Adolescents in the Prevention Vacuum: A Policy Analysis of Type 2 Diabetes Screening Gaps in the NHS and the Case for Targeted Pilot Programmes

Background: Type 2 diabetes mellitus (T2DM) in children and young people is rising in England and Wales. The National Paediatric Diabetes Audit (NPDA) recorded 1,521 children and young people with T2DM under paediatric diabetes units in 2023/24, an 88% increase from 810 in 2019/20. At the 2023/24 audit, 86% had a body mass index in the obese range, 71% had high or high-normal blood pressure, and 20% had albuminuria. National prevention frameworks in England (the NHS Health Check, the NHS Diabetes Prevention Programme (DPP) and NICE guidance on prevention) apply to adults, and NICE guideline NG18 addresses diagnosis and management rather than case-finding. No national pathway identifies glycaemic risk in adolescents before diagnosis. Objective: To introduce and apply a three-gap analytical framework (a policy gap, an equity gap and an evidence gap) to adolescent T2DM prevention in the NHS, and to set out specific, proportionate recommendations for closing those gaps through evaluation-embedded pilot programmes. Methods: Secondary policy analysis combining review of national surveillance data (NPDA, National Child Measurement Programme) with structured documentary analysis of NHS, NICE and Department of Health and Social Care policy, and comparison with international screening guidance. Narrative synthesis followed Popay et al. (2006), with explicit equity and economic lenses. No primary data were collected. Findings: Adolescent T2DM is concentrated in deprived and ethnic minority populations: 70% of affected children and young people live in the two most deprived quintiles and 63% are from ethnic minority backgrounds. Specialist Complications from Excess Weight clinics now treat children with severe obesity and complications, but no national programme offers systematic, population-level risk identification for 11 to 17 year olds. The DPP specification explicitly excludes under-18s. Professional bodies in the United States, Canada and internationally recommend targeted, risk-based screening of youth, generally those with overweight or obesity plus additional risk factors, while the US Preventive Services Task Force judges the evidence insufficient. No UK cost-effectiveness evaluation of adolescent screening exists. Conclusions: The evidence does not support immediate universal screening, but nor does it justify the continued absence of any structured approach. Evaluation-embedded pilots of targeted risk identification within high-prevalence integrated care systems, co-designed with young people and linked to existing services, would be deliverable through existing structures and are the most direct route to the evidence that national decision-makers require. Policy implications: NHS England should commission evaluation-embedded pilots of targeted risk identification. NICE should consider case-finding in asymptomatic at-risk children and young people through its topic prioritisation process. A youth diabetes prevention pathway for 16 and 17 year olds with non-diabetic hyperglycaemia should be piloted and evaluated. Preprint, not peer reviewed.