Insulin Resistance - A Slow Motion Train Wreck
Ravi Kulkarni (kulkarnr@gmail.com)
Editor: ChatGPT
Disclaimer: This is not medical advice and I am not a medical professional. Please consult a board certified physician for your personal health issues.
Introduction
Insulin resistance is a basic mechanism of the body that, while it exists to protect the body, can end up damaging and destroying it. While insulin resistance is extremely common, it hardly gets any attention unlike its bigger cousins, pre-diabetes and diabetes. This article is an attempt to spotlight insulin resistance, explain the terrible damage it can eventually cause, and what you can do to prevent, slow, or reverse it.
Confronting an Impending Crisis
Dialysis Machine
Imagine the challenges of living with a missing limb or the constant worry of monitoring blood sugar levels and restricting oneself from enjoying favorite foods. Millions of individuals worldwide who suffer from type 2 diabetes (T2D) live this nightmare. According to the US National Diabetes Surveillance System, approximately 1 in 9 residents of the US are diagnosed with T2D, and an additional 1 in 3 are pre-diabetic.
This alarming situation, which began unfolding three decades ago, shows no signs of improvement. The complications associated with T2D severely impact the quality of life for those affected. The personal and societal costs of this disease are undeniably significant. However, it hasn't always been this way. Just a few generations ago, T2D was not as widespread. In the early 20th century, diabetes was not a common condition. If people during that time managed to largely avoid diabetes, there is hope that we can follow suit. To achieve this, it is crucial to understand the underlying physiological and environmental factors that contribute to the disease and take preventive actions to stop it from taking hold in the first place.
Prediabetes and Diabetes: Tips of the Iceberg
If your fasting blood sugar level is below 100 mg/dl then you are normal, above that you are pre-diabetic until 140 after which you are type 2 diabetic. You are the same person with the same body, what changed between these two numbers? One day you are normal and the next living with disease. The decades of experience and research has shown that rather than being an abrupt transition, T2D disease is a continuum. It has taken several years, decades even, to take root. Is there any way to know whether we are on the wrong path and if anything can be done about it? The answer to both questions is a resounding yes!. In most cases insulin resistance(IR) eventually leads to prediabetes and diabetes. The bad news is that prediabetes and diabetes are just two of the many diseases caused by IR; see the picture for illustration. But, there is good news too. In most cases, it is possible to reverse IR.
Effects of Insulin Resistance on human body
Demystifying Insulin Resistance
Imagine you are trying to arrange a glucose absorbing party in that special place: a cell. Once your guests, the glucose, arrive, you want to admit them quickly so that they are not a danger to the surroundings, your organs. IR is like that loud and obnoxious friend who becomes progressively loud once they down one or two drinks. If this friend is in the party, you can’t hear anyone wanting to enter it due to all the noise. You see, insulin, the hardworking hormone produced by the pancreas, is in charge of regulating blood sugar levels. It's like the bouncer at the cellular nightclub, allowing glucose to enter muscle, fat, and liver cells, where it can be put to good use. But when your friend IR crashes the party, things go downhill.
Insulin knocks on the door, expecting the cells to open up and welcome glucose inside. But instead, the cells are like, "We can’t hear nothing, nananana nana!. We'll just hang out here without any energy, thanks." It's like trying to get into an exclusive club but being met with closed doors. Frustrated insulin, the bouncer, starts shouting, "I'm insulin, damn it! Let me in!". Failing which, the insulin brings even more insulin to facilitate the process but to no avail.
This insulin overload creates a whole mess of problems. It's like when you accidentally send a text to the wrong person and end up in an awkward situation. Except in this case, the awkward situation is a chain of health complications. Insulin resistance likes to start early, crashing the party as soon as late teens or early twenties. And it doesn't stop there—it keeps getting worse.
The main victims of this IR chaos are the skeletal muscles, liver, and fat cells. They struggle to absorb glucose efficiently, leaving them starved of their essential fuel. It's like they're on a never-ending diet of deprivation, and it's not fun. To compensate for this energy shortage, the pancreas goes into overdrive, pumping out more insulin than a barista at an espresso bar. But instead of solving the problem, it just makes things worse. It's like trying to put out a fire with gasoline.
