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To evaluate racial/ethnic and sex differences in the relationship between metabolic syndrome (MetS) diagnosis and fasting insulin in adolescents.We analyzed data from the National Health and Nutrition Evaluation Survey 1999-2008 for 3693 non-Hispanic-white, non-Hispanic-black, and Hispanic adolescents (12 to 19 years of age). We used linear regression to evaluate differences in fasting insulin levels between those with and without an adolescent adaptation of ATPIII-MetS in a sex- and race/ethnicity-specific basis.Females had higher insulin levels than males, and non-Hispanic blacks and Hispanics had higher levels than non-Hispanic whites. Adolescents with MetS had higher insulin levels than those without MetS. The difference in insulin levels between those with and without MetS was greater in non-Hispanic blacks than in non-Hispanic whites (P < .05) but not Hispanics (P = .10). The sensitivity of MetS in detecting elevated insulin levels was lower in non-Hispanic blacks and females than in other ethnicities and males, respectively. Correlations between insulin and individual MetS components were similar among ethnicities.MetS diagnosis performed more poorly in predicting elevated insulin levels in non-Hispanic blacks and in females. These data support the hypothesis that non-Hispanic blacks do not meet current criteria for MetS until they have reached a more advanced degree of insulin resistance.