We recruited a group of individuals with expertise in diabetes prevention or adolescents (referred to as professionals for brevity) to participate in 1 HCD session. Initially, the primary investigator reached out to colleagues who were involved in diabetes prevention or experts working with adolescents. Examples include physicians, diabetes educators, and community youth organizations. Additional professionals were recruited through a snowball sampling technique as initial participants invited colleagues who met the aforementioned criteria. Professionals were invited to participate in one 90-minute session and were compensated with US $50 per hour for their time.

Adolescents and parents were recruited in 4 ways. First, the professional group members recruited adolescents and parents in connection with their organizations by distributing flyers and word of mouth. Second, adolescents and parents were recruited from a youth diabetes prevention clinic. Third, adolescents and parents were recruited from an existing local family-focused nutrition and physical activity program. Finally, a school-based adolescent group was recruited by a school nurse from a local high school.

Fourteen individuals participated in the professional group session. This session took place at a community church that had space to accommodate this group size. The group consisted of physicians, researchers, diabetes educators, school personnel, Young Men’s Christian Association staff members, a nurse manager at a community health center, a church pastor, a youth mentor, and a youth counselor.

The first adolescent and parent session consisted of 18 people with 5 parents and 13 adolescents and took place at a community church. The second adolescent and parent session consisted of 14 people with 6 parents and 8 adolescents and took place at a community center. The school-based adolescent group session consisted of 12 adolescents and took place at a high school.

The session findings are presented based upon the objectives of the session. No other evaluation of participation was conducted.

Both adolescents and professionals stated that creating an environment where healthy choices are acceptable and appealing was important. One professional stated, “What they would actually want to do, not what they feel like they’re supposed to do or have to do, but that the healthy choice is like the awesome choice.”

Both adolescents and professionals stated that it was important that a diabetes prevention program was affirming and not judgmental.

Parents and adolescents reported they wanted a program that avoided focusing on what not to do. This was best illustrated with cupcakes on the table with a sign reading “do not eat” (Multimedia Appendix 3).

Adolescents and parents felt that trying new foods and activities was an important part of adopting healthy behaviors that fit their lifestyle. Adolescents were interested in trying activities that were out of the ordinary or taking ordinary things and experiencing them in novel ways. For instance, adolescents created a drinkable swimming pool as a component of the diabetes prevention party (Multimedia Appendix 4). This idea represents a new spin on the recommendation to drink water instead of sugary drinks.

Adolescents, parents, and professionals reported barriers such as lack of access to reliable transportation, access to healthy foods, and safe places for physical activity.

Adolescents reported that food choices are often limited by the options offered by parents, schools, and vending machines. As one adolescent described, “If you go to the vending machine, everything has some sort of sugar or fat in it. There aren’t really options for healthy stuff.”

All groups discussed the costs of healthy versus processed foods as a significant barrier. In addition, participants viewed wasted food as wasted money and viewed free food as free money such as buffets and free refills.

Parents felt that the time required to cook healthy meals and engage in exercise was a luxury not afforded to them. As one parent explained, “When they don’t get home and mom doesn’t get home until late, then it’s like, okay throw a pizza in.”

All participant groups identified competing priorities as a barrier. The demands of work, school, financial strain, and unsafe neighborhoods made healthy lifestyle change a lower priority than imminent needs. Adolescents felt that a long sedentary school day coupled with required evening homework time impeded efforts to increase physical activity. Parents’ comments regarding the workday and challenges incorporating physical activity mirrored the adolescents’ sentiments on this topic. Additionally, parents verbalized safety concerns around independent outdoor play for youth. One parent described how different her childhood was from that of her children, “Even though I tried, my kids’ life is so much different from the way I was raised. Some of it was because I was afraid to send them out to play—but I was out and my mom didn’t know where I was most of the day…I would ride my bike 2 or 3 miles from home. That’s just not my kids’ existence. They’ve never had that.”

Adolescents and parents described foods and beverages high in sugar or salt as having an addictive quality. As one parent stated, “I’m trying desperately to find things that taste good and are healthy.” They also felt that situations where others continued to eat those foods in their presence hindered their efforts. Adolescents specifically called out celebrations, which so often center around unhealthy foods, as problematic for maintaining healthy eating habits.

All groups reported that having fun should be the primary focus of a diabetes prevention program.

Adolescents, parents, and professionals identified “play” as an important factor in an ideal program. Adolescents expressed play as participation in sports and free movement activities (eg, basketball, swimming, volleyball, dancing). Parents identified play as hands-on learning activities such as cooking classes, recipe sharing, and exercises not available at home.

All participant groups were averse to didactic lecture-style sessions. For instance, the worst program ever drawings included an instructor in front of a class saying “blah, blah, blah” and a participant saying, “May I speak now?” (Multimedia Appendix 3). Additionally, an adolescent stated, “A lecture is when someone talks at you instead of talking with you.” Participants wanted hands-on, collaborative, and motivating learning experiences such as cooking and socializing. All participants wanted to avoid homework and handouts. As one parent stated, “I want to know how to cook the way my mother cooked but substitute things that are healthier, so I can still get the foods that I like.”