Insulin resistance doesn't follow a straight path. It's a messy web of dietary choices and consequences. As it progresses, you find yourself caught in a spiral of inflammation, diabetes, cardiovascular disease and Alzhaimer’s. It is a tangled mess of wires that you desperately need to untangle.
Insulin Resistance Vicious Spiral
Measuring Insulin Resistance
Truth shall set you free! Knowledge is power and knowing where you stand on your metabolic journey is crucial to good health. Everyone is familiar with fasting glucose levels and A1C but these two numbers don’t tell you the whole story. Even if you are abusing your body constantly with high carb meals and sugary drinks, your trusty bouncer, i.e., insulin keeps the glucose levels under check. Therefore A1C also remains in range. However, you can clearly see this by measuring fasting insulin levels. If your fasting insulin is rising over a period of time, that means you have developed IR.
There are several direct and indirect indicators that tell you about the level of IR in your body. In most cases a single value is not as useful as a trend that shows whether it is getting better or worse.
Triglyceride levels: Elevated triglyceride levels may lead to IR in the skeletal muscle.
Triglyceride glucose index (TyG): This is probably the least expensive test. You can compute it using your recent lipid panel and fasting glucose level.
HOMA-IR: It measures the levels of fasting glucose and the corresponding insulin response.
NMR lipoprofile LP-IR score: Another measure that involves glucose and triglycerides.
Oral glucose tolerance test or OGTT: It is a diagnostic test used to evaluate a person's ability to metabolize glucose effectively.
Kraft insulin survey: This test is similar to OGTT with insulin being measured along with glucose levels.
Preventing and Reversing Insulin Resistance: Empowering Ourselves
Identify the bad apples (metaphorically speaking; apples are actually quite good), among your metabolic friends and don’t invite them to the party. The bouncer at the cellular nightclub needs your help. Simple carbs and sugars are the worst offenders. Highly processed foods are another category you want to exclude. Avoid frequent snacking. Identify the combination of foods that reduce the BG spikes. Order in which foods are consumed also has an effect. An active body consumes more calories, and, pound for pound, skeletal muscles consume far more calories than fat. Even at rest, muscles consume some energy, thereby raising your basal metabolic rate. Strength training and cardiovascular exercises are excellent for overall health. There are many dietary and lifestyle hacks that one can adapt to keep IR at bay. Supplementation may be necessary in some cases.
Eat low glycemic foods
These are your best buddies and well wishers, whom you would love to have in your party. Organically and naturally grown foods are better. Some examples of such foods are:
Seeds: Chia, flax, pumpkin seeds, sunflower seeds, sesame, hemp, fenugreek seeds
Nuts: Almonds, pistachios, walnuts, cashews, brazil nuts, pecans, hazelnuts, macadamia nuts
Leafy vegetables: Spinach, kale, swiss chard, romaine lettuce, arugula, collard greens, beet greens, bok choy, watercress, mustard greens, turnip greens, cabbage (green or red)
Healthy fats: Avocados, olives, coconuts, wild caught fish
Animal source foods: dairy, eggs, chicken, beef, pork
Spices: Turmeric, cinnamon, garlic, ginger, black pepper
Fruits: Berries, apples, bananas, citrus, pears, kiwi
Consume some foods in moderation
These are like certain relatives, in laws and other acquaintances, whom you want to invite only on certain occasions. Some examples are:
Whole grains: While whole grains provide important nutrients and fiber, they still contain carbohydrates. Portion control and balancing with other foods is key. Examples include whole wheat bread, brown rice, quinoa, and oats.
Starchy vegetables: Vegetables like potatoes, sweet potatoes, and corn are higher in carbohydrates compared to non-starchy vegetables. Enjoy them in moderation and be mindful of portion sizes.
