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Introduction: Several studies have confirmed the increasing rate of type 1 diabetes mellitus (T1DM) in children and the link with increasing BMI at diagnosis termed the 'accelerator hypothesis'. Our objective was to assess whether changing incidence of type 1 diabetes in a group of children and adolescent from the Midwest United States was associated with changes in BMI. Methods: Data from 1618 (52.1% M/47.9% F) newly-diagnosed children and adolescents (,19 years) with T1DM, admitted to Children's Hospital of Wisconsin (CHW) between January 1995 and December 2004, was analyzed in relationship to body mass index (BMI) standard deviation score (SDS). Results: An overall, 10-year cumulative incidence of 27.92 per 100,000 (19.12 to 41.72/100,000) was observed, with an average yearly cumulative incidence of 2.39%. The increase was largest in the younger age groups, 0-4, 5-9, and 10-14 having an average yearly increase of 2.4, 2.3, and 3.0%, respectively, corresponding to a relative 10-year increase of 25.3, 33.8, and 38.0%, respectively. Age at diagnosis was inversely correlated with BMI SDS (p,0.001) and remained significant for both males and females. Conclusions: Annual incidence of T1DM increased two-fold at CHW over the 10-year study period. The majority of the increase was observed in the youngest age groups, which also appeared to be the heaviest. This research adds to the growing literature supporting the hypothesis that excess weight gain during childhood may be a risk factor for early manifestation of T1DM. [ABSTRACT FROM AUTHOR]