How would someone know they have insulin resistance?
It’s hard to define insulin resistance. Something that Dr. Westman and I mentioned in the book we wrote together (End Your Carb Confusion
) is that we don’t like the phrase “insulin resistance,” because if you ask ten different doctors or healthcare professionals for a definition, you’ll get ten different definitions. I much prefer the phrase “chronic hyperinsulinemia.” Hyperinsulinemia is just a big word that means your insulin level is too high too much of the time. “Chronic” means ongoing or all the time; “hyper” means high; and “insulinemia” means insulin in the blood. If you call it chronic hyperinsulinemia, the definition is built right into the phrase. “Oh, my insulin is too high, too often.” Then, the solution or many potential solutions become self-evident: you need to lower your insulin, and there are a lot of ways to do that.
With regard to determining if you have insulin resistance or chronic hyperinsulinemia, you can get your insulin level tested, just like you can get your blood glucose tested in a regular lab test or a checkup. They can test your insulin. There are a couple of problems with that, though. And the two real quick ones are that just like your fasting blood glucose, there are many people in whom the fasting level is normal, but if they eat a meal – especially a meal that’s high in carbohydrates – the blood sugar and the insulin will skyrocket. You won’t see how high that is if you only test the fasting level. Sometimes that can be misleading. Fasting levels of anything are a little bit volatile.
Going in the other direction, sometimes a fasting insulin can be a little higher than you would expect, but it doesn’t automatically indicate there’s a problem. Without testing at all, without measuring anything, things to look out for that can clue you in that you might have a problem with chronically high insulin include any of the things that we define metabolic syndrome by. Metabolic syndrome has five official points of diagnostic criteria: elevated fasting blood sugar, large waist circumference (if you’re large around the middle), high triglycerides, low HDL-cholesterol, and high blood pressure. If you have any of those and you can’t really explain why, you might have high insulin.
People who have high uric acid or who have gout may have high insulin. There are some doctors who think high uric acid should be added to that diagnostic criteria of metabolic syndrome.Apart from all of that, for women who have PCOS, chronically high insulin is the cause of PCOS. I don’t use that term lightly. That is from the scientific literature, and they don’t use that word lightly – to say that something is the cause of something, rather than it’s associated with it or it’s seen in conjunction with it. They have said that chronically high insulin is the cause of PCOS
Also, if you have a lot of skin tags or a skin condition where the folds of your skin (like in the elbow, in the neck, the back of the knees, the knuckles) look gray or ashy or black, it’s a condition called acanthosis nigricans, and that’s from chronically high insulin.
There are a lot of people who have non-alcoholic fatty liver disease (NAFLD), which often goes hand in hand with high insulin, so even without measuring the insulin at all, you can be tipped off to the fact that this is a problem. There are other ways to test for it. Just like when we do an oral glucose tolerance test where you drink glucose and your blood glucose is measured at intervals of up to two hours, there’s a similar test where instead of only testing your blood glucose, your insulin will also be tested. There are millions of people who have normal blood sugar, but the sugar is only normal because very, very high insulin levels are keeping that blood sugar controlled. You won’t know that unless you actually measure the insulin. When doctors do one of these glucose tolerance tests and they measure both, they can see, “Oh my gosh, if we had only measured glucose, this person looks totally healthy; there’s no sign of diabetes whatsoever. But now we measure the insulin and we can see that there’s a major problem.” This is called the Kraft test, named after Dr. Joseph Kraft, who pioneered the use of that test.
How does the test help understand someone’s insulin response?
It shows how sensitive you are to it, meaning how much insulin does your body require to bring that glucose back down to normal, and how quickly does it happen?” This is one of the things we actually see in people with hypoglycemia, meaning low blood sugar. They start out with a normal blood sugar level, and when they eat or drink something very high in carbs (especially refined carbs), the blood sugar might not go up that much, but the insulin really, really goes high, and then it comes down very quickly. And that very quick drop or even if the insulin doesn’t come down, the insulin stays high, and the blood sugar tanks, that’s when they get that feeling of shakiness, panic, wooziness, hunger, and the heart starts to race – all those things we associate with hypoglycemia. It’s not even so much the blood sugar as it is what the insulin is doing to the blood sugar.
In your opinion is the keto diet the best antidote for chronic hyperinsulinemia?
In my opinion, yes, it is. But, there are a lot of researchers and doctors that would say that fat loss is the best way, and whatever way you can achieve that would be the solution. The insulin resistance tends to come because of a buildup of fat in the liver and in the pancreas, in and around the organs primarily responsible for regulating blood sugar. I’m reminded of a point that I should have made earlier: when we talk about this chronically high insulin or insulin resistance, this can happen in people at any body weight. This is not something that only happens to people who are overweight or obese. You can be at a “normal weight” and have all of these same problems because it’s not about carrying a certain amount of body fat. It’s where that body fat is stored and what the effect of that is. You can be very lean-looking on the outside but have a lot of fat built up in and around these organs. I do think that ketogenic diets are the most effective for improving that, for improving that visceral fat, for getting the fat out of those organs. I also think that because of how well keto controls blood sugar and insulin, it helps control hunger and appetite. That’s why keto is, in my opinion, the most effective way and the most enjoyable way. You get to eat a lot of foods that are off-limits in most other ways of eating. I think keto is the most effective, but it’s not the only way to do it.
