She didn’t follow the rules

Monica is a petite 12-year-old who presented with diabetes at 9 years. Her parents noted that she was going to the bathroom a lot and sought medical care before she developed ketoacidosis – a very smart move on their part. Her blood glucose was approximately 350 mg/dL, C-peptide and insulin were not measured, and she was started on insulin twice-daily. After a few weeks of therapy she was transitioned to an insulin pump and did very well for about 15 months when she began to experience episodes of hypoglycemia. Gradually her daily dose of insulin was reduced to <1 unit daily and she persuaded her parents and her doctor to let her stop the insulin.

She remained off insulin for the next year until she began to experience the same symptoms that first brought her to medical attention. This time, however, she required increasing doses of insulin and became quite frustrated by not knowing how best to manage her diabetes.

She now weighs 52 kg and is 62 inches in height, with a BMI of 21 and requires 40 to 50 units of insulin daily to maintain reasonable blood glucose control. She is doing fairly well at this with an HbA1c of 6.9. She clearly has insulin resistance and has converted from a seeming type 1 diabetic to a type 2 diabetic – so called “flatbush” diabetes or type 1.5 diabetes.

This presentation with type 1 diabetes - followed by a period seemingly free of diabetes, only to present a year or so later as type 2 diabetes - is most common in the United States in young blacks. Within this group there is often a family history of diabetes and some of the patients are overweight. None of these characteristics were present in Monica. The etiology of her current insulin resistance remains unclear and she is in no mood to go hunting for a reason. She just wants her diabetes to be controlled so she can get on with her busy life.

She will respond to oral therapies, but after discussion she opted to go back to her pump with the addition of a continuous glucose monitor. What she really wanted to know was whether she would have to go through this annoying “I have diabetes and then I don’t have diabetes” for the rest of her life. I have no easy answer for her. For now she has to accept that she appears to have insulin resistance with no clearly apparent cause.

Not everyone who is overweight or obese develops diabetes. Not everyone with type 2 diabetes is overweight or obese.