The case for broader use of HOMA-IR in pediatric metabolic assessment: a narrative review

The reliance on Body Mass Index (BMI) and fasting glucose as primary indicators of pediatric metabolic health may systematically fail to detect the earliest phase of metabolic dysfunction: chronic hyperinsulinemia. This narrative review, conducted in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA) framework, synthesises current literature to evaluate the evidence for the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) as a potential first-line tool in pediatric metabolic assessment. We examine the physiological mechanisms of early-onset insulin resistance, the epigenetic and intergenerational consequences of obesogenic environments, the limitations of current diagnostic criteria, and the economic implications of delayed detection. We discuss both universal and targeted screening strategies, comparing HOMA-IR with alternative insulin resistance indices including the Quantitative Insulin Sensitivity Check Index (QUICKI), the Triglyceride-Glucose (TyG) index, and the Single Point Insulin Sensitivity Estimator (SPISE). We critically appraise the principal limitations of HOMA-IR-including insulin assay variability, pubertal physiological variation, and the absence of prospective screening trial data demonstrating improved clinical outcomes. We conclude that while the mechanistic and epidemiological evidence supporting HOMA-IR is substantial, prospective population-level screening trials are required to confirm that HOMA-IR-guided intervention improves clinical outcomes at scale, and we identify such trials as a research priority.