Is it possible for someone who has implemented the keto diet according to Dr. Westman’s Adapt protocols to stall?
Yes. It could be for any number of reasons. They could be eating too much. We hate the “C-word” – I mean calories. I hate the C-word, but we can’t ignore the fact that food coming in has to be dealt with. It’s food energy. Calories are a unit of energy. If you are taking in too much energy from the outside, then your body doesn’t need to use its stored energy, all of this energy that we store on our bellies and hips and thighs and backsides. So that’s one reason.
In some cases it may not be a stall, it’s just in some people with very severe, long-standing health problems, sometimes it takes a long time for keto to kick in, in terms of weight loss. Some people will see a lot of other changes that will show them that keto is having a beneficial effect, even if they’re stalled, even if the weight loss isn’t moving. They might see the triglycerides come down a lot, they might feel more energy, heartburn might go away, or the HDL might come up.
There are actually some studies where researchers provided the participants with food and it was specifically designed to give them enough calories so that they didn’t lose weight. These people did not lose weight or maybe they lost one kilo or just a couple of pounds, and yet they reversed metabolic syndrome, which basically is insulin resistance. They reversed it even though their weight was almost the same. All of those biomarkers and all of the measurements were improved so much that they would not have been diagnosed with insulin resistance anymore.
Does the level of insulin resistance play a role in a fat loss stall?
I think it does. I think the more severe your issue, the longer it’s going to take for something to happen. People really have to go into this with realistic expectations. You can’t compare yourself to anyone else’s rate of weight loss because your medical history, your dietary history, your current biological situation might be really different. I don’t know if there’s any way to predict how quickly people lose weight or how quickly insulin resistance resolves because some people who have morbid obesity, type 2 diabetes, or are on all kinds of drugs will lose weight and have massive improvements almost immediately, like in a shocking amount of time. Their blood sugar can normalize and they can lose a large amount of weight. And other people are doing everything right, there’s nothing that they need to change. They’re honestly really following the plan, and it’s just slower. I wish there was a magical answer to it. Sometimes it’s just slower.
If somebody has metabolic syndrome or chronic hyperinsulinemia and they come to you, what are the top two or three things that you would tell them to do?
If they know that they have this, if they’re not already doing a low-carb or ketogenic diet, that would be my advice. If you know that the problem is chronically high insulin, then the thing that we need to do is bring your insulin level down, and the most powerful way to do that is to just fast. But we don’t recommend that. We don’t recommend long-term extended fasting. We like for people to eat and nourish their bodies. Stick to foods that have the lowest impact on blood sugar and insulin, and for most people that’s going to be refined carbohydrates, especially liquid carbs, like sugar-sweetened sodas and fruit juice or smoothies. For some people, when you have a severe metabolic problem, even the wholesome carbohydrates, the carbohydrate foods that we would normally consider a perfectly healthy food, even those have to be restricted just to make sure that insulin is going to be low most of the time. If insulin gets in the way of fat burning, if you want to lose weight, if you want to get rid of body fat, including some of the fat that’s building up in the liver and pancreas, we’ve got to get insulin out of the way. The way to do that is to stick to foods that affect insulin the least, and that’s going to be fat and protein.
Fasting is not required. Even intermittent fasting – skipping a meal here and there, having a compressed eating window, eating for just a certain number of hours of the day and then going the rest of the day without eating – that’s not required, but it can be helpful, especially if somebody is prone to chronic overeating or just grazing all throughout the day. That can help a little bit because if your body is exquisitely sensitive and if you eat anything (even just fat and protein), you’re going to have a little bit of a reaction, then you might benefit from going some extra length of time during the day without eating. You can have coffee and tea and things like that, but that just helps your body have a little bit more time in a period where your insulin is going to be low and you’ll be running on fat. Exercise is a little controversial here because exercise is not a fat loss tool. It really doesn’t help many of us lose body fat, and I think most of us learned that the hard way by spending years and years slogging away on a treadmill or an elliptical machine only to see no change whatsoever in our physique or our weight. But I do think that exercise can help improve insulin sensitivity. The more muscle mass you have and the more you use it, think of muscles as little sponges for glucose. So if your muscles are hungry for fuel, they’re going to gobble it up right away, and you don’t need a whole lot of insulin to deal with that fuel. Your muscles are going to take it in regardless. If your weight or your mobility or your health situation right now is such that you can’t exercise, that’s okay. The beauty of keto is that it works without exercise for fat loss. Dr. Westman did a video a while back with a patient who was wheelchair-bound, who lost 50 pounds on keto with no exercise. You don’t have to exercise, but if you can, I do think that’s another arrow in the quiver of trying to help your body require less insulin to do its job.
Watch the full video here.