Most Significant Future Health Risk Factor
The combination of high BMI (obesity) and family history of diabetes represents the most significant factor for this teenager's future health risk, as obesity is the strongest tracking risk factor from adolescence to adulthood and directly drives the development of type 2 diabetes, cardiovascular disease, and metabolic complications. 1, 2
Why Obesity and Family History Dominate Risk
Obesity tracks more strongly than any other cardiovascular risk factor from childhood into adulthood. 1 The American Heart Association's longitudinal data from the Bogalusa Heart Study demonstrates that 100% of severely obese adolescents developed adult BMI ≥30 kg/m², with 88% reaching BMI ≥35 kg/m², and 65% reaching BMI ≥40 kg/m². 1, 2 This near-universal persistence makes obesity the most powerful predictor of future health outcomes.
The combination of obesity with family history of diabetes creates multiplicative risk. 1, 2 Among youth with type 2 diabetes, 74-100% have a first-degree family history of the disease, and 85% are obese. 2 This teenager possesses both risk factors simultaneously, placing her at extraordinarily high risk for developing type 2 diabetes—a condition that will then drive accelerated cardiovascular disease throughout her lifetime.
Why Other Factors Are Secondary
Hypertension as a Consequence, Not Primary Driver
The hypertension this teenager exhibits is likely secondary to her obesity rather than an independent primary risk factor. 3 Obesity accounts for 65-78% of cases of primary hypertension, operating through sympathetic nervous system overactivation, renin-angiotensin-aldosterone system stimulation, and structural renal changes. 3
Higher BMI is associated with tracking of elevated blood pressure levels in longitudinal pediatric cohort studies. 1 The Minneapolis Children's Blood Pressure Study demonstrated that youth with the greatest increase in BMI over 16 years had the highest risk of elevated blood pressure. 1 This means addressing obesity will simultaneously address the hypertension, whereas treating hypertension alone leaves the root cause untouched.
Poor Diet as a Modifiable Contributor
While poor diet contributes to obesity development, it is the established obesity itself—not the ongoing dietary pattern—that represents the greatest future risk. 2 The damage is already done in terms of adiposity tracking. The American Heart Association guidelines emphasize that obesity in childhood strongly tracks into adulthood regardless of subsequent dietary changes, making early intervention critical. 2
Diet modification is important for treatment but does not supersede the established risk from existing obesity. 1 Longitudinal studies show that risk factors measured in childhood and adolescence are better predictors of adult atherosclerosis severity than risk factors measured in adulthood. 1
Elevated Fasting Blood Sugar: Unknown Status
The question indicates uncertainty about whether elevated fasting blood sugar is present. If present, this would indicate progression to prediabetes or diabetes, which would be a consequence of the obesity and family history rather than an independent risk factor. 2 The American Heart Association recommends fasting plasma glucose testing given this patient's multiple risk factors. 2
The Cascade of Risk from Obesity
Obesity drives cardiovascular risk factor clustering over time. 1 Adolescents with higher degrees of obesity demonstrate clustering of insulin resistance, elevated triglycerides, reduced HDL cholesterol, and elevated blood pressure—the metabolic syndrome pattern. 1 This clustering is among the reasons the obesity epidemic is considered one of the most important public health challenges. 1
Severe obesity in childhood is strongly associated with future development of type 2 diabetes, which then becomes an independent predictor of eventual cardiovascular disease. 1 The risk of developing type 2 diabetes increases greatly with increasing BMI, and severe obesity at baseline is an independent predictor of eventual diabetes development. 1
Childhood obesity predicts intermediate cardiovascular outcomes in adulthood, including target-organ damage. 1 This includes increased left ventricular mass, left ventricular hypertrophy, increased carotid intima-media thickness, and aortic stiffness. 1 These structural changes begin as early as age 10 years. 1
Clinical Implications
This teenager requires immediate intensive lifestyle intervention targeting weight reduction of at least 5% body weight, DASH diet with sodium restriction, and moderate to vigorous physical activity 3-5 days per week for 30-60 minutes. 4 However, the evidence suggests that behavioral interventions alone are often insufficient to achieve adequate weight loss in severely obese adolescents. 5
Screening for type 2 diabetes with fasting plasma glucose is indicated given the combination of obesity, family history, hypertension, and sedentary lifestyle. 2 Screening should be repeated at minimum every 3 years, with consideration for more frequent testing given this high-risk profile. 2
The answer is D: Family history and high BMI. These two factors together create the highest future risk for mortality and morbidity through the development of type 2 diabetes and subsequent cardiovascular disease, with obesity demonstrating the strongest tracking of any risk factor from adolescence into adulthood.