Tropical fruits: Fruits such as bananas, pineapples, and mangoes are higher in natural sugars and carbohydrates. Enjoy them in moderation and pair them with protein or healthy fats to slow down the release of sugars.
Natural sweeteners: Natural sweeteners like honey, maple syrup, and agave nectar are still forms of sugar. Use them sparingly and be mindful of overall sugar intake.
Dairy products: Dairy products like milk and yogurt contain lactose, a natural sugar. Opt for unsweetened options or those with lower lactose content. Greek yogurt can be a better choice due to its higher protein content.
Legumes: While legumes such as lentils, chickpeas, and beans provide fiber and protein, they also contain carbohydrates. Monitor portion sizes and pair them with non-starchy vegetables and healthy fats.
Foods to avoid altogether
They are like drug peddlers, your exes, and other known troublemakers you absolutely don’t want in your party. Here are some examples:
Added sugars: This includes sugary beverages, candy, desserts, pastries, and processed snacks. Read labels carefully, as added sugars can be hidden in various packaged foods.
Refined carbohydrates: Foods made with refined grains like white bread, white rice, and pasta have a high glycemic index and can cause rapid spikes in blood sugar levels.
Trans fats: Foods high in trans fats, such as fried foods, commercially baked goods, and processed snacks, should be avoided as much as possible due to their negative impact on insulin sensitivity and heart health.
Highly processed foods: Processed foods often contain unhealthy fats, added sugars, and artificial additives. Opt for whole, minimally processed foods whenever possible.
Sugary drinks: Sodas, energy drinks, fruit juices, and sweetened teas are typically high in added sugars and can quickly raise blood sugar levels.
Alcohol: Alcoholic beverages can interfere with blood sugar regulation and liver function, making it advisable to consume them in moderation or avoid them altogether.
Supplementation
As much as you try to cook everything for the party yourselves, sometimes it helps to order from a nearby caterer. It is difficult to get all the micronutrients from food alone, especially for someone over 30 years old. Vegetarians are particularly vulnerable to deficiencies.
Magnesium: Magnesium is involved in over 300 enzymatic reactions in the body, including insulin signaling and glucose metabolism. Studies have shown that magnesium deficiency is associated with insulin resistance. Increasing magnesium intake through diet or supplementation can help improve insulin sensitivity.
Chromium: Chromium is involved in carbohydrate and lipid metabolism, and it enhances the action of insulin. It aids in regulating blood sugar levels and improving insulin sensitivity. Chromium supplementation has shown potential benefits in individuals with insulin resistance and type 2 diabetes.
Vitamin D: Vitamin D deficiency has been linked to insulin resistance and impaired glucose metabolism. It plays a role in pancreatic beta-cell function and insulin release. Adequate vitamin D levels are associated with improved insulin sensitivity, and supplementation may be beneficial in individuals with deficiency.
Omega-3 fatty acids: Omega-3, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been shown to improve insulin sensitivity and reduce inflammation. They can be obtained from fatty fish, fish oil supplements, and plant sources like flaxseeds and chia seeds.
Zinc: Zinc is involved in the synthesis, storage, and release of insulin. It also affects the action of insulin at the cellular level. Zinc deficiency may impair insulin sensitivity, and supplementation has been shown to improve glucose control in individuals with insulin resistance.
B vitamins: B vitamins, such as B1 (thiamine), B6 (pyridoxine), and B12 (cobalamin), are important for carbohydrate metabolism and nerve function. Deficiencies in these vitamins can contribute to insulin resistance and impaired glucose metabolism. Ensuring adequate intake of B vitamins through a balanced diet or supplementation can support insulin sensitivity.
Exercise
In a healthy person almost 80% of the glucose intake is absorbed by the skeletal muscle. Most of the rest is taken up by the liver and the remaining by fat tissues. Quickest way to address IR must start with resolving the muscular IR. Exercise has a significant impact on overall health.
