: Early-onset diabetes (EOD), diagnosed at ≤35 years, is a growing public health crisis in low- and middle-income countries, including Pakistan. Identifying modifiable and non-modifiable risk factors is critical for developing effective prevention strategies. This study aimed to investigate the risk factors associated with EOD in Sindh, Pakistan, focusing on genetic, lifestyle, and metabolic determinants. : A multicenter cross-sectional study was conducted across diabetic clinics in Sindh, with primary data collection at Baqai Institute of Diabetology and Endocrinology (Karachi, Pakistan) and secondary sites in Hyderabad, Larkana, and Sukkur. Following institutional ethical approval and informed consent, we enrolled 754 individuals (type 1 and type 2 diabetes, age at diagnosis: 15-35 years). Data on anthropometric, clinical, biochemical, and lifestyle parameters were collected via structured questionnaires. Statistical analyses included Pearson's Chi Square tests and multivariate logistic regression in determining associations. : Logistic regression revealed key predictors of early-onset diabetes (EOD). A two-generation diabetes family history showed a strong association (aOR:1.86, 1.12-3.43). Significant lifestyle risks included physical inactivity (OR:1.40, 1.03-1.90), frequent sugary beverage intake (OR:1.93, 1.89-1.98), and abnormal sleep duration (<6 h: OR:1.58, 1.04-2.40; >8 h: OR:1.86, 1.21-2.85). Hypertension was a major metabolic predictor (elevated BP: OR:1.79, 1.28-1.54; Stage I: OR:1.81, 1.34-1.77). Cardiovascular disease and uncontrolled fasting glucose lost significance after adjustment, indicating confounding effects. : This study highlights familial predisposition, sedentary behavior, poor diet, sleep disturbances, and hypertension as key contributors to EOD in young Pakistani adults. Early screening and targeted lifestyle interventions are urgently needed to mitigate this escalating epidemic.