INS and obesity due to melanocortin 4 receptor deficiency: Similarly, markers of glucose intolerance and insulin resistance, including HbA1c levels, fasting insulin level, HOMA-IR, and prevalence of prediabetes and type 2 diabetes, were significantly elevated in children and adolescents with obesity classes 4 to 5 (Figure 3), extending earlier results.32,40,41 The association between pediatric obesity and cardiometabolic risk factors is well established.34,42 This study found an even stronger correlation between extremely severe obesity and these conditions.