Strength training must be the top priority: Exercise all muscles of the body at least 2 times per week. This will not only build muscles and make you stronger, it will potentially reduce IR, improve brain health and improve mood as well. Here are some advantages of strength training:
Increased Resting Metabolic Rate (RMR): Muscle tissue is metabolically active, meaning it requires energy even at rest. Building muscle increases your RMR, leading to a higher calorie burn throughout the day.
Improved insulin sensitivity: Resistance training and muscle development enhance insulin sensitivity, allowing cells to better respond to insulin and efficiently regulate blood sugar levels. This can reduce the risk of insulin resistance and type 2 diabetes.
Enhanced glucose control: Building muscle helps improve glucose uptake and utilization by muscle cells, leading to better blood sugar control and decreased risk of metabolic disorders.
Increased fat burning: Muscles play a significant role in fat metabolism. Having more muscle mass can increase the utilization of fatty acids for energy, promoting fat burning and weight management.
Elevated post-exercise caloric expenditure: Intense resistance training sessions can lead to an "afterburn effect" called excess post-exercise oxygen consumption (EPOC). This means your body continues to burn calories at an elevated rate even after the workout, aiding in weight management.
Preservation of lean body mass: Building and maintaining muscle mass helps prevent the loss of lean body mass, which can occur during weight loss or as a result of aging. Preserving muscle mass contributes to a healthier body composition and metabolic function.
Improved metabolic profile: Muscle building can positively impact various metabolic markers, including improved lipid profile (lower triglycerides, increased HDL cholesterol), reduced blood pressure, and decreased markers of inflammation.
Increased energy expenditure during exercise: Building muscle can enhance exercise performance and increase the intensity of workouts. This leads to a higher energy expenditure during exercise, further supporting weight management and metabolic health.
Bone health and metabolic function: Resistance training stimulates bone remodeling and improves bone mineral density. Strong bones are essential for overall metabolic health and reduce the risk of osteoporosis and fractures.
Enhanced overall metabolism: Building muscle improves overall metabolic efficiency and contributes to a healthier metabolism. It helps create a favorable balance between energy intake and expenditure, promoting optimal metabolic function.
Dietary hacks
Despite your best efforts, some undesirable elements end up in your fabulous party anyway. Best way of achieving an optimal diet is to wear a CGM (continuous glucose monitor) and systematically identify the foods that you want to place in each of the three groups above. CGM can be a powerful and effective bouncer for you. In general the following hacks are known to work, see which one works for you.
Continuous glucose monitoring: Nothing tells you more about your body than a CGM. It gives you immediate and continuous feedback about your habits. If you are persistent, you can finetune your diet and lifestyle to optimize your health.
Clothe your carbs: Naked carbs spike your glucose levels. Adding other foods to carbs reduces their glycemic index.
Change the eating order: Eat high fiber foods, fats or proteins, and simpler carbs in that order. It means eat the dessert after the meal.
Consume vinegar: Drink some form of vinegar (e.g., apple cider vinegar) ten minutes before a high carb meal.
Control portion sizes: Portion sizes do matter and usually the higher portions instigate disproportionately higher glucose spikes.
Delay your breakfast: As you rise from bed, your BG levels are naturally rising to cope with increased energy demand
Exercise: Exercise for 10 minutes before or after a meal
Conclusion
Insulin resistance is a silent epidemic that is at the root of the modern healthcare crisis. Its effects get compounded over decades and become complex diseases such as type 2 diabetes, heart disease, Alzheimer's and many cancers. These lifestyle diseases are incredibly complex, expensive and difficult to treat, whereas IR can be easier to deal with.
Insulin resistance can be measured by its proxies. There are simple exercise and dietary interventions that can prevent and reverse insulin resistance and these are within reach for most individuals. Continuous glucose monitors aid in identifying your metabolic profile and identify hacks that improve it.
It is our individual and collective responsibility to help wake up the society to the perils of insulin resistance and save it from going over the healthcare precipice.
Acknowledgements
I sincerely thank my dear friend Iggy Fernandez for his feedback, encouragement and editorial help.
Amazing details and lot of effort. nice article:)
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