses and preferences for T2D management. Even though the findings cannot be generalised due to the non-probabilistic nature of the sample, they can inform policies to address existing risks to prevent T2D among young people. Thirdly, through working with a Pacific primary care provider with strong ties to Pacific community groups, this research ensured that cultural considerations in the responses to the questionnaire were maintained and accurately communicated.

This study indicates a relatively high awareness about T2D among our study participants, yet significant risks exist. It underscores the necessity for regular T2D screening and targeted prevention strategies to mitigate T2D development, particularly among youth. The evidence gathered serves as a baseline for future screenings and research on risk factors, guiding T2D prevention and management policies for youth, particularly those of Pacific and Māori descent.