Adolescents wanted a facilitator who incorporates fun. Parents desired a facilitator that adolescents can look up to. All participants wanted program staff who were fun, engaging, and respectful.

Adolescents, parents, and professionals saw value in rewarding success. Adolescents verbalized money or access to an experience as motivating rewards. For instance, in one of the diabetes prevention party drawings, adolescents envisioned a reward where trying healthy behaviors gained them access to “the real party” (Multimedia Appendix 4). Parents verbalized rewards such as gym memberships while professionals thought that free or discounted food or cooking equipment were good incentives.

A central focus for all participants was the inclusion of delicious healthy foods to try.

Adolescents, parents, and professionals saw value in friendships and personal relationships as part of the program. All participants identified personal relationships as vital to the success of their program or party drawings. One adolescent explained, “I think you get to know the people that you’re going to be doing the class with and it’s a lot easier. So, if you do some sort of like fun game or activity at the beginning and people get to know each other pretty well, it’s much easier to have a good time.” The ability to collaborate was also important in their drawings.

All participants agreed that messaging can be vital to getting adolescents to the program. Parents suggested using an acronym that sounded fun and social, such as “FIT: Fight it Together.” Adolescents suggested using messaging that sounded better than the actual program in order to get adolescents to the door. One adolescent answered the question about how to get adolescents to attend a diabetes prevention program by saying, “Probably make it sound better than it is because once they are there, they probably won’t leave.”

All groups thought it was important to use rewards that promote healthy behaviors and celebrate success.

Adolescents felt that “diabetes prevention” and “health” were not motivating messages to lead with because they were associated with uninteresting didactic learning experiences such as health class. Components of the program that adolescents and parents found most important (eg, play, making friends, trying new things, being active) should be highlighted in visual and written messaging and marketing of the program.

There is a need for efficacious diabetes prevention interventions for adolescents and their parents. We used HCD methods to better understand barriers, improve diabetes prevention program design, and optimize participant engagement. We found that lack of financial resources, limited access to healthy foods and safe places for physical activity, and competing priorities were significant barriers to adopting lifestyle changes. This is consistent with the findings that adolescents of low socioeconomic status have lower quality diets and lower levels of physical activity than their counterparts of high socioeconomic status [30].

We found that participants want interactive, novel, hands-on learning sessions that incorporate a sense of fun and play. Adolescents and their parents desire opportunities to try new behaviors in a supportive group environment and to work toward healthy incentives and rewards. It is important to make healthy choices intrinsically motivating because they are fun, they align with important values, or they are part of someone’s identity. If healthy choices are seen as obligatory, boring/uncool, or unenjoyable, they are less likely to be adopted. Stakeholders are averse to “one-size-fits-all” lecture-style sessions that focus on “what not to do,” recommending that the focus be kept on their interests.

Other types of formative research have been used in diabetes prevention program design. Vangeepuram and colleagues [42] conducted in-depth interviews with youth workers and focus groups with adolescents to learn about program preferences. They found that offering choices, interactive workshops, personal stories, and games were the preferred methods for program delivery [42]. Community-based participatory research, another collaborative approach to research design, has been shown to be feasible and effective with adolescents in the design of health interventions [43-47]. MacDonald et al [47] used arts-based methods to engage adolescents in the process of designing a sexual health curriculum and concluded that partnering with adolescents improved the relevance of a prevention resource for them. Unfortunately, the inclusion of adolescents and parents in the design of prevention messaging and curriculum is often neglected [34]. Traditional pediatric weight management approaches often used to decrease T2D risk focus on evidenced-based lifestyle changes to promote healthy weight [48]. While evidenced-based messaging is key, program design is not typically informed by adolescents, their parents, or the professionals in their community. This may contribute to poor outcomes and attrition [49-51]. In this study, we engaged not only adolescents but also parents and professionals in the design of a diabetes prevention program that they would want to use. Thus, this study addresses this gap in the literature by describing HCD methods and findings to better understand barriers, design diabetes prevention programs, and activate at-risk adolescents and their families.

This study has the following limitations. Recruitment strategies may have attracted participants who were more keen on making lifestyle changes. Participant perspectives may not be representative of the general population as the sample was small and from 1 urban community. Demographics of the research participants were not collected. The HCD sessions focused on desired program content rather than the delivery platform. We plan to further translate these findings into a curriculum and test its effectiveness in a larger sample size. Future research should investigate participant engagement by using different delivery modalities.

The findings of this study highlight important insights regarding diabetes prevention and lifestyle change from 3 specific stakeholder groups and demonstrate that, with appropriate methods and facilitation, adolescents, parents, and professionals can be empowered to co-design diabetes prevention programs.