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April 27, 2010

Diagnosis and Symptoms

Question from Harlan, Kentucky:

My daughter turned 11 years old in September. She began menstruating about six months earlier. When she went to the RNP the other day, her fasting glucose was 114 mg/dl [6.3 mmol/L], her insulin level was 17, and her A1c was 5.2. The RNP said she doesn't think that children need to be treated for insulin resistance but I'm concerned. She is 5 feet, 3 inches and weighs 147 pounds. Last May, she weighed 164 pounds. She has not done anything to lose weight; she still eats the same. For several months, she has had problems with being sick to her stomach in the morning, which causes vomiting of yellow stomach acid. I am now very concerned. I am considering finding a pediatric endocrinologist with whom to consult. Are my concerns valid? Am I just overreacting? Anything you can tell me would be a great help.


It sounds like your daughter is overweight with a high BMI. Also, at least she can be diagnosed as having the metabolic syndrome or pre-diabetes with an abnormal fasting glucose. Some would say this is also diabetes even without symptoms. Insulin levels done in this fashion are not terribly helpful but she did not have enormously high insulin levels so not much “insulin resistance” at that moment in time. Her A1c was also not elevated. So, the key issue is how to assist with weight loss. I would assume that she overeats either at meals or snacks or both and also that activity is less than needed since one or both would usually explain the extra weight. You did not mention if she also has acanthosis nigricans, hypertension or lipid abnormalities. This sounds like mildly early but otherwise normal menses so perhaps also some mild precocious puberty as part of this metabolic syndrome complex. Measuring vitamin D levels and measuring baseline bone density would also be important since this, too, is part of the syndrome and adds future risk factors which can be ameliorated. It is unclear if she needs to see a pediatric endocrinologist at this stage, but certainly the entire family and your daughter need to sit with an experienced doctor, nurse, exercise person and/or nutrition specialist to find out ways to decrease caloric intake and increase caloric expenditure: less food in and more activity on a daily basis. Stopping high caloric school lunches will help. Cutting down television and computer time will help. Having the entire family role model what needs to be done will help. Sometimes medications like metformin can also be useful.